Education and Training

Introduction

The education and training requirements of a trauma and emergency system must reflect the system in which it operates and ensure efficient and effective trauma management and continuous quality improvement.

The education system must account for the continuum of needs from undergraduate education, postgraduate/specialist training through to continuing education programs for skill maintenance and knowledge improvement. Education strategies need to encompass training in trauma management, including advanced life support skills for the various disciplines involved in managing major trauma.

Servicing these educational needs will, in part, address system deficiencies identified in previous research (McDermott et al., 1996; Danne et al., 1998). The education processes inherent in the system need to ensure two key features:

1. There should be opportunities for quality training in trauma care within the system.
   Achieving and maintaining the skills necessary for expert trauma care requires not only training but exposure to time-critical trauma cases. The system should allow for training opportunities for the various health professionals involved in trauma care. It is envisaged that the MTS will have the largest clinical caseload of major trauma patients. Training programs provided by the MTS should give opportunities for advanced training in medical, nursing and other health specialties. These opportunities can incorporate traditional clinical rotations as well as innovative distance education programs utilising other education methodologies.
2. There should be motivated and dedicated personnel available to undertake trauma care.
   The care of a major trauma patient is a 24-hour-a-day commitment. Institutions designated as major, metropolitan or regional trauma services should be able to guarantee the continued availability of specialist staff, especially experienced surgical staff. There is a limited availability of sub-specialty surgical staff who can provide both the experience and the motivation to undertake the rigours of major trauma care.

This chapter discusses educational strategies related to trauma management currently in place in Victoria and outlines areas for improvement.

System Guidelines

The relative immaturity of the trauma system concept, especially in Australia, means that there is a lack of guidelines to help drive the education of the system. While considering this, it is important to place the education services aimed at trauma care in the perspective of their component of overall emergency care.

The Model Trauma Care System Plan (US)

The Model Trauma Care System Plan (1992) published by the US Department of Health and Human Services provides a sound approach to education and training of the system. Of note are the following recommendations:

• A well-planned needs assessment that identifies current resource levels and availability is an essential prerequisite to developing further educational activities (p. 19).
• Quality management programs for monitoring courses and instructor certification/re-certification should be established (p. 19).
• Educational programs may be particularly important in facilities that do not receive a high volume of trauma patients (p. 20).

National Road Trauma Advisory Council (NRTAC)

The NRTAC Report of the Working Party on Trauma Systems (1993) recommends that a training program should be an integral component of an overall quality management program. In addition it recommends that:

• There should be developed clinical training posts with a trauma emphasis. Such posts may allow the rotation of advanced trainees or the appointment of clinical fellows.
• Formal trauma care education programs should be developed and offered to:
  • Specialists in surgery, emergency medicine, anaesthetics and intensive care
  • Nurses
  • Allied health personnel
  • General practitioners.
• Continuing education for both medical and nursing staff in rural areas has to be addressed as a special issue. To some extent, this could be done through staff working temporarily with MTS. This would, however, require the support for locums, travel and accommodation (p. 70).

Australian Council of Healthcare Standards Guidelines

The ACHS guidelines are based on information from the NRTAC Report of the Working Party on Trauma Systems (1993).

Some comments pertinent to the area of trauma education and training include:

• Major and regional trauma services contribute to training in trauma management for medical, nursing and paramedical staff, particularly in rural regions.
• It is expected that medical practitioners who may be involved, even rarely, in the management of severe trauma undertake the EMST course of the RACS, or equivalent.
• Medical specialty trainees attached to trauma services are closely supervised by senior staff of the specialty (ACHS, 1997, p. 7).

Gaps in System Guidelines

The ACHS document provides a guide to the minimum standards that can be expected by some of the practitioners within the system. There is no guidance for capacity building of the system and the roles that the various trauma system components play in developing and promoting the system.

The NRTAC guidelines provide more direct guidance on how to operate an education program. In particular, they emphasise the roles that various components of the trauma system play in the education plan. This approach is attractive and needs further evaluation before implementing in Victoria.

Role of Director of Trauma Services

The emerging role of the Director of Trauma Services in Victoria, whether it be on a Network or hospital basis, should have responsibilities for all staff, not just medical, involved in trauma care at a trauma service. The focus of the position must include integrating the trauma service into the wider emergency system. As such, there will be a significant role in coordinating education programs, both within the hospital and with other agencies involved in trauma care.

Medical Education

Undergraduate

Undergraduate medical education is provided in Victoria by the University of Melbourne and Monash University. Principles in the management of trauma patients are delivered through structured workshops and tutorials and the quantity and quality of this instruction is likely to be variable.

Postgraduate

The EMST course has been offered in Australia since 1988 by the RACS. The course is adapted from the Advanced Trauma Life Support (ATLS) course initially developed in the US and now conducted in more than 16 countries.

Training in ATLS aims to assist relatively inexperienced medical officers to handle complicated clinical situations in a controlled setting (Drummond, 1993). It teaches 'one safe system of assessing and managing victims of trauma in the first hour' (Gwinnutt, Driscoll, 1996). 'The course is a combined educational format of lectures associated with lifesaving skills and practical laboratory experiences' (Collicott, 1992, p. 749). Assessment of the impact of ATLS on patient outcome is difficult to assess since results of outcome studies are often confounded by external factors including the standard and responsiveness of prehospital care.

An EMST qualification is now seen as the minimum standard qualification of the trauma team leader, a prerequisite for admission into many advanced training programs and a compulsory component for registrars in the Rural Training Stream. Neither the ACEM nor the Royal Australasian College of General Practitioners (RACGP) has successful completion of the EMST as a prerequisite for registration, although the majority of fellows of the ACEM have completed the course. Despite the lack of evidence that ATLS improves patient outcome, it is seen as a legal standard of care for trauma patients in the USA. No such legislation is in place in Australia.

An Advanced Paediatric Life Support (APLS) course has recently been established in Australia. APLS (Australia) is a not-for-profit organisation established with the aim of providing practical courses to medical and nursing personnel in the immediate assessment and treatment of the acutely ill and injured child.

Advanced Training

Advanced medical training programs are conducted through the medical colleges. Many medical disciplines have a crucial role in the care of trauma and emergency patients including, but not limited to, surgery, emergency medicine, anaesthesia and intensive care.

The RACS training in surgery is through a combination of supervised workplace experience in the full spectrum of patient management as well as academic pursuits. RACS is thus independent of universities and government in determining professional standards. Emphasis is constantly placed on the quality of the training, more than on the nature of the qualification, notwithstanding the importance of the latter.

The Fellowship of RACS is an 'exit' qualification, a mark of completed training, guaranteeing to the community an appropriately qualified surgeon. Further post-fellowship training may be undertaken either locally or overseas.

Gaps in Education Programs

There appears to be a need for a standard curriculum for the orientation and postgraduate training of medical interns in trauma and emergency management. The current method of in-house orientation, while adequate, is likely to be highly influenced by the priorities and specialties of the particular hospital.

EMST courses are available across Australia, however,there is a need to increase the availability of these courses for rural practitioners and address some of the barriers that limit the availability of rural GPs to attend these courses. The development of the APLS course is an encouraging sign in developing advanced skills in the treatment of paediatric emergencies, but addressing some of the barriers to attendance would optimise the success of this training.

Currently, there is no advanced surgical training in trauma. One of the important factors in developing an advanced training program in trauma surgery will be ensuring an adequate experience level for trainees. There has been ongoing controversy in defining the level of exposure that is necessary to obtain and maintain expertise with trauma care. The low incidence of trauma in Australia makes this problematic.

Nursing Education

Undergraduate

Undergraduate nurses typically have minimal exposure to, and emphasis on, the initial management of the trauma and emergency patient. There are usually some brief clinical placements to emergency departments and other critical care areas during the latter stages of undergraduate nursing education. The principles of resuscitation and acute trauma and emergency care are covered but the development of competence in this area is usually not an objective.

Postgraduate

Postgraduate nursing training is variable, depending on the institution involved. The standard graduate year involves a structured education program with additional tutoring by nurse educators, some rotation through various clinical areas and the completion of some academic work.

Most specialist clinical areas have the support of nurse educators who are primarily responsible for the orientation and development of knowledge and skill levels of new nursing staff.

There are many private and professional agencies that conduct continuing education programs for registered nurses, often concerning advanced skills and techniques. For example, an offspring of the ATLS educational format is the Trauma Nursing Core Course (TNCC) developed in America by the Emergency Nurses Association for national and international dissemination as a means of identifying standards of nursing care based on current knowledge relating to trauma.
In Australia, it is organised and conducted by the Emergency Nurses Association in NSW on license from the US. In each state of Australia there is a coordinator who directly deals with NSW to organise courses. All nurses dealing with trauma patients are encouraged to attend this course, however current access to such courses for Victorian nurses is severely limited and is being addressed by the Victorian Emergency Nurses Association in the near future. The Taskforce endorses the statewide introduction of a single, standard training course that is locally accessible for Victorian nurses involved in trauma resuscitation and care.

Advanced Training

In line with the move of undergraduate nursing training into the tertiary education sector, most advanced training courses are now conducted in conjunction with a hospital and a university. Commonly, these courses are conducted over a 12-month period, with the students employed by the hospital and attending the academic program at the university. Successful completion of a postgraduate course is generally seen as a minimum standard for advanced practice in a critical care area.

Gaps in Education Programs

For many years there has been an inadequate supply of qualified and experienced critical care, emergency and perioperative nurses in Victoria. This has caused many problems for the health care system, especially with limitations on ICU bed availability. There is an ongoing demand in most hospitals for nurses with critical care skills and qualifications, and some academic institutions are unable to fill all the training places available.

Nurses with advanced skills contribute significantly to the efficient and effective treatment of emergency and trauma patients. However, the Review of Emergency and Critical Care Services in Victoria (1994) recognised that education needs were an issue and recommended:

• All hospitals providing an emergency medical service should ensure access to clinical teaching support for their emergency nurses.
• Hospitals should provide clinical teaching support in critical care units to assist with the orientation of new staff, in-service education and ongoing clinical support for all staff.
• Hospitals should recognise the need for extensive orientation and supervision of non-certificated staff and budget for sufficient supernumerary orientation time (Health and Community Services 1994, pp. 12, 37).

Prehospital Care Providers

The education and training of ambulance officers is crucial to the efficient operation of the trauma system and optimal patient outcomes. Ambulance paramedics are trained in basic life support through a three-year Associate Diploma of Health Science to enable primary intervention in the prehospital setting. The availability of adequate supervision for students and recent graduate ambulance officers is a necessary requirement when considering placements.

A MICA paramedic has an additional year of postgraduate training in a range of advanced life support techniques, including endotrachael intubation, intravenous infusion, drug therapy, relief of tension pneumothorax and cardiac monitoring.

The progressive introduction of paramedics across Victoria is a welcome development in introducing advanced prehospital skills to rural Victoria. Appropriate mechanisms need to be developed to ensure that high skill levels
are maintained.

Continuing Education and Professional Recertification

'Professional recertification is a process that stipulates continuing education as a means of maintaining professional competence' (Victorian Department of Health and Community Services Vol. 1, 1995, p. 12). The Committee on Quality made the recommendation that all health care professionals should recertify and quality should be mandated as part of this process. This should be essential for all practitioners involved in trauma care, regardless of the setting. The ACEM is implementing a compulsory program of CME.

Continuing education programs should be developed and implemented in any organisation that treats trauma patients. This can include case reviews and audits of performance in clinical management. The development of local trauma committees can facilitate the involvement of the multidisciplinary trauma care team.

Rural Education

All staff providing trauma care management in rural areas need appropriate education and skills in initial resuscitation, stabilisation and continuing care prior to transfer to definitive care. The educational requirements of rural practitioners are similar to those of clinicians elsewhere in the system. However, there are some unique needs for clinicians in some areas, relating to infrequent exposure to trauma and emergency patients; geographical isolation from high level services and clinical advice in some areas; limited access to advanced training courses; and significant financial burdens in participating in advanced training courses.

The Taskforce recognises that rural GPs encounter additional financial difficulty in undertaking skills training through loss of income and locum cover charges, and recommends that strategies be developed to assist with skills training.

Training is vital to improve and maintain trauma management skills in rural areas, especially in light of some concerns about potential deskilling. These concerns result from triage and transfer of, albeit small, additional numbers of major trauma patients from each region to the MTS. Educational strategies might include:

• Mobile simulator/training aids.
• Telehealth/telemedicine.
• Combined team training to maximise the capacity to respond to time-critical patients, especially in isolated areas. Teams involve GPs, ambulance personnel and nurses. The nurse practitioner model currently under review may have significant impact and provide opportunities for isolated rural areas. The STC should develop an appropriate model of combined team training.

Participating Agencies

Collaboration between participating agencies is crucial to the development of a cohesive emergency and trauma education plan in rural areas that meets clinician needs and avoids duplication of programs. The formation of regional CCECCS in Victoria is an important step in the process of coordinating rural education programs, but these bodies need to continue to liaise with other key organisations.

Several groups currently address, organise or promote education programs for rural practitioners. These include the Divisions of General Practice, the Coordinating Unit for Rural Health Education in Victoria Inc (CURHEV), RWAV, RDAV and its Lives @ Risk subcommittee.
The Taskforce supports the recommendations of the Lives @ Risk subcommittee (1998) that:

• A GP Opt-in System should be established for rural GPs who wish to be on call for emergencies, and who will have identified themselves for this role and as having up-to-date specialist emergency/life support skills, such as EMST, APLS, ELS.
• Rural GPs should be trained in skills and guidelines for providing emergency support in individual and group response settings and with ambulance services.
• Rural GPs should be equipped to provide emergency services in their clinics or as first responders; to supplement the response kits of ambulance services; and for there to be emergency response kits with agreed minimum contents in identified locations.
• Opt-in GPs should have access to communication systems that will work in remote or 'dead' areas and GPs should be included in the ambulance guidelines for call.

Public Education and Injury Prevention

Safety First is a key achievement of Taking Injury Prevention Forward. This program, launched in 1995, aims to reduce the incidence, severity and cost to the community of road crashes. It has targeted priority areas identified by research data and adopted an innovative spectrum of prevention strategies ranging through integrated education, enforcement, promotion and engineering strategies, to produce progressive falls in Victoria's road toll which are the envy of other Australian States and most other nations (Health and Community Services, 1995).

The RACS provides an outstanding example of the leadership and advocacy role that professional bodies can achieve in injury prevention through its collaborative work in road trauma across the areas of education and public awareness, research and evaluation.

The Victorian State Trauma System and participating hospitals will have major opportunities to use their community standing and expertise to promote public awareness about general and targeted injury prevention strategies, either as part of statewide strategies or local community efforts (NHPA, 1998: NRTAC, 1993; ACS, 1993).