On January 1, 2017 the NREMT launched Phase 1 of the new Paramedic Psychomotor Competency Exam. The test now has six stations, five from the old exam (Patient Assessment -Trauma, Dynamic and Static Cardiology, and two oral scenarios are unchanged), and a new Integrated Out Of Hospital scenario station. For the IOOH scenario, candidates are dispatched to a simulated call with a paramedic partner and lead assessment and care of a simulated patient. The scenario is graded based on mandatory actions and critical failures for patient assessment and care, scene management, communication and professionalism. Here are 10 things candidates and paramedic educators need to know to succeed in the NREMT IOOH scenario station:
1. Prepare for the exam like you would prepare to work in the field.
Paramedic students and educators used to prepare for the NREMT Psychomotor exam by practicing skills and memorizing skill sheets. The Registry acknowledged that skill assessment alone does not assess how a candidate would perform in the context of caring for a patient and managing a scene [1]. The IOOH scenario does just that. Now paramedic students must have a portfolio that documents competency in isolated psychomotor skills and scenario performance throughout their program, and are assessed on their ability to lead a call on testing day.
2. Skills must actually be performed on the simulated patient.
Unlike oral stations where interventions may be verbalized, in the IOOH scenario candidates must actually perform or delegate any interventions that they feel are necessary on the simulated patient. Candidates are given a stocked first-in bag, including IV supplies, simulated medication vials and airway equipment, and a cardiac monitor/defibrillator. Their simulated patient may be a high fidelity mannequin or a human patient actor with task trainers, such as an IV trainer secured to an actor’s arm [1]. All assessment and interventions also take place in real time [1]. For example, an intravenous medication can only be administered after the candidate assesses the patient to determine if it is necessary, a saline bag has been spiked and the intravenous line is established and secured.
3. Verbalizing “BSI, scene safety” will not make or keep the scene safe.
The scenario will likely have a safety threat that must be recognized and managed, which may be present upon entry into the scene or develop later in the scenario. A safety threat may be as simple as moving a rug that is a tripping hazard or ensuring that a barking dog is secured. Candidates must also be vigilant about patient and crew safety, such as properly disposing of needles and ensuring team members are clear during electrical therapy.
4. Being nice is critical.
Interpersonal relations are a critical grading criteria and candidates must maintain professional behavior with the patient and crew members. Candidates should introduce themselves to the patient, explain what they are doing, ask if they are comfortable and consider the need to administer pain medication. The patient and the partner also assist the evaluator with grading [1].
5. Communicate clearly and use available resources.
Part of team leadership is task delegation, clear communication and ensuring that messages are received as intended. Candidates may confirm treatment decisions and delegate skills to their paramedic partner. Instructions to the partner for skills should be specific, such as stating what size drip set of intravenous line tubing and flow rate if asked to start an intravenous line. Medication cross-checks between partners is also encouraged.
6. The paramedic partner will challenge the candidate before an error is made.
If a candidate is about to make an error that would harm the patient, the paramedic partner will question the decision but not tell the candidate what to do. For example, the partner may say “confirming that you are going to defibrillate a patient with a pulse” while the candidate is charging the defibrillator, or ask “is there another treatment option?” The partner will do this twice before allowing the candidate to make the error. A near miss may result in a point deduction, but not necessarily be a critical failure [1]. The allowance of safety prompts reflect how a team should actually work together to maintain patient safety in the field.
7. Non-electronic references are allowed in the station.
Candidates may bring non-electronic reference tools into the station that they would normally carry in the field. These include medication dosing charts, AHA references and local protocols. However, candidates must maintain situational awareness while using the reference and it should not significantly slow down the scenario.
8. Expect a curveball.
During the scenario, there will be an “event,” such as a sudden change in the patient’s condition, a new safety threat or equipment failure. A change in patient conditions does not necessarily reflect the candidate’s performance. Like in real life, the simulated patient may get better or worse with or without appropriate treatment.
9. Patient movement and transport is verbalized.
All simulated patients in the scenario will be transported to a hospital, and the candidate must verbalize when and how the patient should be moved to the ambulance, such as using a stair chair versus walking [1]. The simulated ambulance may consist of chairs positioned around a stretcher, and the patient will move on their own when directed.
Once in the ambulance, the candidate must state when they want to initiate transport, the hospital destination — such as a trauma center versus community hospital, whether the transport should be with lights and sirens or non-emergent, and provide rationale for their decision. The partner then becomes the driver and is no longer available for patient care. Transport time will be the scene time subtracted from 20 minutes, and during that time the candidate should provide a succinct report to the hospital.
10. The scenario will be 20 minutes — no more, no less.
The IOOH scenario will end at 20 minutes, regardless of whether patient care is finished or if a critical error was made earlier in the scenario. If patient care is complete before the 20 minute mark, the remaining time may be used to reassess the patient and perform a detailed head-to-toe exam.
This is Phase 1 of implementation of the new NREMT Psychomotor Competency Exam. Later versions may include an assessment of team membership. There is no change planned at the EMR, EMT or AEMT levels for the psychomotor exam.
The NREMT Integrated Out Of Hospital scenario station may seem daunting, but it is really no different than what is expected of paramedics on their first day in the field. The new exam encourages paramedics and students to prepare that way.
More information about the new Paramedic Psychomotor Competency Exam is available from the NREMT.
Reference
National Registry of Emergency Medical Technicians. The NREMT Out of Hospital Scenario Update (2016 September 22). Retrieved from: https://www.nremt.org/rwd/public/document/paramedic-portfolio
