Why EMS Needs Simulation Standards

A lot has changed since EMS began using healthcare simulation more than 45 years ago. Modalities such as manikins and role-play by faculty have evolved into an evidence-based practice where patient and provider safety has become of leading importance. Over the past 20 years, research has brought greater depth and breadth of understanding to the science of simulation by establishing best practice standards.¹ Preparing participants and attesting to competency for working or volunteering in the most uncontrolled, unpredictable patient care environments takes precision. Just as EMS has matured, so has the healthcare simulation profession. 

Simulation Best Practices

The International Nursing Association for Clinical Simulation and Learning (INACSL) has published best practice simulation standards. These standards address core topics such as design, operations, debriefing, interprofessional education, and facilitation. The standards are regarded as the foundation for sound simulation experiences and have been adopted across health professions. 

Despite the name including nursing, they are not intended to be nursing-centric. When simulation is based on science, it is agnostic to a specific profession. Simulation has long been utilized in other industries to improve accuracy and safety; the aviation, military, nuclear medicine, and shipping industries have all successfully enhanced safety and reduced error using simulation. Delivery of evidence-based simulation activities promotes identification of error-producing practices. Promoting a safe learning environment where error identification is welcomed improves patient safety in a live care environment. This improvement in quality yields safer practices that positively impact patients and providers. 

The Society for Simulation in Healthcare (SSH) is an international organization whose purpose is to serve a global community of simulation practice that enhances the quality of healthcare. It annually offers a comprehensive healthcare simulation conference where global leaders and vendors meet to share and discover strategies for improved simulation design, delivery, and debriefing.

Although SSH membership ultimately brings access to many simulation resources, nonmembers can also access work groups and other assets. One highly functioning group is the EMS affinity group, which has more than 2,500 global members. This group shares simulation information via discussion board posts and has a developed resource library. This virtual community is waiting to help solve EMS simulation dilemmas. SSH membership has expanded access to a peer-reviewed journal, more expansive working groups, volunteer opportunities, and collaborating mechanisms to expand simulation knowledge and personal practices. 

SSH has free access documents focused on enhancing the standardization of simulation methods. The simulation dictionary is in its second version and translated into many languages. Standardizing the language of the profession is a fundamental goal required for effective outcomes from simulation activities.² SSH’s ethical standards for simulation have been translated into 15 different languages.³ This guide outlines aspirational core values necessary for safe, ethical practices in simulation. Both documents are excellent resources required for providing optimal activities. 

EMS Simulation

EMS utilizes simulation in all levels of initial education programs. It serves as a core principle for building the required paramedic portfolio of clinical practice for CoAEMSP (Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions) accreditation and NREMT licensing access. Paramedicine is one of few health professions that utilizes simulation as part of its initial licensing process. The paramedic licensing exam includes an integrated out-of-hospital simulation scenario where a candidate is required to effectively manage a simulated patient for 20 minutes. 

After initial licensing recurring competency assessments are often conducted through simulation activities. These assessments are meant to capture continued competence of providers. Despite this high integration and use of simulation, few EMS educators have obtained a certification in healthcare simulation or accredited their EMS education program’s simulation activities. Drawing a quality standard on EMS simulation activities is vital since simulation-based assessments are utilized for determining provider competence and workforce readiness. Shortcutting this level of quality can negatively impact providers and ultimately patient safety. 

Certification, Accreditation

Certification is a credential achieved by an individual that attests to their competence in a specific subject. SSH has certifications for both simulation operation specialists (CHSOS), personnel who implement simulations, and simulation healthcare educators (CHSE), personnel who design, deliver, and debrief activities. 

One way to improve the standardization and quality of EMS simulation is to promote the adoption of these certifications. The importance of certification is that it sets a common, psychometrically verified standard. Both certifications have competency and advanced levels. The minimum requirement for the competency level is two years of simulation experience and a bachelor’s degree. For simulationists who have many years of experience but lack an academic degree, a mechanism exists for a review of experience and completed education for equivalency of the academic requirement. The examination blueprints are available on the SSH website and serve as a great starting point for educators and operators to review topics included on the exam as well as identify a professional development pathway in simulation. 

Accreditation is an important process of self-review, discovery, and improvement. SSH offers accreditation of simulation programs. As an outside entity, reviewers evaluate submitted evidence from the program that demonstrates how the program meets comprehensive standards. At a minimum accredited programs meet core administrative and operational standards; based on program activities, programs add additional areas for accreditation consideration. These areas are teaching/education, assessment, research, and systems integration. 

Achieving accreditation is important for maturing the simulation profession and supporting the overall quality of simulation design and delivery. The accreditation standards and interpretive companion documents are available on the SSH website. These documents serve as a starting point for program self-evaluation, formalization, and preparation for accreditation. 

Formalizing Sim Practice

The days of having a manikin on a table, using a scenario based on a call from the shift before, and having participants talk their way through the sim all need to end. The science of safe simulation practice must be deliberately integrated into EMS education design and delivery. This practice is nonjudgmental and fosters acceptance, promotes safety principles, allows participants to discover error, and is crisp and purposeful in its execution, driven by sound objectives. It exudes the skills we want our students to embrace to function effectively in an uncontrolled patient care environment. This deliberate practice is driven by quality, not quantity; built from an environment free from ridicule; and safe to support learning, even from errors. Designed activities are based on student readiness and level of function, require established objectives, are trialed before being delivered, utilize assessment rubrics, promote participant self-reflection, and are debriefed by experienced facilitators. While this list may appear lofty, it consists of items that are at the core of high-quality simulation practice that should be the hallmark of all simulation activities. These items are essential to evolving simulation practices so they can have the most impact on safety. 

As EMS matures, so should our simulation practices. Our patients and profession depend on the outcomes of our simulation activities to determine who enters healthcare as a licensed professional and who can stay an active clinician. We owe it to each other to embrace higher simulation standards. Adopting the SSH dictionary and ethical standards is an easy first step. Developing standards for simulation certification and program accreditation ensures the quality meets minimum standards. It is imperative we set up our clinicians for success so that when the EMS call for help is answered, our patients receive high-quality care. 

Defining standards defines excellence. Excellence is something EMS strives for daily, and raising the bar for our expectations of simulation will help us achieve it.  

References 

1. International Nursing Association for Clinical Simulation and Learning. INACSL Standards of Best Practice: Simulation, www.inacsl.org/inacsl-standards-of-best-practice-simulation/.

2. Lopreiato JO. Healthcare Simulation Dictionary. Rockville, MD: Agency for Healthcare Research and Quality, 2016.

3. Society for Simulation in Healthcare. Healthcare Simulationist Code of Ethics, www.ssih.org/SSH-Resources/Code-of-Ethics. 

Jennifer McCarthy, MAS, NRP, CHSE-A, serves as the director of simulation and clinical associate professor for the School of Health and Medical Sciences at Seton Hall University, where she designs and delivers simulation activities for six graduate healthcare programs. She is also the president and founding member of 579 Solutions, LLC, a consulting company dedicated to enhancing innovation and positive change for patient care-focused organizations. McCarthy holds several positions with the Society for Simulation in Healthcare.