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Distance Learning Studies
Using Remote Instruction to Improve EMS Knowledge and Skills
Pullum, J.D., Rushton, D.B.

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The Pediatric Emergency distance learning pilot test included self-study materials contained on an Internet World Wide Web site, in published textbooks, and on interactive CD-ROM programs. The training was conducted by an instructor in Salt Lake City, UT, who communicated with 9 prehospital providers using E-mail and desktop video conferencing. The instructor reviewed and critiqued videotapes of the ambulance crew membersí performance skills. The pilot program shows promise for making high quality training, including performance skills training, available to all prehospital providers, regardless of their location.

The intimate partner violence training package includes a self-study, interactive CD-ROM, print training manual and web site. The materials combine text, graphics and video to introduce emergency medical services providers to the topic of intimate partner violence and to provide examples and suggestions both for keeping themselves safe in these volatile situations and for extending a helping hand to the victims.

Alternative Training Methods: A Retrospective Analysis
Pullum, J.D., Sanddal, N.D., and Obbink, K.O. (1999) Training for rural prehospital providers: A retrospective analysis from Montana. Prehospital Emergency Care 3:231-238

This paper provides a retrospective analysis of training methods used by rural Montanaís prehospital providers. Drawn from both published and unpublished sources and spanning the past 25 years, it examines the origins of training in this vast rural state and aims to shed light on successful, nontraditional training delivery methods currently being used. Because volunteer personnel traditionally provide prehospital emergency care in rural areas, development and implementation of effective training programs are generally considered important to helping these practitioners maintain the knowledge and skills they use in their lifesaving methods. Examining five different training methods, the paper suggests that remote training methods that train the providers directly are effective and popular. It also suggests that the application of electronic media and other distance learning techniques have demonstrated a positive impact on the frequency, quality, and standardization of training for volunteer prehospital EMTs.

Effectiveness of CD ROM Training
Sanddal, N.D., Sanddal, T.L., Werner, S.M., Dawson, D.E. (1999) A comparison of self-study/remote televideo and traditional PALS instruction. Bozeman, MT: Critical Illness and Trauma Foundation.

Objective: To compare the effectiveness of a guided self-study and remote evaluation PALS course with traditional PALS instruction. Differences were measured by pre, post and 3 month follow-up  written exams and performance video tapes.  

Methods: Two locations were selected to participate in the experimental group and two in the control group. A medium size (15-25,000) and a small (< 2500) community was paired in each of the two groups. The experimental group received self-instructional materials including video tapes, workbooks and textbooks. Participants in those groups had to reach criteria on the written examination prior to being included in the remote teaching and evaluation session. That session was conducted using two way interactive video teleconferencing. The instructor/evaluator was in one location and the students in another. An assistant helped secure equipment and conduct administrative tasks at the student site. At the two control sites the PALS course was taught using standard methods by two outside faculty members. Measures included a written exam administered prior to the course, an end-of-course and a 3 month follow-up exam. Additionally, performances in the evaluation stations were videotaped for later evaluation by an independent panel. A true Likert scale was developed by the review panel by reviewing performance tapes from individuals who had not participated in the entire course.  

Results: Both experimental groups and one control groupís knowledge improved when measured independently between the pre and the end-of-course written examinations. (Experimental group one (EG1) t 3.518, df 5, p = .017, CI 3.28 - 21.06; experimental group two (EG2) t 12.484, df 3, p = .001 CI 23.10 - 38.90; control group two (CG2) t = 4.938, df 7, p = .002, CI 12.38 - 35.12). The remaining group (CG1) combined scored lower on the end-of-course examination than on the pre test by an mean of 6%. The combined experimental group (EG1 + EG 2) and combined control group (CG1 + CG2) performed similarly on the written pre test (EG 75.6%, CG 70.5%), indicating similarities in prior knowledge. However, the experimental group performed better on the written end-of-course exam (experimental 95.3%, control 84.25%; t 3.631, df 20, p = .002 CI 4.7 - 17.4). Three month follow-up scores were calculated for both experimental groups and one of the control groups. The comparative results between the end-of-course and three month retention follow-up showed a non-significant degradation in scores of 5.5% for the experimental group and 4.5% for the control group.

An independent panel of PALS instructors from another state was convened to review the performance tapes. The panel began to review the performance tapes. However, this activity had to be abandoned since the format of the tapes acquired at the experimental sessions was substantially different from that acquired in the control sessions. Additionally, it was obvious that there was significant coaching that occurred during many of the performances. These two issues made the independent, unbiased,  review and scoring of individual performances impossible.

Conclusion: Remote, self-study and guided evaluation of PALS appears feasible. Students who prepared using these self-study methods performed better in end-of-course measures than did those trained in more traditional courses. Knowledge degradation at three-months post training was similar between the two groups. Unfortunately, the effects of the strategy on performance indicators could not be ascertained in this study due to limitations in the implementation methods and errors in video taping of the performances. Additional trails using more structured and closely controlled methods are warranted.

Effectiveness of Self-Study and Remote Skills Training 
Sanddal, N.D., Sanddal, T.L., Pullum, J.D., Altenhofen, K. B., Werner, S. M., Mayberry, J., Rushton, D.B., Dawson, D.E. (200
1) A randomized, prospective, multi-site comparison of out-of-hospital pediatric training methods. Pediatric Emergency Care (Submitted for publication).

The U.S. Department of Health and Human Services and Emergency Medical Services-Children channeled through the Montana Emergency Medical Services-Children (EMSC) program to contract with CIT to evaluate two very distinct prehospital provider training methods. It was a unique research opportunity for CIT in that Montana was focusing its efforts on electronic training of prehospital providers while Wyoming was using more traditional train-the-trainer methods. After being evaluated by a panel to determine whether there is a measurable difference in performance in one or both of the test sites, as compared with each other and with a control site, the study has been submitted for publication to the Journal of Emergency Care.

Study Hypothesis: Two training methods and a control group were compared. The null hypothesis was that no differences between the methods would be found when measured by pre and post test results.

Methods: The model was a prospective randomized trial involving 12 sites and 4 demographic stratifications. Three states were selected to participate. State EMS agencies provided lists of ambulance services stratified by demographic characteristics. Sites were randomly selected.

Pre-intervention measurements were conducted by a team traveling to each of the 12 sites and included a written measurement and 2 performance scenarios that were videotaped for later evaluation by an independent panel. Training was made available through either CD ROM or train-the-trainer methods. The control group received no training. A follow-up evaluation was conducted at 12 months. Mean changes in written, performance and combined scores were analyzed.

Results and Conclusion: A difference was noted in both the combined scores and the performance evaluation scores between the self-study CD ROM intervention group and the other two groups. No differences were noted in written measurements. Attrition resulted in a small post intervention sample size (N = 77) that precluded analysis by multiple stratifications and may have produced Type II errors and/or selection bias. CD ROM training may improve out-of-hospital care providersí performance. The research model, with modification to protect against the high rate of attrition, shows promise. With refinement, replication of this research approach appears warranted and provides a working model for multi-site EMS education research.


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