Clinical competencies of emergency medical services paramedics in responding to emergency conditions using Objective Structured Clinical Examination (OSCE) in Guilan

Introduction In today’s modern industrial societies, trauma is one of the most important issues in most countries. According to the World Health Organization (WHO), injuries caused by trauma are the main reasons for death in different countries and up to 2020, trauma will be the third cause of death and disability in different age groups (1). Emergencies are high-risk situations in which individuals’ physical or mental conditions are suddenly affected, requiring immediate and appropriate actions to be taken (2,3). To reduce the morbidity and mortality rate of trauma, an appropriate planning for the care and treatment of these patients is needed. Such a planning covers a wide range of treatments, from pre-hospital management to rehabilitation centers. At this stage, an initial diagnosis of the lesions, triage of the injured and early resuscitation occurs. The successful operation of the pre-hospital system will play a crucial role in patients’ outcome (1,3). The most critical and important part of the emergency medical services (EMS) is the competent paramedics (4-6). EMS staff perform extensive activities such as airway management, trauma assessment, advanced cardiopulmonary resuscitation, immobilizing patients, dressing, intravenous (IV) therapy, and other advanced Original Article Volume 7, Issue 2, 2021, p. 101-105

skills (7). Key skills in delivering pre-hospital care include rapid communication and immediate response, proper evaluation of injured people in different ways, effective treatment, and rapid transfer of the victims to the hospital center (8). According to Dyson et al, most of surveyed EMS staff did not have an appropriate level of pre-hospital competency (9). So, it is necessary to periodically evaluate the competencies of EMS personnel (10). The Objective Structured Clinical Examination (OSCE) is a useful method to assess both physical and knowledge-based skills. In this approach, assessment is conducted at a series of stations with one or two aspects of competence being tested at each station (11). In each station participants must address and resolve various simulated clinical situations that are representative of real clinical practice (12). Since its application in 1975 by Harden et al, OSCE is an effective method and many universities use it to evaluate their students' clinical performance (13). Due to the limited number of studies concerning the competencies of pre-hospital EMS staff, this study was designed to determine the clinical competencies of Guilan EMS staff in responding to emergency conditions using OSCE.

Methods
This descriptive cross-sectional study was undertaken on 70 EMS staff in the capital of Guilan (Rasht) who were selected by the convenience sampling method. Inclusion criteria included: having a minimum of undergraduate or bachelor degree in medical emergencies and willingness to participate in the study. Exclusion criteria were any psychological disorders in participants.
After obtaining informed consent from participants, in order to survey EMS staff competencies, we designed nine OSCE stations in the skill lab of the school of medicine. So, nine core skills including trauma and triage examination, airway management, carrying the injured victim, vehicle extrication, spinal cord immobilization, venipuncture, life-saving measures (controlling bleeding and shock), injured joint immobilization, and injured bone immobilization were evaluated. Each station time was 10 minutes. To check the performance of the subjects at each station, a performance checklist was designed based on a review of the literature. The validity of the questionnaire was measured by content validity and calculating content validity index (CVI) (0.7) and content validity ratio (CVR) (0.8). A test-retest method was used to assess the reliability of the questionnaire. The questionnaires were administered to 15 EMS staff and were completed twice in 10-day intervals. Then the correlation was calculated (0.89).
To collect data, the main researcher (AA) used the designed checklist at the stations to observe and record the performance of the participants. Each station's score was determined based on the number of items considered for the checklist in each category. In each of the checklists, the score was divided into weak, medium and good levels by dividing the total score of each station by 30-40, 41-80 and 81-122 and they were considered as weak, medium and good scores, respectively. To evaluate the test performance of each station, an evaluator was selected before the test was performed and full details were given on how to complete the checklist. After collecting data, based on the questionnaires, information was entered into SPSS software version 22. Descriptive statistics (standard deviation and mean) and inferential statistical tests (chisquare tests) were used for data analysis.

Results
The findings of this study showed that the mean age of paramedics was 32±1.1 and the mean of their work experience was 7.2±1.3. Other demographic information is depicted in Table 1.
The findings on participants' average performance scores on triage skills, airway management, life-saving measures, and some basic clinical skills are summarized in Table 2. According to this table, EMS staff in two skills of spinal cord immobilization and vehicle extrication received low mean scores and had major skills problem.
Furthermore, based on chi-square test, a significant relationship was observed between the performance scores of EMS staff at different stations and their educational level (P = 0.02) and work experience (P = 0.03) ( Table 3).
According to Table 4, 56.3% of participants had weak clinical competency and 31.3% had medium clinical competency and none of them had good clinical competency.

Discussion
This study explored the level of competency of paramedics working in EMS bases in the capital of Guilan to perform nine basic core skills. The findings of the current study indicated that the competencies of paramedics were at low to moderate levels and generally the lowest scores were related to spinal column immobilization and vehicle extrication. According to the study conducted by Shakeri et al, it was found that paramedics were poorly trained in two skills namely, immobilization of spinal column and use of traction splint (14). This finding is not consistent with our research and special training should be provided to EMS in this regard and its importance should be emphasized. Based on the study by Aliakbari et al, it was found that the competencies of nurses in performing these skills were at low to moderate levels and special attention should be paid to this area (15).  (14). According to their findings, there was a significant but inverse correlation between the clinical skills of EMS staff and their age, which is consistent with our results. This can be assumed that as EMS staff become older, their mastery over clinical skills is reduced. One reason for this may be the presence of more experienced and older EMS staff on the outskirts of the city with few missions since the mastery over skills is reduced in the course of time if they are not practiced. Emergency missions are not separated by the age and the background experience of the EMS staff, and paramedics must be able to perform the skills appropriately and wherever and whenever they are. Therefore, it is necessary to pay special attention to further training of this group of employees. Our findings, as well as those of Shakeri et al (14), show that higher education is not a reason for having better clinical skills in the pre-hospital setting, as EMS staff have better mastery over clinical skills than physicians and nurses. This may be due to the education they receive during their studies. High school graduates had the lowest scores for clinical skills among other EMS staff (17). In this regard, Garza et al, who compared the performance of basic-level emergency medical technicians with advanced medical emergency technicians on the ability of decision making on protocols of spinal column immobilization in patients, showed that this skill was similar in both groups. They also found that by providing the necessary training, some skills can be taught to  (20).

Limitations of the study
This study had its own limitations. We evaluated core clinical skills in different OSCE stations which is not a real situation. Therefore, we suggest exploring mastery over clinical skills in real and non-emergency circumstances.

Conclusion
Paramedics are the first people who arrive at the accident scene and save lives. Based on the obtained results, there is a need for skill training concerning pre-hospital emergency services as paramedics have intermediate proficiency in some of the skills and some of them have poor performance. So, improving the curriculum of emergency medical students is needed.

Ethical Issues
The EMS staff participating in this study gave their informed consent. The personal data of participants has remained confidential and the results of the study have been reported without divulging the data.