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Abstract
Introduction To develop and run a primary healthcare (PHC) refresher package to address the range of clinical presentations to Combat Medical Technicians (CMTs) on deployment and improve their confidence and capability in providing PHC for Op Herrick 18, with particular regard to the first month of deployment.
Methods A regimental level, two-and-a-half day refresher package was developed following analysis of PHC conditions most likely to be seen on Op HERRICK 18. It consisted of lectures and skill stations with written and case-based assessment phases to demonstrate effective and safe use of CMT clinical protocols on simulated patients. Internal feedback assessed the CMT's subjective understanding of each individual section. A qualitative questionnaire was used to retrospectively evaluate the package after 1 month of deployment.
Results Immediate feedback showed that the refresher training was well received. Following the first month of deployment, CMTs who had attended the PHC refresher package felt more confident in managing PHC patients and felt they had received training for the majority of PHC conditions witnessed during their deployment in comparison with CMTs who had not.
Discussion By delivering a training package acceptable to the majority of medics, we have increased the confidence and capability of CMTs in delivering PHC within the context of their protocols and prepared them for their first month of deployment. It suggests that PHC delivery can be improved by such a package and consideration should be given to formalising this into a military training qualification.
- Primary Care
- Medical Education & Training
- Education & Training (see Medical Education & Training)
- Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT
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- Primary Care
- Medical Education & Training
- Education & Training (see Medical Education & Training)
- Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT
Key messages
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The confidence and capability of CMTs in delivering operational PHC can be improved by a short, intensive package of pre-deployment training.
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Assessment of CMT delivered PHC can be achieved pre-deployment against a policy derived standard (CMT protocols).
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A short intensive package of training is acceptable to CMTs, with practical elements the most valuable.
Introduction
The bulk of clinical interaction during recent operations, notably the UK mission in Afghanistan, known as Op HERRICK, has been the delivery of Role 1 primary healthcare (PHC),1 ,2 a proportion of which has been delivered solely by Combat Medical Technicians (CMTs) with remote supervision.1 The inexperience of CMTs in providing PHC in the firm base coupled with the unbalanced employment model of clinical versus regimental duties for CMTs is a risk that the Army has historically accepted.3 CMTs report the highest degrees of discomfort in managing PHC conditions in the first month of their deployment.1 The recent review of Role 1 capability felt that ‘a solution that supports CMT continuing clinical experience as central to Role 1 operational success is essential within the emerging structure and contractual framework of the joint Defence Primary Healthcare Service’.3
An estimate process by the Role 1 Med Group identified two issues which required addressing prior to deployment on Op HERRICK 18: the scope of presenting PHC complaints CMTs would see in theatre and the evidence that ‘many (CMTs) required supervision to examine patients and utilise protocols’1 and took approximately 1 month to be confident in following them.
In order to address these issues, the presenting complaints seen in theatre were reviewed with a view to developing and running a PHC refresher package to provide CMTs with standardised training prior to deployment. This was to ensure CMTs were confident and capable in providing PHC on Op HERRICK 18, with particular regard to the first month of deployment.
Methods
A training needs analysis was conducted in May 2012 to identify the PHC conditions seen in theatre in order to match training to operational output. The limited published evidence for Op HERRICK PHC was supplemented with the broad categories of EPINATO data from Op HERRICK 14 and expert evidence from a recently deployed Camp Bastion Senior Medical Officer. A risk assessment was then conducted to inform the training needs analysis, thus targeting PHC presentations in terms of frequency and greatest clinical or operational significance (Figure 1).
An extract from the analysis of primary healthcare complaints which a Combat Medical Technician might be presented with showing frequency and operational impact. The full matrix is available online, see the online supplementary file.
The primary purpose of the package was to refresh deploying CMTs as to their scope of practice and provide them with the tools to deliver safe and operationally effective PHC. The package identified, trained and tested the practical skills implied in the CMT protocols.
An assessment of the validity and evidence base for the current CMT PHC protocols as a tool for delivery of non-triaged PHC is beyond the scope of this paper. Where the protocols did not cover the assessed range of conditions that a CMT would see during operations, the Military Acute Care Manual or Clinical Guidelines for Operations were used.
The refresher package was constructed by junior medical officers using the Battlefield Advanced Trauma Life Support (BATLS) model which the authors considered to have credibility among CMTs and wider force elements (Figure 2). The main reason for using the BATLS model was the ability to rapidly integrate existing policy and guidance into a cohesive package. The package was run over two-and-a-half days with lectures derived from the available protocols. Simple, practical and effective sign recognition as described in the protocols was addressed at a skill station. A written and practical case-based assessment phase was used to demonstrate effective and safe use of the protocols on simulated patients, identification of ‘red flags’ as well as presentation of the case to a more senior clinician. Simulated patients were necessarily drawn from the Regiment and thorough briefing and consistent scripts used to maximise credibility. The content was a reiteration of current scope of practice with the assessment used to guide further training into pre-deployment training and was not pass/fail or graded. Four packages were run as part of mission-specific training (MST) for CMTs across the whole deploying force both regular and reserve.
The timetable for the two-and-a-half day training package.
Validation of the training occurred immediately after completion using an internal feedback process reviewing the CMTs’ subjective understanding of each individual section and their views on the delivery of training, time allocated, the assessment and administration. In order to assess the operational effectiveness of the training an in-theatre service evaluation attempted to question all CMTs 1 month into their deployment by someone not directly connected with the training package so as to minimise potential bias.
Results
Validation forms were collected from all the CMTs who undertook the refresher training over four packages throughout MST with a total of 96 completed (Table 1). Overall, 82% of CMTs attending the refresher training thought it to be good or excellent in the above domains with an increase throughout MST from 77% in the initial cohort; the majority (70%) thought the length of the training to be just right and 30% felt it too short; no one thought it too long.
Training validation results. Each domain was graded poor (1 point), adequate (2 points), good (3 points) or excellent (4 points). Non-applicability scored 0
The in-theatre service evaluation was conducted by 72 medics at the end of their first month of deployment and 65 (90%) had seen PHC patients (Table 2). Overall, 38 CMTs had attended the PHC course and 35 had not.
Impact of primary healthcare (PHC) package on Combat Medical Technicians confidence in managing PHC
Of the 38 CMTs who had attended the package, 82% agreed or strongly agreed that ‘The 2½ day PHC refresher package increased my confidence in and the practical use of the CMT protocols’ with 18% being neutral, disagreeing or strongly disagreeing and 76% of CMTs agreed or strongly agreed that ‘I feel the 2½ day PHC refresher package has reasonably prepared me for the PHC patients that I have seen in my initial month in theatre’ in comparison with 24% being neutral, disagreeing or strongly disagreeing.
Discussion
Operational PHC must deliver as safe a service as possible within the limitations of the deployment. The consistency of service provided by a protocol-based system at CMT level allows assurance of the care provided against demonstrable standards. This package has reinforced the CMT scope of practice and use of protocols with 82% of CMTs having confidence in using the protocols, both their practical application and the applicability of the protocol content. The statement of Hawksley et al that ‘many (CMTs) required supervision to examine patients and utilise protocols’1 infers that the quality of care that would have been delivered by a lone CMT in the first month would have been reduced by their examination skills and working outside of their PHC scope of practice. The training was designed to mitigate this subjective short fall.
The package, as structured and delivered, was acceptable to 82% of medics and relevant to operations. If this concept was to be further developed, confirmation of the best structure from a formal educational perspective should be sought. It was identified through feedback that a largely practical package was better received by the target audience. It was recognised during the process that a minority of medics, despite education and a mandatory scope of practice, do not agree with the principle of protocol-based care and find it at odds with their perceived clinical abilities.
The majority of medics (90%) had had some exposure to PHC within their first month of deployment. Previous tours have reported high degrees of CMT discomfort in managing PHC conditions during this period.1 ,3 This was considered to be due to their lack of exposure to PHC in firm base.3 The in-theatre service evaluation provided the opportunity to compare the medics who attended the PHC package with those who did not. CMTs who had attended were demonstrably more confident in managing PHC patients. They also felt they had received training for the majority of PHC conditions they had witnessed in their first 4 weeks in theatre. It is accepted that the questionnaire undertaken after the first month of deployment is only a surrogate marker for quality. Formalised assessment of CMT quality of care, against standardised criteria and standards, is underway on Op HERRICK 18, but it would be speculative to formally ascribe any positive results directly to this training.
The training package described has successfully addressed the two issues highlighted prior to deployment to improve the quality of care as a direct consequence of the estimate process. It was not a formalised educational study nor does this paper seek to validate the package delivered as a future template.
If such a course were formally developed, the assessment could become a military training qualification. It might also form a foundation for giving CMTs a training package the NHS could recognise in order to facilitate NHS placements. Akin to BATLS, it would move us away from the idea that CMT-delivered PHC cannot be assessed or validated. The test is how well they deliver care against whatever protocol-based system they are required to use in delivering PHC. CMT PHC training must be resourced and consistently delivered from Phase 2 training through CMT 2 and CMT 1 at regimental duty. A week-long, faculty led, validated Role 1 CMT course consisting of BATLS and PHC (2.5 days each) could have significant utility in founding subsequent training both for any MST and contingency.
Conclusions
The vast amount of patient–clinician interaction in theatre is PHC, with significant proportion delivered by the CMT. A concise two-and-a-half day package has increased CMTs’ confidence in working within their scope of practice. It has given them exposure to conditions they are likely to see on operations and given them the confidence to deal with these conditions from the start of their deployment. Consideration should be given to the formal development of PHC course against a defined, evidence-based and comprehensive scope of practice for CMTs as we return to contingency.
Acknowledgments
The authors thank Col RG Simpson for commenting on the assessment of operational PHC to be covered in the refresher training and the GDMOs of 5 Medical Regt who contributed both written lessons and practical delivery to the refresher training package.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online appendix
Footnotes
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Contributors RJW developed the conceptual framework and conducted the estimate. ITP developed the package content and delivered the training. MPR was the primary organiser of the training package, revising and developing content as well as delivering lessons.
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Competing interests None.
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Ethics approval Service evaluation cleared by the Medical Director; no other permissions required.
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Provenance and peer review Not commissioned; externally peer reviewed.