Slide 1

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 2

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 3

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 4

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 5

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 6

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 7

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 8

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 9

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 10

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 11

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 12

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 13

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 14

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 15

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 16

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 17

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 18

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 19

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 20

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 21

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 22

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 23

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 24

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 25

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 26

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 27

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 28

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 29

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 30

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 31

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 32

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 33

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 34

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 35

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 36

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 37

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 38

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 39

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 40

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 41

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 42

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 43

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 44

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 45

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 46

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 47

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 48

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 49

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 50

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 51

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 52

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 53

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 54

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 55

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 56

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 57

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 58

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 59

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 60

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 61

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 62

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 63

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 64

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 65

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 66

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 67

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 68

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…


Slide 69

Welcome to the S-SV EMS Agency
Altered Standard of Care
Administrative Module 3
This is the third of three modules of the Altered Standard of Care
Training. This section focuses on:
• Altered Field Response Protocols
• Family/Patient Brochure
• Just-In-Time Training (JITT)
This module will take approximately 1 hour to complete. At the
end of this module there will be a 10 question quiz. You must
complete the quiz with an 80% success rate to pass. The
questions will be based on the information learned during the
training module.
NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the
current 911 system may be altered during a
major disaster or pandemic outbreak. The
scenario and changes shown in this module are
hypothetical only and should not be taken as
actual changes to the system. System changes
may follow the model that is shown in this
training, but could vary based on the severity
and type of incident.

The purpose of the Altered Standard of Care
Training is to provide information regarding the
alteration of the EMS system in response to an
increased demand for medical-aid services,
beyond the capacity of the current system
providers.

After completing this training, you should
be able to:
• Describe the purpose and process for
establishing QRV’s.
• List several changes that might be made to
the paramedic scope of practice.
• Identify elements to include in a
Family/Patient Brochure.
• List several important elements of Just-InTime Training.

A pandemic outbreak has affected a large portion of
the population. It is a severe variation of the annual
flu virus. The EMS system has increasingly become
overwhelmed, and there is no estimated time when
this impact will end.

We simply do not have the resources and
personnel to handle the demand for more
ambulances.

Ahead we will discover what changes can be made
to the system to handle this type of overload

Now that we have modified the medical dispatch
system by altering dispatch protocols, developing a
Scheduled Transport Center, and establishing a
Public Access Number, we will now look at
alterations to the EMS Field Response protocols.

The MHOAC and EMS Agency Medical
Director must collaborate with the OA EOC to
develop a plan that will allow the EMS
system to expand and meet the needs of the
EMS system when the demand for response
exceeds the ability of the current system.

www.disasterdoug.com

One solution may be to convert all ALS ambulances
to BLS transport units, allowing us to place
paramedics on Quick Response Vehicles (QRVs)
This implementation will quickly expand available
EMS resources.

With this change, we may see paramedics
responding to 911 calls in a supervisor vehicle, fire
engine, fire battalion chief vehicle, public works
vehicle, or any other vehicle modified to be used for
911 response.
www.disasterdoug.com

Establishing QRVs will allow the paramedic to:

•
•
•
•

Rapidly respond to 911 medical calls
Provide ALS intervention as needed
Transfer care to a BLS transport unit
Clear the scene quickly to be able to respond
to the next call

www.disasterdoug.com

Vehicles Secured for use as
must be modified and equipped with
ALS equipment/supplies,
communications, etc.

In cooperation with fire, ambulance, and OES;
establishing strategic EMS staging areas
throughout the county, will allow us to share
resources, including:
• personnel,
• equipment, and
• supplies.
Consolidating our resources will reduce
duplication, and ensure that only the necessary
resources are deployed to each call.

Paramedics have been taken off of the
ambulance and placed in a QRV in order to
respond to more calls without having to
transport the patients to the hospital.
Which of the following would be considered a
QRV?

www.disasterdoug.com

If you answered,
are

, you

CORRECT
Paramedics may be placed in an alternate vehicle for
response to 9-1-1 calls known as a Quick Response
Vehicle or QRV.

Now we have staffed and equipped vehicles
that may be used by paramedics as QRVs
and our ambulance fleet has been
converted to all BLS transport.

Now let’s look at an altered triage process that ranks
patients based upon the severity of need. This triage
system will use the following categories:
requires immediate medical intervention
needs medical attention, however, the
response can be somewhat delayed.
May be assisted with self-care or system
resources other than 911 medical resources.

Needs non-medical community services.
www.disasterdoug.com

IMMEDIATE

Treat and
Transport

DELAYED
Treat and
Release or
Refer

MINOR

DECEASED

Refer to
Public
Access
Number

Witnessed= Use
First Round ACLS
protocols
Unwitnessed =
refer to public
access number

IMMEDIATE
Patients presenting with life
threatening conditions such as Acute
MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will
require treatment and transportation.

www.disasterdoug.com

DELAYED
Patients who respond to treatment on scene and
afterward present with normal mental status,

normal vital signs, and blood sugar will be given
a patient brochure then released or referred.
Options for referring patients may include:
•The Public Access Number
•Doctors office
•Self-care

www.disasterdoug.com

MINOR
Upon arrival, if the patient does not present with
life-threatening conditions and does not require any
EMS medical intervention, the patient would be
given a Patient/Family Brochure and released on
scene.

www.disasterdoug.com

DECEASED
• Only if the patient had a witnessed cardiac arrest
would the field responders intervene. The patient
would be given first round ACLS care and if there is
no response the patient would be determined dead
in the field. Family would be given a patient
brochure prior to clearing the scene.

www.disasterdoug.com

To relieve the impact on the emergency rooms,
the MHOAC and the EMS Agency Medical
Director might expand the paramedic protocols to
include a Disaster Flu Cache.
This cache should include indications and
contraindications, along with the revised
protocols for items such as: powdered Gatorade,
Compazine suppositories, ibuprofen, etc.

www.disasterdoug.com

Using the Altered Standard Field Triage,
who would be considered IMMEDIATE?
A. A patient with nausea and vomiting with no other
symptoms.
B. A patient with signs and symptoms of an MI.
C. A patient bleeding from an abrasion on his knee.

If you answered, B. A patient with signs and
symptoms of an MI, you are..

CORRECT
Patients presenting with life threatening conditions
such as Acute MI, uncontrolled hemorrhage, severe
shortness of breath, ALOC, etc., will require
treatment and transportation.

In addition to implementing the Altered
Standard of Care plan, the MHOAC and the
EMS Agency Medical Director, in collaboration
with the OA EOC , must develop a
Patient/Family Brochure. that may be
distributed by EMS field personnel to patients
and family members.

www.disasterdoug.com

This brochure is designed to be distributed by
EMS field personnel to patients and family
members, including:
• Family members of patients transported to the
hospital
• Patients treated and released on scene
• Family of deceased patients
• Patients with non-medical emergencies

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• information about the current
situation, explaining the
significant impact of the
incident on the population

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• health threats, including
current and projected effects

www.disasterdoug.com

The Patient/ Family Brochure
should contain:
• impact on the hospitals,
describing limited resources
and alternatives

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
• EMS system changes, including
changes in 911 protocols, as well as,
what to expect when EMS responders
arrive.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding the local
Public Access Number for
individuals with non-medical
emergencies

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding Web-based
health information such as the
CDC website, local Public Health
website, or other private sites
such as WebMD, etc.

www.disasterdoug.com

The Patient/ Family Brochure should
contain:
-Information regarding self-care
such as at-home treatment for
fever, flu symptoms, minor firstaid, etc.

www.disasterdoug.com

The Family/Patient Brochure will be provided to:
A. Family members of patients being
transported to the hospital.
B. Patients treated and released on scene.
C. Family of deceased patients
D. All of the above.

If you answered, D. All of the above, you are…

CORRECT
The Patient/Family Brochure is designed to
be distributed by EMS personnel to any
patient or family member during a significant
event.

In the event that a major disaster takes place and
overwhelms the system, field responders and
dispatchers must be provided with “Just-In-Time
Training” on the Altered Standards of Care. This
training should include didactic as well as practical
application of the revised protocols.
In this section we will discuss important principles
of Just-In-Time Training (JITT).

After establishing Altered Standard Orders,
responders must be provided with training including:
• Rolls and responsibilities of EMS system
providers,
• Changes made to system protocols, and
• Changes made to overall system design

www.disasterdoug.com

Just-In-Time training would normally be
conducted by supervisors or management
at each provider agency.

www.disasterdoug.com

Following any Just-In-Time Training,
personnel should be provided an
opportunity to:
• Practice any new skills
• Become familiar with any new equipment
or tools
• Review new or revised protocols
www.disasterdoug.com

Just-In-Time Training is a process that allows
responders or dispatchers to have just the right
information or skills at just the right time using just
the right presentation.

Just the right
information

Just the right time

Just the right
presentation

Just-In-Time Training incorporates only the
pertinent information that is needed to take care
of the situation at hand. Information not
pertaining to this situation could overwhelm the
responder or dispatcher causing them to make
mistakes or overlook important steps.

Research confirms that understanding (i.e.,
knowing)—especially in times of stress—depends
on effective neural pathways that connect action
(i.e., doing) and emotion (i.e., feeling). Next are
examples of each:

Although responders need to know about their
assigned tasks, they also need information
beyond their role and specific duties.
For example, a responder may want a better
understanding of how the overall response
organization operates, and who is involved in
each part of the operation.

Responders must understand how to perform
their assigned task(s). Examples of how JITT
encourages hands on learning include:
• Incident-specific scenarios
• Practicing administering vaccines/meds
• Practicing filling out forms and other
documentation
• Practicing interviewing techniques with
peers
• Practicing using assigned communication
equipment (for example, two-way radios)

Responders need to feel comfortable with a
given skill set and feel motivated to continue
performing under pressure. Responders also
need to be reassured that their contributions to a
response effort are valued.
Failing to provide this feedback may result in
decreased job performance and affect a
responder’s sense of duty— potentially
compromising the overall response.

It is impossible to be trained prior to an incident
until the circumstances are actually known. Once
this information is known, the ability to be trained
on when, what, where, why, and how can begin.
This also gives personnel a chance to understand
what is expected of them.

In order for personnel to make sense of what they
are being trained on, the information must be
presented in a logical manor according to the
incident or circumstance. It must capture their
interest and have a flow to it that can be easily
followed.

There is no one-size-fits-all teaching technique. To
convey the most information to the broadest
audience, your program must employ all of the
training techniques at your disposal:
• auditory,
• visual, and
• experiential.
Ahead we will look at these techniques.

Auditory learners respond best to didactic (or
instructive) lectures enhanced by skillful dialog and
case studies.

Visual learners respond best to images, handouts,
or demonstrations that reinforce the lessons.

Experiential learners need to practice specific tasks
or procedures. For example, a responder might
practice preparing an injection site or delivering a
phone bank script.

Although JITT may be augmented by tools such as
position descriptions, video training, or job action
sheets, it seldom takes into account different
learning styles of responders.
Many JITT curricula focus on auditory and visual
learners only, and do not offer responders an
opportunity to practice what they have learned.

Due to the nature of the types of incidents that we
respond to as part of EMS, it is important that if
there are new skills to be implemented or
administration of medications outside current
protocols, there needs to be hands on training as
well.

Practicing these skills will give the responder
confidence when performing the skills. They will
also be able to focus clearly on the task at hand.

For JITT to be successful, managers and
administrators should support its concepts and
guiding principles on a continuum, or at regular
intervals.
The JITT method is a cyclical process: feedback
from responders triggers changes to the training
and materials. Revised materials are used during
subsequent training.

Preparedness leaders can support the strategy of
JITT through planning, regular training of core
responders, and making sure staff understand and
can apply JITT principles.

Using JITT during an incident ensures that various
learning styles of responders are considered, since
the trainer determines how to best implement
elements of JITT.

JITT doesn’t end once an emergency response
does. Preparedness staff should carefully evaluate
JITT using responder evaluation forms to determine
the effectiveness of, and any needed improvements
to the trainings and materials.

Example of a post-response evaluation card:

• Before an incident, managers and trainers would
have tested and refined the training principles and
techniques.
• During an incident, evaluate operations and staff
Performance to improve the content of ongoing
JITT training.
• After an incident, responders would fill out a
survey about the JITT received earlier in the day.

The three learning styles most effective for learners include:
A. Auditory, Visual, and Olfactory
B. Auditory, Visual, and Experiential
C. Preparedness, Response, and Recovery

If you answered, A. Auditory, Visual, and Olfactory, you should
know that Smelling (Olfactory) is not a proven learning style.
The correct answer is, B. Auditory, Visual, and Experiential.

To convey the most information to the broadest audience, your
program must employ all of the training techniques at your
disposal auditory, visual, and experiential.

In this section you’ve learned how JITT offers a more
thoughtful approach to current training methods. The
JITT model considers different learning styles along
with the intellectual, behavioral, and emotional needs
of responders.
Supporting the model of JITT before an incident,
implementing its principles during an incident, and
evaluating it after an incident helps preparedness
leaders better execute responder training, resulting in
improved operational performance and effectiveness.

As you can see, many changes will be made to the
field protocols to compensate for the increased
demand on the 911 system. During an incident like
this EVERYONE has a part to play to make the 911
system run as proficiently as possible.

Now that we have reviewed the elements for the field
using Altered Standard of Care guidelines, you will
now be quizzed on what you have learned.
Thank you for participating in the…