Wednesday, March 16, 2011

Learning CPR, Telemetry vs. Data, and RTI

In the Pyramid Response to Intervention (PRTI) framework, Austin Buffum describes Tier II and Tier III interventions as "Learning CPR". He shares a scenario about a student who suffered an asthma attack at school. The student's medical needs were obvious and critical. A clearly articulated school emergency plan was implemented, and ultimately saved the student's life. Buffum goes on to discuss how the typical educational system is so much slower at responding to students' learning deficits and crises. So slow in fact, that students sometimes die a slow academic death as they fall further and further behind. He proposed that a ubiquitous PRTI system would recognize, assess, intervene, and reassess students' learning needs, providing ongoing support by highly qualified professionals. This new culture of learning is timely, targeted, and directive.

A recent "tweet" by John Carver, added to my thinking about this medical analogy for education. He wrote, "Old thinking "Data" is [a] dated snap shot of a condition[.] New thinking "telemetry" is real time input from multiple channels." I envisioned the telemetry monitors that I saw in the nurses stations at the hospital where my mother worked when I was a child. Sitting at the desk, the nurse could glance up and see exactly how each patient was doing at that precise moment. In my mind, "Telemetry may be the key... But, do they use telemetry for every patient? When do they implement it? When do they remove it? ... Telemetry? When do medical professionals use this technology? How does it connect to RTI and learning CPR?"

My husband is a critical care paramedic, who works for Lifeflight at Methodist Hospital in Des Moines. He is a trauma specialist on the front lines of the medical scene. I started questioning him about these thoughts. During his career, he has always worked for hospital-based ambulance or flight services. This means that he works within the hospital setting when not at a scene or transferring patients. Surely if I had seen these telemetry monitors as a visitor, he had a much deeper understanding of their use.

Patients in the hospital intensive care unit (ICU) are directly monitored all of the time. They are hooked up to cardiac heart monitors, automatic blood-pressure cuffs, pulse oximeters, and other specialty devices. They have the most specialized medical staff, and the smallest staff to patient ratio. There is one nurse for every one to two patients. Telemetry is not used with these patients because of the low staff to patient ratio and the constant assessment taking place by all of the medical devices.

A patient is ready to leave the ICU when they are stable - medications and medical interventions are working. The medical team determines that the patient is ready to "step down" at this point. The Step-Down Unit is where telemetry is used. Patients need to be monitored, but are no longer hooked up to many of the specialty devices used in the ICU. The staff to patient ratio changes in the Step-Down Unit to about 5:1. When the medical team determines that patients do not require step-down care to remain stable, they are either discharged or moved to long-term care.

In my mind, the ICU correlates to Tier III interventions, and Step-Down care correlates to Tier II interventions. As educators we very rarely move directly to the ICU stage from Tier I core instruction. From my husband's perspective as a critical care paramedic, this is the opposite. His patients almost always go to the ICU first. In his paradigm, patients rarely move from home or long-term care to Step-Down, and then to ICU. Typically, there is an "event" and medical staff intervene swiftly with the highest intensity. Past educational practice also often moved students from general education directly to a special education placement, Tier I to Tier III. But why? Was there a critical event?

Many students were not having "an event" that would warrant this level of intervention. What happened to the middle ground?

At this point in my thinking about RTI and the Learning CPR analogy, I have wandered away from thinking strictly about "telemetry" and have started thinking about the idea of "learning events" as signals for intervention. Please continue reading at your own risk, as the waters get a little muddy at this point.

As we grow in our profession, I think we have more skills to provide a comprehensive Tier I and Tier II program. The medical analogy above is missing a piece, the family practice physician. The critical care paramedic has a specialized set of skills, life-saving skills, but they are narrow compared to the skills of a physician. Every time I ask my husband about a rash I get a same response "Are you bleeding? Are you having chest pain? Follow my finger with your eyes? ... Sorry, I don't do rashes. You need to see the doctor."

Most interventions in Tier I are for those "rashes." But even a rash needs diagnosed and monitored. Some are simply rashes. With time, ointment, and some TLC they clear up. But, other rashes are symptoms of a more serious illness. The physician recognizes the rash, and prescribe specific medications. Then, they have patients come back in a few weeks for a check-up, and try other medications if necessary. This usually happens several times before a specialist gets involved.

When the specialist joins the team, they don't say, "Let's cut off your arm. That will clear up your rash... Medic!" They continue a cyclic process of testing, treating, monitoring, and testing. Educational specialists include reading and math intervention teachers, special education teachers, school psychologists, school social workers, and other service care providers. These specialists support Tier I interventions, and may recommend Tier II interventions. The goal is to provide treatment, without involving the "medic."

I think the medical analogy for RTI is a good one. The analogy isn't as cut and dry as I first envisioned when I started writing this post a week ago. But then again, the learning process isn't as cut and dry as was once believed either.

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