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BACKGROUND: Getting effective fall prevention into the homes of medically and physically vulnerable individuals is a critical public health challenge. Community paramedicine is emerging globally as a new model of care that allows emergency medical service units to evaluate and treat patients in non-emergency contexts for prevention efforts and chronic care management. The promise of community paramedicine as a delivery system for fall prevention that scales to community-level improvements in outcomes is compelling but untested. OBJECTIVE: To study the impact of a community paramedic program’s optimization of a fall prevention system entailing a clinical pathway and learning health system (called Community-FIT) on community-level fall-related emergency medical service utilization rates. METHODS: We used an implementation science framework and quality improvement methods to design and optimize a fall prevention model of care that can be embedded within community paramedic operations. The model was implemented and optimized in an emergency medical service agency servicing a Midwestern city in the United States (~35,000 residents). Primary outcome measures included relative risk reduction in the number of community-level fall-related 9-1-1 calls and fall-related hospital transports. Interrupted time series analysis was used to evaluate relative risk reduction from a 12-month baseline period (September 2016 - August 2017) to a 12-month post-implementation period (September 2018 – August 2019). RESULTS: Community paramedic home visits increased from 25 in 2017, to 236 in 2018, to 517 in 2019, indicating a large increase in the number of households that benefitted from the efforts. A relative risk reduction of 0.66 (95% [CI] 0.53, 0.76) in the number of fall calls and 0.63 (95% [CI] 0.46, 0.75) in the number of fall-related calls resulting in transports to the hospital were observed. CONCLUSIONS: Community-FIT may offer a powerful mechanism for community paramedics to reduce fall-related 9-1-1 calls and transports to hospitals that can be implemented in emergency medical agencies across the country.

Background: Emergency medical services (EMS) professionals demonstrate low adherence to physical activity guidelines and experience a high prevalence of obesity and incidence of injury. The authors investigate the barriers to participating in physical activity among EMS professionals. Methods: The EMS professionals employed by 15 North Carolina EMS agencies were surveyed with validated items. Multivariable logistic regression models were used to estimate the odds (odds ratio, 95% confidence interval) of not meeting physical activity guidelines for each barrier to being active, controlling for age, sex, body mass index category, race/ethnicity, certification and education level, and work hours. Results: A total of 1367 EMS professionals were invited to participate, and 359 complete responses were recorded. Half of the respondents (48.2%) met Centers for Disease Control and Prevention physical activity guidelines. According to standard body mass index categories, 55.9% were obese. There were increased odds of not meeting physical activity guidelines for the following barriers: lack of energy (5.32, 3.12–9.09), lack of willpower (4.31, 2.57–7.22), lack of time (3.55, 2.12–5.94), social influence (3.02, 1.66–5.48), and lack of resources (2.14, 1.12–4.11). The barriers of fear of injury and lack of skill were not associated with meeting physical activity guidelines. Conclusion: Half of EMS professionals did not meet physical activity guidelines, and the majority were obese. Significant associations exist between several modifiable barriers and not meeting physical activity guidelines.

Background: With the emergence of the 2019 novel coronavirus disease (COVID-19), appropriate training for emergency medical services (EMS) personnel on personal protective equipment (PPE) is essent...

Trauma is a leading cause of death in the United States. Ultrasound use in the prehospital environment has the potential to change trauma management. Although ultrasound use for prehospital trauma is increasing, the role of this modality is not clearly defined.We examined the use of prehospital ultrasound (PHUS) for trauma patients and the use by different provider types. Specific factors of interest were if prehospital ultrasound has been shown to improve providers' ability to recognize conditions that can be managed in the prehospital setting, treat these conditions, change transport destination, or improve overall mortality rates for trauma patients.We searched MEDLINE/PubMed, EBSCOhost, Cochrane Library, and Embase medical literature databases for articles that addressed our outcomes. Abstracts and articles were examined and studies that did not specifically evaluate ultrasound in the prehospital setting for trauma and duplicates were eliminated. Studies included in this comprehensive review were assessed for the use of ultrasound in the prehospital setting to aid in the diagnosis, treatment, and transport of trauma patients. We also conducted an analysis of bias in the included articles. Due to the large heterogeneity in the included studies, no meta-analysis could be performed.Sixteen studies were identified comprising 3,317 patients. One study evaluated Emergency Medical Services (EMS) professionals as the ultrasound operator while five studies involved mixed practitioners and ten studies involved only physicians. Diagnostic accuracy was similar amongst physicians and mixed practitioners with no studies reporting PHUS accuracy for EMS providers alone. Seven studies evaluated treatment and transport impact of PHUS though the variables measured were inconsistent and results varied by protocol and outcomes measured. There were no studies that evaluated PHUS and its impact on patient mortality.Ultrasound use in the prehospital setting for trauma is feasible and demonstrates potential. However, the evidence in the medical literature mainly consists of prospective observational studies of physicians utilizing ultrasound for trauma in a HEMS setting. Further scientific research must be undertaken to firmly establish the role of prehospital ultrasound in trauma management by all types of EMS providers.

Background:The utility and efficacy of bolus dose vasopressors in hemodynamically unstable patients is well-established in the fields of general anesthesia and obstetrics. However, in the prehospital setting, minimal evidence for bolus dose vasopressor use exists and is primarily limited to critical care transport use. Hypotensive episodes, whether traumatic, peri-intubation-related, or septic, increase patient mortality. The purpose of this study is to assess the efficacy and adverse events associated with prehospital bolus dose epinephrine use in non-cardiac arrest, hypotensive patients treated by a single, high-volume, ground-based Emergency Medical Services (EMS) agency.Methods:This is a retrospective, observational study of all non-cardiac arrest EMS patients treated for hypotension using bolus dose epinephrine from September 12, 2018 through September 12, 2019. Inclusion criteria for treatment with bolus dose epinephrine required a systolic blood pressure (SBP) measurement Results:Forty-two patients were treated under the protocol with a median (IQR) initial SBP immediately prior to treatment of 78mmHg (65-86) and a median (IQR) initial mean arterial pressure (MAP) of 58mmHg (50-66). The post-bolus SBP and MAP increased to 93mmHg (75-111) and 69mmHg (59-83), respectively. The two most common patient presentations requiring protocol use were altered mental status (55%) and respiratory failure (31%). Over one-half of the patients treated required both advanced airway management (62%) and multiple bolus doses of vasopressor support (55%). A single episode of transient severe hypertension (SBP>180mmHg) occurred, but there were no episodes of unstable tachyarrhythmia or cardiac arrest while en route or upon arrival to the receiving hospitals.Conclusion:These preliminary data suggest that the administration of bolus dose epinephrine may be effective at rapidly augmenting hypotension in the prehospital setting with a minimal incidence of adverse events. Paramedic use of bolus dose epinephrine successfully increased SBP and MAP without clinically significant side effects. Prospective studies with larger sample sizes are needed to further investigate the effects of prehospital bolus dose epinephrine on patient morbidity and mortality.

Death notification is a difficult task commonly encountered during prehospital care and may lead to burnout among EMS professionals. Lack of training could potentiate the relationship between death notification and burnout. The first objective of this study was to describe EMS professionals' experience with death notification and related training. The secondary objective was to assess the associations between death notification delivery, training, and burnout.

Background: Emergency medical services (EMS) personnel frequently encounter occupational factors that increase the risk of poor sleep and stress. The national prevalence of poor sleep and stress in...

BACKGROUND The chaotic and complex nature of delivering patient care in the prehospital setting complicates the provision of real-time formative feedback to paramedic students. Although the use of simulations is widespread in emergency medical services (EMS) education, a high degree of variability precludes consistent performance assessment in EMS. Objectives: The objective of this study was to define and validate key domains required to evaluate paramedic prehospital performance. Methods: We conducted a two-phase study that combined focus group and Delphi methodology. Participants were purposefully selected to attain diverse panels regarding sex, race, ethnicity, professional roles, levels of education, geographical area, and experience as a paramedic and educator. In Phase I, a panel of 11 subject matter experts (SMEs) were tasked with identifying the essential domains to be evaluated in a paramedic performance assessment. In Phase II, another panel of 11 SMEs and a four-round modified Delphi method with 28 paramedic program directors were used to validate the domains identified in Phase I. Results: The first focus group identified and achieved consensus on five domains: (1) effective communication, (2) scene management, (3) patient assessment, (4) patient management, and (5) professional behavior. These domains were validated by the second focus group. The first round of the Delphi process generated 64 content domains, which were reduced to nine unique content domains via thematic analysis. These nine content domains fit well within the broader domains identified by the focus groups with one specific area, critical thinking and reasoning, being listed in two key areas based on the definitions of the focus group domains of patient assessment and patient management. Conclusion: The content domains identified in this study provide EMS educators a theoretical framework for designing the performance assessment of newly trained professionals in the prehospital setting.

Introduction The delivery of emergency medical services is primarily performed by emergency medical technicians and paramedics in the United States. More recently, nurses and physicians have become more involved in the delivery of emergency medical services. Advanced placement paramedic education bridging programs have been developed to prepare the workforce, but the success of these programs is unknown. This study evaluated the demographics and performance of nonemergency medical services health care professionals who attended an advanced placement paramedic education program at a Midwestern university. Methods This was a retrospective evaluation of student data from 2007 to 2017. Descriptive statistics were used to tabulate demographics, program performance, and individual performance in the National Paramedic Certification Examination. Results The program admitted 305 students; registered nurses (95%) were the majority of students. Of the 305 admitted students, 271 (88.9%) fulfilled all program requirements and were eligible to take the National Registry of Emergency Medical Technicians paramedic certification examination. Of these 271 eligible students, 201 (74.2%) took the National Paramedic Certification Examination. A total of 195 (97%) obtained certification at the first test attempt, whereas 200 (99.5%) obtained certification within 3 attempts. Of the 200 who passed the test, 175 (88%) successfully demonstrated entry-level competency in paramedic-level psychomotor testing. Discussion The advanced placement paramedic program evaluated in this study had high rates of successful program completion, as well as high first-time and cumulative passing rates for the National Paramedic Certification Examination. Further research is needed to identify the best practices in determining student requirements and the methodologies in delivering advanced placement paramedic education bridging programs.

High quality cardiopulmonary resuscitation (CPR) is critical to improve survival from cardiac arrest. While low dose- high frequency case-based training enhances CPR skill retention, it is unclear if this training method is feasible in a clinical environment and if it yields improved clinical CPR quality during in-hospital cardiac arrest. We evaluated the implementation of a novel platform providing low dose- high frequency psychomotor CPR training and its impact upon CPR quality.The described training platform was launched on two nursing units (60 beds) in a university teaching hospital. Quarterly utilization of the platform was integrated into normal clinical duties of hospital staff. Simulated CPR performance and staff compliance were evaluated pre- and post-intervention. In addition, clinical CPR performance was evaluated for periods of six months before and after four quarters of implementation (median, IQR).The low dose, high frequency CPR training led to retention of simulated CPR skills (compression rate, depth and fraction) during each quarter exceeding high-quality guideline thresholds. Clinical CPR quality, measured by compression fraction (Pre: 83% (73, 95) and Post: 93% (88, 98), p 0.001) and rate (Pre: 109 (96, 126) and Post: 120 (108, 130), p = 0.008) increased significantly following platform implementation. Over the intervention period, program compliance was greater than 97%.Low dose-high frequency case based psychomotor CPR training is feasible in a clinical setting with high compliance. In two nursing units, this method of training resulted in enhanced CPR skill retention and improved in-hospital clinical CPR quality.

Objectives Emergency departments (EDs) patient satisfaction metrics are highly valued by hospitals, health systems, and payers, yet these metrics are challenging to analyze and interpret. Accurate interpretation involves selection of the most appropriate peer group for benchmark comparisons. We hypothesized that the selection of different benchmark peer groups would yield different interpretations of Press Ganey (PG) patient satisfaction scores. Methods Emergency department PG summary ratings of "doctors section" and "likelihood-to-recommend" raw scores and corresponding percentiles were derived for three benchmark peer groups from three academic years (2016, 2017, and 2018). The three benchmarks are: 1) the PG Large database; 2) the PG University HealthSystem Consortium (UHC) database; and 3) the Academy of Administrators in Academic Emergency Medicine (AAAEM) database, which is composed only of EDs from academic health centers with emergency medicine residency training programs. Raw scores were converted to percentile ranks for each distribution and then compared using Welch's ANOVA and Games-Howell pairwise comparisons. Results For both patient satisfaction raw scores evaluated, the AAAEM database was noted to have significantly higher percentile ranks when compared to the PG Large and PG UHC databases. These results were consistent for all three time frames assessed. Conclusions Benchmarking with different peer groups provides different results, with similar patient satisfaction raw scores resulting in higher percentile ranks using the AAAEM database compared to the two PG databases. The AAAEM database should be considered the most appropriate peer group for benchmarking academic EDs.

Background: The nationally-certified advanced emergency medical technician (AEMT) level was created as an intermediate level of care integrating both basic life support and limited advanced...

Background: Workforce diversity can reduce communication barriers and inequalities in healthcare delivery, especially in settings where time pressure and incomplete information may exacerbate the effects of implicit biases. Emergency medical services (EMS) professionals represent a critical entry point into the healthcare system for diverse populations, yet little is known regarding changes in the demographic composition of this workforce. Our primary objective was to describe the gender and racial/ethnic composition of emergency medical technicians (EMTs) and paramedics who earned initial National EMS Certification from 2008 to 2017. Secondarily, we compared demographic characteristics of the 2017 EMT and paramedic cohorts to the U.S. population. Methods: As a proxy for recent graduates likely to enter the workforce, we conducted a serial cross-sectional analysis of all EMTs and paramedics earning initial National EMS Certification from January 1, 2008 to December 31, 2017. Cuzick's non-parametric test of trend was used to assess for changes in the gender and racial/ethnic composition of the EMS cohorts over time. For 2017, we calculated differences the gender and racial/ethnic composition of the EMT and paramedic cohorts to the U.S population, stratifying by Census region. Results: The study population included 588,337 EMTs and 105,356 paramedics. The proportion of females earning initial EMT certification rose from 28% in 2008 to 35% in 2017. Throughout the study period, less than one-fourth of newly certified paramedics were female (range: 20-23%). The proportion of EMS professionals identifying as black remained near 5% among EMTs and 3% among paramedics. The proportion of newly-certified Hispanic EMS professionals rose from 10% to 13% among EMTs and from 6% to 10% among paramedics. Compared to the U.S. population, females and racial/ethnic minorities were underrepresented among EMTs and paramedics earning initial certification and these representation differences varied across geographic regions. Conclusions: The underrepresentation of females and minority racial/ethnic groups observed during this 10-year investigation of EMTs and paramedics earning initial certification suggests that EMS workforce diversity is unlikely to undergo substantial change in the near future. The representation gaps were larger and more stable among paramedics compared to EMTs and suggest an area where concerted efforts are needed to encourage students of diverse backgrounds to pursue EMS.

Introduction: During pregnancy, women may be exposed to teratogenic medications resulting in a risk of complications and poor maternal-fetal outcomes. The objective of this study was to evaluate the prescription of teratogenic medications in women of childbearing age and the associated prescription of contraception in the primary care setting. Methods: The use of high-risk, potentially teratogenic, medications was retrospectively evaluated in women of childbearing age (13 to 45 years old) at 2 family medicine practices. Charts were reviewed for medication use and whether patients received a form of birth control (medication, sterilization, or postmenopausal) with the teratogenic medications. A multivariable logistic regression model was used to estimate the age-adjusted association between receiving a teratogenic medication and contraception. A subgroup analysis excluding ondansetron was also performed. Results: A total of 3,956 nonpregnant women were included with 988 (25%) prescribed at least 1 high-risk medication. The most commonly prescribed high-risk medications were ondansetron (n = 724, 73%) and lisinopril (n = 195, 20%). More than half (55%) of the women prescribed a high-risk medication were without a form of birth control. When ondansetron was excluded, 10% of the population was prescribed at least 1 high-risk medication with 62% also without a form of birth control. Women less than 25 years of age had decreased odds of receiving contraception when prescribed a teratogenic medication (adjusted odds ratio, 0.47; 95% confidence interval, 0.34–0.66). Conclusion: In a family medicine setting, 25% of women of childbearing age were prescribed a high-risk medication with over half not having evidence of contraception management. Interestingly, younger age women had lower odds of receiving contraceptive management when prescribed high-risk medications. Prescribers should be aware of and counsel on the risks of teratogenic medications and regularly evaluate reproductive plans for patients.

Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans. The epidemiology of opioid-associated out-of-hospital cardiac arrest in the United States is changing rapidly, with exponential increases in death resulting from synthetic opioids and linear increases in heroin deaths more than offsetting modest reductions in deaths from prescription opioids. The pathophysiology of polysubstance toxidromes involving opioids, asphyxial death, and prolonged hypoxemia leading to global ischemia (cardiac arrest) differs from that of sudden cardiac arrest. People who use opioids may also develop bacteremia, central nervous system vasculitis and leukoencephalopathy, torsades de pointes, pulmonary vasculopathy, and pulmonary edema. Emergency management of opioid poisoning requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled to compressions in the setting of opioid-associated out-of-hospital cardiac arrest. Effective ventilation is challenging to teach, whereas naloxone, an opioid antagonist, can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest. Opioid education and naloxone distributions programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions, and perform rescue breathing. Current American Heart Association recommendations call for laypeople and others who cannot reliably establish the presence of a pulse to initiate cardiopulmonary resuscitation in any individual who is unconscious and not breathing normally; if opioid overdose is suspected, naloxone should also be administered. Secondary prevention, including counseling, opioid overdose education with take-home naloxone, and medication for opioid use disorder, is important to prevent recurrent opioid overdose.

Objective: Few areas of prehospital care are supported by evidence-based guidelines (EBGs). We aimed to identify gaps in clinical and operational prehospital EBGs to prioritize future EBG development and research funding. Methods: Using modified Delphi methodology, we sought consensus among experts in prehospital care and EBG development. Five rounds of surveys were administered between October 2019 and February 2020. Round 1 asked participants to list the top three gaps in prehospital clinical guidelines and top three gaps in operational guidelines that should be prioritized for guideline development and research funding. Based on responses, 3 reviewers performed thematic analysis to develop a list of prehospital EBG gaps, with participant feedback in Round 2. In Round 3, participants rated each gap's importance using a 5-point Likert scale, and participants' responses were averaged. In Round 4, participants rank-ordered 10 gaps with the highest mean scores identified in Round 3. In Round 5, participants indicated their agreement with sets of the highest ranked gaps. Results: Of 23 invited participants, 14 completed all 5 rounds. In Rounds 1 and 2, participants submitted 65 clinical and 58 operational gaps, and thematic analysis identified 23 unique clinical gaps and 28 unique operational gaps. The final prioritized list of clinical EBG gaps was: 1) airway management in adult and pediatric patients, 2) care of the pediatric patient, and 3) management of prehospital behavioral health emergencies, with 79% of participants agreeing. The final prioritized list of operational EBG gaps was: 1) define and measure the impact of EMS care on patient outcomes, 2) practitioner wellness, and 3) practitioner safety in the out-of-hospital environment, with 86% of participants agreeing. Conclusions: This modified Delphi study identifies gaps in prehospital EBGs that, if prioritized for development and research funding, would be expected to have the greatest impact on prehospital clinical care and operations.

Background: The EMS Practice Analysis provides a vision of current prehospital care by defining the work performed by EMS professionals. In this manuscript, we present the National Advanced Life Su...

Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post–cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.

INTRODUCTION Short or long sleep duration is a risk factor for cardiovascular disease, but the association between sleep duration and cardiovascular health is unclear. Our objective was to quantify the association between sleep duration and ideal cardiovascular health (CVH) in US adults. We hypothesized that very short (

Emergency medical response is provided by volunteer emergency medical services (EMS) professionals in many parts of the United States. However, little is known about those who serve as volunteer EMS professionals, especially as their main EMS job. Our objective was to compare the characteristics of nationally-certified volunteer versus paid EMS professionals in the U.S.

The emergency medical services (EMS) workforce is a key component of healthcare in the U.S. Characteristics of active EMS professionals who are treating patients in the prehospital setting is unclear. The purpose of this study was to describe the roles and settings in which nationally certified EMS professionals are providing patient care and to evaluate similarities and differences of the demographics and practice settings of the three major certification levels.We conducted a cross-sectional evaluation of all nationally certified EMS professionals in the U.S. that recertified between October 1, 2017 and March 31, 2018 and October 1, 2018 and March 31, 2019. Within the recertification application, EMS professionals completed an optional demographic profile. Those who were nationally certified, functioning as a patient care provider for at least one nonmilitary EMS organization, aged 18 to 85 years, and recertified at the EMT level or higher were included. Demographic, agency and job characteristics were assessed and descriptive statistics were calculated.In 2017-2018, 101,363 EMS professionals recertified and 87,471 (86%) completed the profile; in 2018-2019, 106,893 EMS professionals recertified and 92,640 (87%) completed the profile. Of the 142,751 EMS professionals who met inclusion criteria, the population was primarily male (76%) and age increased by certification level. By race/ethnicity, 85% were white, 5% were Hispanic/Latino, 5% were Black/African American, 2% were American Indian/Alaskan Native, 2% were Asian and 1% were Native Hawaiian/Pacific Islander.Paramedics had the highest proportion of associate degrees (EMT:16.0%; AEMT:16.6%; paramedic:28.5%); some college experience was common for all certification levels (EMT:34.7%; AEMT:37.2%; paramedic:31.6%). Most EMS professionals reported 3-7 years of experience, were working full-time (78%) and 28% were working for 2 or more agencies. Most were working for a fire department (48%) or private agency (21%) and providing 9-1-1 service (72%). No substantial differences were observed between the two recertification cycles.This is the most comprehensive study evaluating the demographics of the national EMS workforce of active patient care providers. Understanding the characteristics of EMS professionals and the settings they practice in is important for educational and training initiatives, as well as protocols and policies.

Introduction: The necessity of rapid preload and afterload reduction in patients with decompensated congestive heart failure (CHF) and acute pulmonary edema (APE) is well established. In the hospit...

The fundamentals of cardiac resuscitation include the immediate provision of high-quality cardiopulmonary resuscitation combined with rapid defibrillation (as appropriate). These mainstays of therapy set the groundwork for other possible interventions such as medications, advanced airways, extracorporeal cardiopulmonary resuscitation, and post–cardiac arrest care, including targeted temperature management, cardiorespiratory support, and percutaneous coronary intervention. Since 2015, an increased number of studies have been published evaluating some of these interventions, requiring a reassessment of their use and impact on survival from cardiac arrest. This 2019 focused update to the American Heart Association advanced cardiovascular life support guidelines summarizes the most recent published evidence for and recommendations on the use of advanced airways, vasopressors, and extracorporeal cardiopulmonary resuscitation during cardiac arrest. It includes revised recommendations for all 3 areas, including the choice of advanced airway devices and strategies during cardiac arrest (eg, bag-mask ventilation, supraglottic airway, or endotracheal intubation), the training and retraining required, the administration of standard-dose epinephrine, and the decisions involved in the application of extracorporeal cardiopulmonary resuscitation and its potential impact on cardiac arrest survival.

Survival after out-of-hospital cardiac arrest requires an integrated system of care (chain of survival) between the community elements responding to an event and the healthcare professionals who continue to care for and transport the patient for appropriate interventions. As a result of the dynamic nature of the prehospital setting, coordination and communication can be challenging, and identification of methods to optimize care is essential. This 2019 focused update to the American Heart Association systems of care guidelines summarizes the most recent published evidence for and recommendations on the use of dispatcher-assisted cardiopulmonary resuscitation and cardiac arrest centers. This article includes the revised recommendations that emergency dispatch centers should offer and instruct bystanders in cardiopulmonary resuscitation during out-of-hospital cardiac arrest and that a regionalized approach to post–cardiac arrest care may be reasonable when comprehensive postarrest care is not available at local facilities.

As the opioid epidemic in the United States has continued since the early 2000s (1,2), most descriptions have focused on misuse and deaths. Increased cooperation with state and local partners has enabled more rapid and comprehensive surveillance of nonfatal opioid overdoses (3).* Naloxone administrations obtained from emergency medical services (EMS) patient care records have served as a useful proxy for overdose surveillance in individual communities and might be a previously unused data source to describe the opioid epidemic, including fatal and nonfatal events, on a national level (4-6). Using data from the National Emergency Medical Services Information System (NEMSIS),† the trend in rate of EMS naloxone administration events from 2012 to 2016 was compared with opioid overdose mortality rates from National Vital Statistics System multiple cause-of-death mortality files. During 2012-2016, the rate of EMS naloxone administration events increased 75.1%, from 573.6 to 1004.4 administrations per 100,000 EMS events, mirroring the 79.7% increase in opioid overdose mortality from 7.4 deaths per 100,000 persons to 13.3. A bimodal age distribution of patients receiving naloxone from EMS parallels a similar age distribution of deaths, with persons aged 25-34 years and 45-54 years most affected. However, an accurate estimate of the complete injury burden of the opioid epidemic requires assessing nonfatal overdoses in addition to deaths. Evaluating and monitoring nonfatal overdose events via the novel approach of using EMS data might assist in the development of timely interventions to address the evolving opioid crisis.

OBJECTIVES Ultrasound (US) has become an indispensable skill for emergency physicians. Growth in the use of US in emergency medicine (EM) has been characterized by practice guidelines, education requirements, and the number of EM US practitioners. Our purpose was to further document the growth of EM US by profiling the breadth, depth, and quality of US-related research presented at EM's most prominent annual research conference: the Society for Academic Emergency Medicine Annual Meeting. METHODS We reviewed published research abstracts from the annual Society for Academic Emergency Medicine conferences from 1999 to 2015. Abstracts related to US were identified and examined for the number of authors and rigor of the research design. Designs were categorized as experimental, quasiexperimental, and nonexperimental. Abstract submissions were analyzed by the average rate of change over time. RESULTS From 1999 to 2015, we observed a 10.2% increase in the number of accepted abstracts related to US research. This rate compared to a 3.2% average rate of change for all abstracts in general. The number of unique authors engaged in US research increased at a rate of 26.6%. Of the 602 abstracts identified as US related, only 12% could be considered experimental research. CONCLUSIONS We observed larger increases in the number of US-related research relative to the total number of abstracts presented at a national conference. The number of investigators engaging in this research has also steadily increased. The research design of these studies was found to be primarily quasiexperimental. To improve the quality of EM's use of point-of-care US, more rigorous research with experimental designs is needed.

BackgroundUse of ketamine in the prehospital setting may be advantageous due to its potent analgesic and sedative properties and favorable risk profile. Use in the military setting has demonstrated both efficacy and safety for pain relief. The purpose of this study was to assess ketamine training, use, and perceptions in the civilian setting among nationally certified paramedics (NRPs) in the United States.MethodsA cross-sectional survey of NRPs was performed. The electronic questionnaire assessed paramedic training, authorization, use, and perceptions of ketamine. Included in the analysis were completed surveys of paramedics who held one or more state paramedic credentials, indicated “patient care provider” as their primary role, and worked in non-military settings. Descriptive statistics were calculated.ResultsA total of 14,739 responses were obtained (response rate=23%), of which 10,737 (73%) met inclusion criteria and constituted the study cohort. Over one-half (53%) of paramedics reported learning about ketamine during their initial paramedic training. Meanwhile, 42% reported seeking ketamine-related education on their own. Of all respondents, only 33% (3,421/10,737) were authorized by protocol to use ketamine. Most commonly authorized uses included pain management (55%), rapid sequence intubation (RSI; 72%), and chemical restraint/sedation (72%). One-third of authorized providers (1,107/3,350) had never administered ketamine, with another 32% (1,070/3,350) having administered ketamine less than five times in their career. Ketamine was perceived to be safe and effective as the vast majority reported that they were comfortable with the use of ketamine (94%) and would, in similar situations (95%), use it again.ConclusionThis was the first large, national survey to assess ketamine training, use, and perceptions among paramedics in the civilian prehospital setting. While training related to ketamine use was commonly reported among paramedics, few were authorized to administer the drug by their agency’s protocols. Of those authorized to use ketamine, most paramedics had limited experience administering the drug. Future research is needed to determine why the prevalence of ketamine use is low and to assess the safety and efficacy of ketamine use in the prehospital setting.BucklandDM, CroweRP, CashRE, GondekS, MalusoP, SirajuddinS, SmithER, DangerfieldP, ShapiroG, WankaC, PanchalAR, SaraniB. Ketamine in the prehospital environment: a national survey of paramedics in the United States. Prehosp Disaster Med. 2018;33(1):23–28.

Background CPR training at mass gathering events is an important part of health initiatives to improve cardiac arrest survival. However, it is unclear whether training lay bystanders using an ultra-brief video at a mass gathering event improves CPR quality and responsiveness. Objective To determine if showing a chest-compression only (CCO) Ultra-Brief Video (UBV) at a mass gathering event is effective in teaching lay bystanders CCO-CPR. Methods Prospective control trial in adults (age >18) who attended either a women’s University of Arizona or a men’s Phoenix Suns basketball game. Participants were evaluated using a standardized cardiac arrest scenario with Laerdal Skillreporter™ mannequins. CPR responsiveness (calling 911, time to calling 911, starting compressions within two minutes) and quality (compression rate, depth, hands-off time) were assessed for participants and data collected at Baseline and Post-intervention. Different participants were tested before and after the exposure of the UBV. Data were analyzed via the intention to treat principle using logistic regression for binary outcomes and median regression for continuous outcomes, controlling for clustering by venue. Results A total of 96 people were consented (Baseline = 45; Post intervention = 51). CPR responsiveness post intervention improved with faster time to calling 911 (s) and time to starting compressions (sec). Likewise, CPR quality improved with deeper compressions and improved hands-off time. Conclusions Showing a UBV at a mass gathering sporting event is associated with improved CPR responsiveness and performance for lay bystanders. This data provides further support for the use of mass media interventions.

Inadequate staffing of agencies, increasing attrition rates, and frequent turnover of personnel make employee retention an ongoing concern for Emergency Medical Services (EMS). Faced with increasing demand for EMS, understanding the causes underlying turnover is critical. The objectives of this study were to describe the proportion of individuals that left EMS, likelihood of returning to the profession, and key factors contributing to the decision to leave EMS.This was a cross-sectional study of nationally-certified EMS professionals who left EMS. Respondents to a census survey who reported not practicing EMS were directed to a subsection of items regarding their choice to leave EMS. Demographic and employment characteristics, likelihood of returning to EMS, and factors influencing the decision to leave EMS were assessed. Descriptive and comparative statistics (Chi-square and nonparametric test of trend [p-trend]) and univariable odds ratios were calculated.The overall response rate for the full survey was 10% (n = 32,114). A total of 1247 (4%) respondents reported leaving the profession and completed the exit survey. The majority (72%) reported that they will likely return to EMS. A stepwise decrease in the reported likelihood of returning was seen with increasing years of EMS experience (e.g., 2 or less years of experience: 83%; 16 or more years: 52%; p-trend0.001) and months away from EMS (e.g., 0-2 months: 89%; more than 12 months: 57%; p-trend0.001). The most common factors reported to influence the decision to leave EMS included desire for better pay/benefits (65%), decision to pursue further education (60%), dissatisfaction with organization's management (54.7%), and desire for career change (54.1%).This cross-sectional study found an attrition rate of approximately 4% among nationally certified EMS professionals; however, the majority reported that they intended to return to the EMS profession. Intention to return to EMS decreased as years of experience and months away from the profession increased. Important factors in the decision to leave EMS included a desire for better pay and benefits and the decision to pursue further education. Targeting the factors identified as important in this study should be a priority for key stakeholders in improving recruitment and retention of EMS professionals.

Introduction Intravascular volume status is an important clinical consideration in the management of the critically ill. Point of care ultrasonography (POCUS) has gained popularity as a non-invasive means of intravascular volume assessment via examination of the inferior vena cava (IVC). However, there is limited data comparing different acquisition techniques for IVC measurement by POCUS. The goal of this evaluation is to determine the reliability of three IVC acquisition techniques for volume assessment: sub-xiphoid transabdominal long axis (LA), transabdominal short axis (SA), and right lateral transabdominal coronal long axis (CLA) (aka “rescue view”). Methods Volunteers were evaluated by three experienced emergency physician sonographers (EP). Gray scale (B-mode) and Motion-mode (M-mode) diameters were measured and IVC collapsibility index (IVCCI) calculated for three anatomic views (LA, SA, CLA). For each IVC measurement, descriptive statistics, intra-class correlation coefficients (ICC), and 2-Way Univariate Analyses of Variance (ANOVA) were calculated. Results Thirty-nine volunteers were evaluated yielding 351 total US measurements. Measurements of the three views had similar means (LA 1.9 ± 0.4cm; SA 1.9 ± 0.4cm; CLA 2.0 ± 0.5cm). For B-Mode, LA had the highest ICC (0.86, 95% CI = 0.76 to 0.92) while CLA had the poorest ICC (0.74, 95% CI = 0.56 to 0.85). ICCs for all M-mode IVCCI were low. Significant interaction effects between anatomical view and EP were observed for B-mode and M-mode measurements. Post-hoc analyses reveal difficulty in consistent view acquisition between EPs. Conclusions Inter rater reliability of the IVC by EPs was highest for B-mode LA and poorest for all M-Mode IVC collapsibility indices (IVCCI). These results suggest that B-mode LA holds the most promise to deliver reliable measures of IVC diameter. Future studies may focus on validation in a clinical setting as well as comparison to a reference standard.

IntroductionThe staffing of ambulances with different levels of Emergency Medical Service (EMS) providers is a difficult decision with evidence being mixed on the benefit of each model.Hypothesis/ProblemThe objective of this study was to describe a pilot program evaluating alternative staffing on two ambulances utilizing the paramedic-basic (PB) model (staffed with one paramedic and one emergency medical technician[EMT]).MethodsThis was a retrospective study conducted from September 17, 2013 through December 31, 2013. The PB ambulances were compared to geographically matched ambulances staffed with paramedic-paramedic (PP ambulances). One PP and one PB ambulance were based at Station A; one PP and one PB ambulance were based at Station B. The primary outcome was total on-scene time. Secondary outcomes included time-to-electrocardiogram (EKG), time-to-intravenous (IV) line insertion, IV-line success rate, and percentage of protocol violations. Inclusion criteria were all patients requesting prehospital services that were attended to by these teams. Patients were excluded if they were not attended to by the study ambulance vehicles. Descriptive statistics were reported as medians and interquartile ranges (IQR). Proportions were reported with 95% confidence intervals (CI). The Mann-Whitley U test was used for significance testing (PResultsMedian on-scene times at Station A for the PP ambulance were shorter than the PB ambulance team (PP: 10.1 minutes, IQR 6.0-15; PB: 13.0 minutes, IQR 8.1-18; P=.01). This finding also was noted at Station B (PP: 13.5 minutes, IQR 8.5-19; PB: 14.3 minutes, IQR 9.9-20; P=.01). There were no differences between PP and PB ambulance teams at Station A or Station B in time-to-EKG, time-to-IV insertion, IV success rate, and protocol violation rates.ConclusionIn the setting of a well-developed EMS system utilizing an all-Advanced Life Support (ALS) response, this study suggests that PB ambulance teams may function well when compared to PP ambulances. Though longer scene times were observed, differences in time to ALS interventions and protocol violation rates were not different. Hybrid ambulance teams may be an effective staffing alternative, but decisions to use this model must address clinical and operational concerns.CortezEJ, PanchalAR, DavisJE, KesegDP. The effect of ambulance staffing models in a metropolitan, fire-based EMS system. Prehosp Disaster Med. 2017;32(2):175–179.

Background: EMS professionals frequently work more than a standard 40-hour work week. For some EMS professionals, working overtime or multiple jobs may be necessary to make ends meet. Our objective...

Background:Emergency Medical Services (EMS) professionals face high physical demands in high-stress settings; however, the prevalence of cardiovascular health (CVH) risk factors in this health care workforce has not been explored. The primary objective of this study was to compare the distribution of CVH and its individual components between a sample of emergency medical technicians (EMTs) and paramedics. The secondary objective was to identify associations between demographic and employment characteristics with ideal CVH in EMS professionals.Methods:A cross-sectional survey based on the American Heart Association’s (AHA; Dallas, Texas USA) Life’s Simple 7 (LS7) was administered to nationally-certified EMTs and paramedics. The LS7 components were scored according to previously described cut points (ideal = 2; intermediate = 1; poor = 0). A composite CVH score (0-10) was calculated from the component scores, excluding cholesterol and blood glucose due to missing data. Multivariable logistic regression was used to estimate odds ratios (OR; 95% CI) for demographic and employment characteristics associated with optimal CVH (≥7 points).Results:There were 24,708 respondents that were currently practicing and included. More EMTs achieved optimal CVH (n = 4,889; 48.8%) compared to paramedics (n = 4,338; 40.6%). Factors associated with higher odds of optimal CVH included: higher education level (eg, college graduate or more: OR = 2.26; 95% CI, 1.97-2.59); higher personal income (OR = 1.26; 95% CI, 1.17-1.37); and working in an urban versus rural area (OR = 1.31; 95% CI, 1.23-1.40). Paramedic certification level (OR = 0.84; 95% CI, 0.78-0.91), older age (eg, 50 years or older: OR = 0.65; 95% CI, 0.58-0.73), male sex (OR = 0.54; 95% CI, 0.50-0.56), working for a non-fire-based agency (eg, private service: OR = 0.68; 95% CI, 0.62-0.74), and providing medical transport service (OR = 0.81; 95% CI, 0.69-0.94) were associated with lower odds of optimal CVH.Conclusions:Several EMS-related characteristics were associated with lower odds of optimal CVH. Future studies should focus on better understanding the CVH and metabolic risk profiles for EMS professionals and their association with incident cardiovascular disease (CVD), major cardiac events, and occupational mortality.Cash RE, Crowe RP, Bower JK, Foraker RE, Panchal AR. Differences in cardiovascular health metrics in emergency medical technicians compared to paramedics: a crosssectional study of Emergency Medical Services professionals.Prehosp Disaster Med.2019;34(3):288–296.

Introduction One of the barriers to improving cardiac arrest survival is the low rate of cardiopulmonary resuscitation (CPR) provision. Identifying this as a public health issue, many medical students often assist in training the community in CPR. However, these experiences are often short and are not associated with structured resuscitation education, limiting the student's and the community's learning. In this assessment, we identified a need and developed a curriculum, including defined goals and objectives, for an undergraduate medical education (UME) elective in CPR. Methods At an academic university environment with a strong UME program, we developed a longitudinal UME elective in CPR. The curriculum is a four-year longitudinal experience, which satisfies two weeks of their fourth year of medical school. The curriculum includes structured training over the four-year period in the fundamentals of resuscitation science (through didactics, journal club, and hands-on skills training), in addition to structured community CPR teaching. The elective concludes with a final hands-on summative appraisal. Data concerning medical student program enrollment, CPR training events conducted, venues of events, and the number of individuals trained were collected over a five-year period. Results The CPR elective was developed with clear goals and objectives based on identified needs. Over the five-year period, 186 medical students completed the CPR longitudinal elective, accounting for 8.4% of the total medical student population. Students completed curriculum requirements and satisfied both didactic and hands-on training with all students passing the final summative appraisal. Over the five-year period, students trained 8,694 people in bystander CPR. The summative evaluation had a 100% pass rate. Conclusion Implementation of a longitudinal CPR elective improved resuscitation science education for medical students and fostered increased community CPR training. This describes one local effort to improve resuscitation science education and training for medical students. Further work will need to be done to evaluate the impact of UME resuscitation curricula on medical student career choice and resuscitation outcomes.

Background Disability-adjusted life years (DALY) are a common public health metric used to consistently estimate and compare health loss because of both fatal and nonfatal disease burden. The annual number of DALY because of adult out-of-hospital cardiac arrest (OHCA) in the United States is unknown. Our objective was to estimate the DALY after adult nontraumatic, emergency medical services–treated OHCA, and to compare OHCA DALY to other leading causes of death and disability in the US. Methods and Results The DALY were calculated as the sum of years of life lost and years lived with disability. The years of life lost were calculated using all adult nontraumatic emergency medical services–treated OHCA with complete data from the national Cardiac Arrest Registry to Enhance Survival database for 2016, and actuarial data for remaining life expectancy at the age of death. Cerebral performance category scores from the Cardiac Arrest Registry to Enhance Survival database and previously established disability weights were used to estimate years lived with disability. The cohort’s calculated DALY were extrapolated to a national level to estimate total US DALY. Data were reported as total, mean, and DALY per 100 000 individuals. A total of 59 752 OHCA met study inclusion criteria. The DALY for the study population were 1 194 993 (years of life lost, 1 194 069; years lived with disability, 924) in 2016. The estimated total DALY following adult nontraumatic emergency medical services–treated OHCA in the US were 4 354 192 (years of life lost, 4 350 825; years lived with disability, 3365) for the index year 2016. The rate of OHCA DALY were 1347 per 100 000 population, which ranked third in the US behind ischemic heart disease (2447) and low back and neck pain (1565). Sensitivity analyses yielded similar findings. Conclusions Adult nontraumatic OHCA is a leading cause of annual DALY in the US and should be a focus of public health policy and resources.

Introduction: Emergency Medical Services (EMS) providers may identify and preferentially transport patients experiencing large vessel occlusion (LVO) stroke to appropriate treatment centers. The Rapid Arterial oCclusion Evaluation (RACE) scale was created for prehospital LVO detection, yet few studies have evaluated its function in real-world EMS settings. Our objective was to assess the prehospital performance of the RACE scale for detecting LVO stroke following implementation at a large suburban/rural agency in the United States. Methods: In this retrospective analysis, all 9-1-1 patients with an EMS provider primary or secondary impression of stroke treated by the agency between June 1, 2016 and November 1, 2017 were eligible for inclusion. Patient data were abstracted using a standardized form completed by receiving hospitals. Performance for LVO detection at each RACE cutoff value was evaluated using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). A receiver operating characteristic (ROC) curve was used to evaluate the discrimination of the RACE scale overall. A secondary analysis of RACE for patients experiencing strokes best treated at comprehensive stroke centers (LVO and intracerebral hemorrhage [ICH]) was conducted. Results: There were 440 patients with a documented RACE score and hospital outcome data included in the analysis. About half (51%, n = 220) were female and the median age was 70 years (IQR: 59–81). Last known well time was under 4.5 hours for 76% of patients (n = 261). Over half (61%, n = 269) had a hospital discharge diagnosis of stroke and 64/440 (15%) were classified as LVO. The ROC curve demonstrated adequate discrimination with a c-statistic of 0.72. Performance for identifying LVO in the prehospital setting was greatest for RACE scores ≥5 with a sensitivity of 66% and specificity of 72%, PPV of 29%, and NPV of 93%. A RACE score ≥5 for both LVO and ICH demonstrated sensitivity: 63%, specificity: 77%, PPV: 47% and NPV: 86%. Conclusion: The RACE scale demonstrated acceptable discrimination, yet the sensitivity and positive predictive value were lower in this cohort of EMS professionals in the United States than in the original validation study conducted in Spain. Further work is needed to determine the optimal prehospital screening tool for identification of LVO.

Antiarrhythmic medications are commonly administered during and immediately after a ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. However, it is unclear whether these medications improve patient outcomes. This 2018 American Heart Association focused update on advanced cardiovascular life support guidelines summarizes the most recent published evidence for and recommendations on the use of antiarrhythmic drugs during and immediately after shock-refractory ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. This article includes the revised recommendation that providers may consider either amiodarone or lidocaine to treat shock-refractory ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest.

Objective: Airway management is a common, important intervention for critically ill patients in the United States. A key element of prehospital airway management is endotracheal intubation (ETI). P...

IntroductionEndotracheal intubation (ETI) is a complex clinical skill complicated by the inherent challenge of providing care in the prehospital setting. Literature reports a low success rate of prehospital ETI attempts, partly due to the care environment and partly to the lack of consistent standardized training opportunities of prehospital providers in ETI.Hypothesis/ProblemThe availability of a mobile simulation laboratory (MSL) to study clinically critical interventions is needed in the prehospital setting to enhance instruction and maintain proficiency. This report is on the development and validation of a prehospital airway simulator and MSL that mimics in situ care provided in an ambulance.MethodsThe MSL was a Type 3 ambulance with four cameras allowing audio-video recordings of observable behaviors. The prehospital airway simulator is a modified airway mannequin with increased static tongue pressure and a rigid cervical collar. Airway experts validated the model in a static setting through ETI at varying tongue pressures with a goal of a Grade 3 Cormack-Lehane (CL) laryngeal view. Following completion of this development, the MSL was launched with the prehospital airway simulator to distant communities utilizing a single facilitator/driver. Paramedics were recruited to perform ETI in the MSL, and the detailed airway management observations were stored for further analysis.ResultsNineteen airway experts performed 57 ETI attempts at varying tongue pressures demonstrating increased CL views at higher tongue pressures. Tongue pressure of 60 mm Hg generated 31% Grade 3/4 CL view and was chosen for the prehospital trials. The MSL was launched and tested by 18 paramedics. First pass success was 33% with another 33% failing to intubate within three attempts.ConclusionsThe MSL created was configured to deliver, record, and assess intubator behaviors with a difficult airway simulation. The MSL created a reproducible, high fidelity, mobile learning environment for assessment of simulated ETI performance by prehospital providers.BischofJJ, PanchalAR, FinneganGI, TerndrupTE. Creation and validation of a novel mobile simulation laboratory for high fidelity, prehospital, difficult airway simulation. Prehosp Disaster Med. 2016;31(5):465–470.

Background The Emergency Medicine (EM) Milestone Project provides guidance for assessment of resident trainee airway management proficiency (PC10). Although milestones provide a general structure for assessment, they do not define performance standards. The objective of this project was to establish comprehensive airway management performance standards for EM trainees at both novice and mastery levels of proficiency. Methods Comprehensive airway management standards were derived using standard-setting procedures. A panel of residency education and airway management experts was convened to determine how trainees would be expected to perform on 51 individual tasks in a standardized airway management simulation encompassing preparation, endotracheal intubation, backup airway use, and ventilation. Experts participated in facilitated exercises in which they were asked to 1) define which items were critical for patient safety, 2) predict the performance of a "novice" learner, and 3) predict the performance of a "mastery" learner nearing independent practice. Experts were given a worksheet to complete and descriptive statistics were calculated using STATA 14. Results Experts identified 39 of 51 (76%) airway management items as critical for patient safety. Experts also noted that novice trainees do not need to complete all the items deemed to be critical prior to starting practice since they will be supervised by a board-certified EM physician. In contrast, mastery-level trainees would be expected to successfully complete not only the critical tasks, but also nearly all the items in the assessment (49/51, 96%) since they are nearing independent practice. Conclusion In this study, we established EM resident performance standards for comprehensive airway management during a simulation scenario. Future work will focus on validating these performance standards in current resident trainees as they move from simulation to actual patient care.

Background: Incivility, defined as negative interpersonal acts that violate workplace and social norms, has been linked to negative outcomes in healthcare settings. A minimal amount is known regarding workplace incivility among emergency medical services (EMS) professionals. Our objectives were to (1) evaluate the prevalence of incivility and factors associated with experiencing workplace incivility; (2) describe the association between incivility and workforce-reducing factors (stress, career satisfaction, turnover intentions, and workplace absences); and (3) quantify the association between incivility and the organizational culture of an EMS agency. Methods: A random sample of 38,000 nationally-certified EMS professionals received an electronic questionnaire with an EMS-adapted Workplace Incivility Scale, the Competing Values Framework organizational culture scale, and factors that may negatively impact the EMS workforce. All completed surveys from nonmilitary EMS professionals currently providing patient care at the EMT level or higher were included in these analyses. We constructed multivariable logistic regression models (OR, 95% CI) to identify factors associated with experiencing workplace incivility and to examine the associations between experiencing incivility and workforce-reducing factors. We calculated univariable odds ratios to assess the association between organizational culture type and incivility. Results: A total of 3,741 EMS professionals responded to the survey (response rate =10.3%), with 2,815 (75.2%) meeting inclusion criteria. Incivility from supervisors or coworkers was experienced at least once a week by 47.4% of respondents. Factors associated with increased odds of experiencing incivility included female sex, AEMT/paramedic certification level, increasing years of EMS experience, service types other than 9-1-1 response, and higher weekly call volumes. Exposure to regular incivility was associated with increased odds of dissatisfaction with EMS, a main EMS job or a main supervisor; moderate or higher stress levels; intent to leave one’s job and EMS in the next 12 months; and 10 or more workplace absences in the past 12 months. The organizational culture type “market” was associated with the greatest odds of incivility. Conclusions: Nearly half of respondents experienced incivility once a week or more, and incivility was associated with potential workforce-reducing factors. Further research is needed to understand how organizational climate and interpersonal behaviors in the workplace affect the EMS workforce.

Author(s): Le Parc, Joanna M.; Bischof, Jason J.; King, Andrew M.; Greenberger, Sarah; Way, David P.; Panchal, Ashish R.; Finnegan, Geoffrey I.; Terndrup, Thomas E. | Abstract: Introduction: Emergency endotracheal intubation (ETI) is a common and critical procedure performed in both prehospital and in-hospital settings. Studies of prehospital providers have demonstrated that rescuer position influences ETI outcomes. However, studies of in-hospital rescuer position for ETI are limited. While we adhere to strict standards for the administration of ETI, we posited that perhaps requiring in-hospital rescuers to stand for ETI is an obstacle to effectiveness. Our objective was to compare in-hospital emergency medicine (EM) trainees’ performance on ETI delivered from both the seated and standing positions.Methods: EM residents performed ETI on a difficult airway mannequin from both a seated and standing position. They were randomized to the position from which they performed ETI first. All ETIs were recorded and then scored using a modified version of the Airway Management Proficiency Checklist. Residents also rated the laryngeal view and the difficulty of the procedure. We analyzed comparisons between ETI positions with paired t-tests.Results: Forty-two of our 49 residents (85.7%) participated. Fifteen (35.7%) were female, and all three levels of training were represented. The average number of prior ETI experiences among our subjects was 44 (standard deviation=34). All scores related to ETI performance were statistically equivalent across the two positions (performance score, number of attempts, time to intubation success, and ratings of difficulty and laryngeal view). We also observed no differences across levels of training.Conclusion: The position of the in-hospital provider, whether seated or standing, had no effect on the provider’s ETI performance. Since environmental circumstances sometimes necessitate alternative positioning for effective ETI administration, our findings suggest that there may be value in training residents to perform ETI from both positions.

The widespread availability of ultrasound (US) technology has increased its use for point of care applications in many health care settings. Foc used (point of care) US is defined as the act of bringing US evaluation to the bedside for real-time performance. These images are collected immediately by the practitioner, allowing for direct integration into the physician’s medical decision-making process. The real-time bedside diagnostic ability of US becomes a key tool for the management of patients. The purpose of this review is to (1) provide a general description of the use of focused US for bedside procedures; (2) specify the indications and common techniques used in bedside US procedures; and (3) describe the techniques used for each bedside intervention.

Stroke is the leading cause of disability in the United States and new evidence shows interventional procedures provide better outcomes for large vessel occlusions (LVO). We performed a systematic review of the literature on prehospital stroke scales used to identify LVOs comparing the scales with analysis of the sensitivity, specificity, and predictive values. The goal was to determine if emergency medical services (EMS) are able to accurately identify LVO in the field.In this systematic review, multiple databases were searched for articles that addressed our goal. The identified studies were evaluated for their statistical performance of various stroke scales. In addition, we assessed biases that may explain the varying results reported.Eight studies encompassing 6787 patients were included in our systematic review. Of the 8 studies, 6 were retrospective studies, 1 was a prospective cohort, and 1 was a prospective observational study. Sensitivities of the studies ranged from 49% to 91% while specificity of the studies varied from 40% to 94%.At this time, further evaluations must be done in the prehospital setting to determine the ease of use and true sensitivity and specificity of these scales in identifying LVOs.

Background Cardiac arrest ( CA ) is a leading cause of death in the United States, claiming over 450 000 lives annually. Improving survival depends on the ability to conduct CA research and on the translation and implementation of research findings into practice. Our objective was to provide a descriptive analysis of annual National Institutes of Health ( NIH ) funding for CA research over the past decade. Method and Results A search within NIH Re PORTER for the years 2007 to 2016 was performed using the terms: “cardiac arrest” or “cardiopulmonary resuscitation” or “heart arrest” or “circulatory arrest” or “pulseless electrical activity” or “ventricular fibrillation” or “resuscitation.” Grants were reviewed and categorized as CA research (yes/no) using predefined criteria. The annual NIH funding for CA research, number of individual grants, and principal investigators were tabulated. The total NIH investment in CA research for 2015 was calculated and compared to those for other leading causes of death within the United States. Interrater reliability among 3 independent reviewers for fiscal year 2015 was assessed using Fleiss κ. The search yielded 2763 NIH ‐funded grants, of which 745 (27.0%) were classified as CA research (κ=0.86 [95% CI 0.80‐0.93]). Total inflation‐adjusted NIH funding for CA research was $35.4 million in 2007, peaked at $76.7 million in 2010, and has decreased to $28.5 million in 2016. Per annual death, NIH invests ≈$2200 for stroke, ≈$2100 for heart disease, and ≈$91 for CA. Conclusions This analysis demonstrates that the annual NIH investment in CA research is low relative to other leading causes of death in the United States and has declined over the past decade.

Feedback to EMS professionals is a critical component for optimizing patient care and outcomes in the prehospital setting. There is a paucity of data concerning the feedback received by prehospital providers.The objective of this study was to describe the prevalence of feedback received by EMS professionals in the past 30 days including the types, sources, modes, and utility of feedback. The secondary objective was to identify factors associated with receiving any feedback and, specifically, feedback regarding medical care provided.This was a cross-sectional survey examining currently practicing nationally certified EMS patient care providers (EMT or higher) in non-military and non-tribal settings. Data were collected on provider characteristics along with feedback received. Descriptive statistics were calculated, and multivariable logistic regression models were constructed to assess the relationship between EMS provider characteristics and receiving feedback. A non-respondent survey was administered to assess for non-response bias.Responses from 32,314 EMS providers were received (response rate = 10.4%) with 15,766 meeting inclusion criteria. In the 30 days preceding the survey, 69.4% (n = 10,924) of respondents received at least one type of feedback with 54.7% (n = 8,592) reporting receiving medical care feedback. Multivariable logistic regression modeling indicated that higher certification level, fewer years of experience in EMS, working for a hospital-based agency, air medical service, and higher weekly call volumes were significantly associated with increased odds of having received at least one type of feedback, and specifically medical care feedback. Additionally, providing primarily medical/convalescent transport and more years of EMS experience were significantly associated with decreased odds of receiving feedback.Feedback to EMS providers is critical to improving prehospital care. In this study, nearly a third of providers did not receive any feedback in a 30-day period, and nearly half reported not receiving medical care feedback. Disparities in the frequency of feedback exist between different provider levels and service settings, while reported feedback decreased with years of experience in the profession. Future work is needed to assess the content of feedback and role in improving patient care and safety.

To develop and derive an instrument for assessing airway management proficiency for paramedics.Using a validated difficult airway model simulation, we recorded responses to a standard traumatic brain injury scenario requiring airway management in 197 certified paramedics. Discrete items (N = 131) were developed by an expert panel, and referenced to three performance standard subscales (i.e., intubation, ventilation, and backup airway). Responses were scored and subjected to an iterative process to create a more practical number of items for the final Airway Management Proficiency Checklist (AMPC). Tetrachoric correlations were used to evaluate items for relevance. Kuder-Richardson Formula 20 reliabilities were used to assess internal consistency among checklist items. Finally, a Rasch analysis on each subscale was performed to evaluate items for measurement quality. Items were retained if they were determined to fit the Rasch Model.Items were deleted from the final AMPC for lack of simulation fidelity (26 items), duplicity (15 items), and poor psychometric quality (39 items). In four additional iterations, items were dropped for lack of equipment options (e.g., single mask), lack of instructional clarity (e.g., calculation of GCS score), high inference on the part of the evaluator (6 items), or inadequate measurement of behavioral performance (e.g., passes blade through lips without contacting mouth or teeth). Thirty seven items and three outcome standards (first pass success of the endotracheal tube; assisted ventilation with no interruption of 30 seconds or greater; successful placement of a backup airway device within one attempt) were retained to form three hypothesized subscales.The AMPC represents a psychometrically derived instrument that identified important tasks required for comprehensive airway management. The 37-item instrument will contribute to improving training and measuring the performance of paramedic's airway management skills.

Objectives: Emergency medical services (EMS) professionals often work long hours at multiple jobs and endure frequent exposure to traumatic events. The stressors inherent to the prehospital setting may increase the likelihood of experiencing burnout and lead providers to exit the profession, representing a serious workforce and public health concern. Our objectives were to estimate the prevalence of burnout, identify characteristics associated with experiencing burnout, and quantify its relationship with factors that negatively impact EMS workforce stability, namely sickness absence and turnover intentions. Methods: A random sample of 10,620 emergency medical technicians (EMTs) and 10,540 paramedics was selected from the National EMS Certification database to receive an electronic questionnaire between October, 2015 and November, 2015. Using the validated Copenhagen Burnout Inventory (CBI), we assessed burnout across three dimensions: personal, work-related, and patient-related. We used multivariable logistic regression modeling to identify burnout predictors and quantify the association between burnout and our workforce-related outcomes: reporting ten or more days of work absence due to personal illness in the past 12 months, and intending to leave an EMS job or the profession within the next 12 months. Results: Burnout was more prevalent among paramedics than EMTs (personal: 38.3% vs. 24.9%, work-related: 30.1% vs. 19.1%, and patient-related: 14.4% vs. 5.5%). Variables associated with increased burnout in all dimensions included certification at the paramedic level, having between five and 15 years of EMS experience, and increased weekly call volume. After adjustment, burnout was associated with over a two-fold increase in odds of reporting ten or more days of sickness absence in the past year. Burnout was associated with greater odds of intending to leave an EMS job (personal OR:2.45, 95% CI:1.95–3.06, work-related OR:3.37, 95% CI:2.67–4.26, patient-related OR: 2.38, 95% CI:1.74–3.26) or the EMS profession (personal OR:2.70, 95% CI:1.94–3.74, work-related OR:3.43, 95% CI:2.47–4.75, patient-related OR:3.69, 95% CI:2.42–5.63). Conclusions: The high estimated prevalence of burnout among EMS professionals represents a significant concern for the physical and mental well-being of this critical healthcare workforce. Further, the strong association between burnout and variables that negatively impact the number of available EMS professionals signals an important workforce concern that warrants further prospective investigation.

Objectives To evaluate the effect on outcomes of the Ohio Department of Public Safety statewide geriatric triage criteria, established in 2009 for emergency medical services (EMS) to use for injured individuals aged 70 and older. Design Retrospective cohort study of the Ohio Trauma Registry. Setting All hospitals in Ohio. Participants Individuals aged 70 and older in the Ohio Trauma Registry from January 2006 through December 2011, 3 years before and 3 years after criteria adoption (N = 34,499). Measurements Primary outcomes were in-hospital mortality and discharge to home. Criteria effects were assessed using chi-square tests, multivariable logistic regression, interrupted time series plots, and multivariable segmented regression models. Results After geriatric criteria were adopted, the proportion of older adults qualifying for trauma center transport increased from 44% to 58%, but EMS transport rates did not change (44% vs 45%). There was no difference in unadjusted mortality (7.1% vs 6.6%) (P = .10). In adjusted analyses, subjects with an injury severity score (ISS) less than 10 had lower mortality after adoption (3.0% vs 2.5%) (odds ratio (OR) = 0.81, 95% confidence interval (CI) = 0.70–0.95, P = .01). Discharge to home increased after adoption in the adjusted analysis (OR = 1.06, 95% CI = 1.01–1.11, P = .02). There were no time-dependent changes for either outcome. Conclusion Although the proportion of older adults meeting criteria for trauma center transport substantially increased with geriatric triage criteria, there were no increases in trauma center transports. Adoption of statewide geriatric triage guidelines did not decrease mortality in more severely injured older adults but was associated with slightly lower mortality in individuals with mild injuries (ISS