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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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: 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. Methods: This was a cross-sectional study of nationally-certifiedEMS professionalswho 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. Results: 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%; ptrend < 0.001) andmonths away from EMS (e.g., 0-2 months: 89%; more than 12 months: 57%; p-trend < 0.001). 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%). Conclusion: 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 EMSincluded 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. [ABSTRACT FROM AUTHOR]

This article presents a study on the relationship between traffic-related air pollution (TRAP) and recurrent wheeze in children. The study found that there was no significant association between TRAP and recurrent wheeze in healthy children, but there was a significant association among children who had severe bronchiolitis during infancy. This suggests that severe bronchiolitis modifies the relationship between TRAP exposure and recurrent wheeze. The study highlights the need for further research on TRAP and other respiratory outcomes in later childhood to gain a better understanding of the long-term effects of TRAP on respiratory health. [Extracted from the article]

Objectives: Evidence-based guidelines (EBGs) are widely recognized as valuable tools to aggregate and translate scientific knowledge into clinical care. High-quality EBGs can also serve as important components of dissemination and implementation efforts focused on educating emergency medical services (EMS) clinicians about current evidence-based prehospital clinical care practices and operations. We aimed to perform the third biennial systematic review of prehospital EBGs to identify and assess the quality of prehospital EBGs published since 2021., Methods: We systematically searched Ovid Medline and EMBASE from January 1, 2021, to June 6, 2023, for publications relevant to prehospital care, based on an organized review of the literature, and focused on providing recommendations for clinical care or operations. Included guidelines were appraised using the National Academy of Medicine (NAM) criteria for high-quality guidelines and scored using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Tool., Results: We identified 33 new guidelines addressing clinical and operational topics of EMS medicine. The most addressed EMS core content areas were time-life critical conditions (n = 17, 51.5%), special clinical considerations (n = 15, 45%), and injury (n = 12, 36%). Seven (21%) guidelines included all elements of the National Academy of Medicine (NAM) criteria for high-quality guidelines, including the full reporting of a systematic review of the evidence. Guideline appraisals by the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool demonstrated modest compliance to reporting recommendations and similar overall quality compared to previously identified guidelines (mean overall domain score 67%, SD 12%), with Domain 5 ("Applicability") scoring the lowest of the six AGREE II domains (mean score of 53%, SD 13%)., Conclusions: This updated systematic review identified and appraised recent guidelines addressing prehospital care and identifies important targets for education of EMS personnel. Continued opportunities exist for prehospital guideline developers to include comprehensive evidence-based reporting into guideline development to facilitate widespread implementation of high-quality EBGs in EMS systems and incorporate the best available scientific evidence into initial education and continued competency activities.

People who experience out-of-hospital cardiac arrest often require care at a regional center for continued treatment after resuscitation, but many do not initially present to the hospital where they will be admitted. For patients who require interfacility transport after cardiac arrest, the decision to transfer between centers is complex and often based on individual clinical characteristics, resources at the presenting hospital, and available transport resources. Once the decision has been made to transfer a patient after cardiac arrest, there is little direct guidance on how best to provide interfacility transport. Accepting centers depend on transferring emergency departments and emergency medical services professionals to make important and nuanced decisions about postresuscitation care that may determine the efficacy of future treatments. The consequences of early care are greater when transport delays occur, which is common in rural areas or due to inclement weather. Challenges of providing interfacility transfer services for patients who have experienced cardiac arrest include varying expertise of clinicians, differing resources available to them, and nonstandardized communication between transferring and receiving centers. Although many aspects of care are insufficiently studied to determine implications for specific out-of-hospital treatment on outcomes, a general approach of maintaining otherwise recommended postresuscitation care during interfacility transfer is reasonable. This includes close attention to airway, vascular access, ventilator management, sedation, cardiopulmonary monitoring, antiarrhythmic treatments, blood pressure control, temperature control, and metabolic management. Patient stability for transfer, equity and inclusion, and communication also must be considered. Many of these aspects can be delivered by protocol-driven care.

Objective: Our objective was to identify the hospital- and community-related factors associated with the hospital-level rate of potentially unnecessary interfacility transfers (IFTs) for pediatric patients with asthma exacerbations., Methods: We analyzed California Emergency Department (ED) data from 2016 to 2019 to capture ED visits where a pediatric patient (age, 2-17 years) presented with an asthma exacerbation and was transferred to another ED or acute care hospital. The primary outcome was hospital-level rate of potentially unnecessary IFTs, defined as a visit where length of stay after transfer was <24 hours and no advanced services (eg, critical care) were used. Hospital- and community-related characteristics included urbanicity, teaching hospital status, availability of pediatric resources in the sending facility and patient's community, pediatric patient volume, and Social Vulnerability Index. We described and compared hospitals in the top quartile of potentially unnecessary IFT rate versus all others and used a multivariable modified Poisson model to identify factors associated with potentially unnecessary IFT., Results: A total of 325 sending hospitals were included, with a median 573 pediatric asthma visits (interquartile range, 183-1309) per hospital annually. Nearly half of the hospitals (145/325, 45%) sent a potentially unnecessary IFT. Most (90%) hospitals were urban, 9% were teaching hospitals, 5% had >500 beds, and 22% had a pediatric ED on-site. Factors associated with higher adjusted prevalence of potentially unnecessary IFT included availability of pediatric telehealth (prevalence ratio [PR], 1.5; 95% confidence interval [CI], 1.2-2.0), increased pediatric volume (eg, <1800 vs ≥10,000 visits: PR, 2.6; 95% CI, 1.4-4.7), and higher community Social Vulnerability Index (PR, 1.5; 95% CI, 1.1-1.9)., Conclusions: Several hospital- and community-related factors were associated with potentially unnecessary IFTs among pediatric patients presenting to the ED with asthma exacerbations. These findings provide insight into disparities in potentially unnecessary IFT across communities and can guide the development of future interventions., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Telehealth capacity may be an important component of pandemic response infrastructure. We aimed to examine changes in the telehealth use by the US emergency departments (EDs) during COVID-19, and to determine whether existing telehealth infrastructure or increased system integration were associated with increased likelihood of use. Methods: We analyzed 2016-2020 National ED Inventory (NEDI)-USA data, including ED characteristics and nature of telehealth use for all US EDs. American Hospital Association data characterized EDs' system integration. An ordinary least-squares regression model obtained one-step-ahead forecast of the expected proportion of EDs using telehealth in 2020 based on growth observed from 2016 to 2019. Among EDs without telehealth in 2019, we used logistic regression models to examine whether system membership or existing telehealth infrastructure were associated with odds of innovation in telehealth use in 2020, accounting for ED characteristics. Results: Of 4,038 EDs responding to telehealth questions in 2019 and 2020 (73% response rate), 3,015 used telehealth in 2020. Telehealth use by US EDs increased more than expected in 2020 (2016: 58%, 2017: 61%, 2018: 65%, 2019: 67%, 2020: 74%, greater than predicted 71%, p = 0.004). Existing telehealth infrastructure was associated with increased telehealth innovation (OR = 1.88, 95% CI: 1.49-2.36), whereas hospital system membership was not (odds ratio [OR] = 1.00, 95% confidence interval [CI]: 0.80-1.25). Conclusions: Telehealth use by US EDs in 2020 grew more than expected and preexisting telehealth infrastructure was associated with increased innovation in its use. Preparation for future pandemic responses may benefit from considering strategies to invest in local infrastructure to facilitate technology adoption and innovation.

Background: Prehospital obstetric events, including out-of-hospital deliveries and their complications, are a rare but high-risk event encountered by emergency medical services (EMS). Understanding the epidemiology of these encounters would help identify strategies to improve prehospital obstetric care. Our objective was to determine the characteristics of out-of-hospital deliveries and high-risk complications treated by EMS clinicians in the U.S., Methods: We conducted a cross-sectional analysis of EMS patient care records in the 2018 and 2019 National EMS Information System Public Release Version 3.4 datasets. We included EMS activations after a 9-1-1 scene response for patients aged 12-50 years with evidence of an out-of-hospital delivery or delivery complication, or where the patient was a newborn aged 0-<6 h. We examined patient, community, emergency response, and clinical characteristics using descriptive statistics., Results: Of the 56,735,977 EMS activations included in the 2018 and 2019 datasets, there were 8,614 out-of-hospital deliveries, 1,712 delivery complications, and 5,749 records for newborns. Most maternal (76%) out-of-hospital deliveries involved patients between the ages of 20-34 years, occurred on a weekday (73%), were treated by an advanced life support crew (85%), and occurred in a home or residence (73%). EMS-assisted field delivery was documented in 3,515 (34%) of all maternal activations but only 2% of activations with a delivery complication. Few patients received an EMS-administered medication (e.g., 0.4% received oxytocin). Supplemental oxygen was administered in 870 (15%) of newborn activations. Activations from counties with the most racial/ethnic diversity were more often treated by a BLS-level unit (16% vs. 12%, p  < 0.001), and activations from rural areas had significantly longer transport times (19.7 min [IQR 8.7, 32.8] vs. urban, 13.1 min [IQR 8.7, 19.7], p  < 0.001)., Conclusion: In this large, national repository of EMS patient care records from across the U.S., most activations for out-of-hospital delivery, delivery complication, or a newborn included only routine EMS care. There were potential disparities in level of care, clinical care provided, and measures of access to definitive care based on maternal and community factors. We also identified gaps in current practice, such as for postpartum hemorrhage, that could be addressed with changes in EMS clinical protocols and regulations.

Aim: We describe emergency medical services (EMS) protocols and prehospital practice patterns related to traumatic cardiac arrest (TCA) management in the U.S., Methods: We examined EMS management of TCA by 1) assessing variability in recommended treatments in state EMS protocols for TCA and 2) analyzing EMS care using a nationwide sample of EMS activations. We included EMS activations involving TCA in adult (≥18 years) patients where resuscitation was attempted by EMS. Descriptive statistics for recommended and actual treatments were calculated and compared between blunt and penetrating trauma using χ 2 and independent 2-group Mann-Whitney U tests., Results: There were 35 state EMS protocols publicly available for review, of which 16 (45.7%) had a specific TCA protocol and 17 (48.5%) had a specific termination of resuscitation protocol for TCA. Recommended treatments varied. We then analyzed 9,565 EMS activations involving TCA (79.1% blunt, 20.9% penetrating). Most activations (93%) were managed by advanced life support. Return of spontaneous circulation was achieved in 25.5% of activations, and resuscitation was terminated by EMS in 26.4% of activations. Median prehospital scene time was 16.4 minutes; scene time was shorter for penetrating mechanisms than blunt (12.0 vs 17.0 min, p < 0.001). Endotracheal intubation was performed in 32.0% of activations, vascular access obtained in 66.6%, crystalloid fluids administered in 28.8%, and adrenaline administered in 60.1%., Conclusion: Actual and recommended approaches to EMS treatment of TCA vary nationally. These variations in protocols and treatments highlight the need for a standardized approach to prehospital management of TCA in the U.S., (Copyright © 2022 Elsevier B.V. All rights reserved.)

The burgeoning occupational callings literature has shown that feeling called to a job is associated with an array of positive job-, career-, and health-related outcomes. However, recent studies have begun to indicate that there may also be a "negative side" of callings. The present study builds on this emerging perspective to examine whether feeling called to a job makes helping professionals more vulnerable to the negative effects of acute stressors. Specifically, we integrated identity, cognitive rumination, and psychological detachment theories to explain how feeling called to one's job (i.e., the strength of one's calling intensity) might bolster the negative, indirect relationship between emotionally disturbing work and strain (i.e., mental exhaustion, sleep quality, and alcohol consumption) through negative work rumination. Results from a 10-week diary study with a national U.S. sample of 211 paramedics revealed that on weeks that paramedics experienced more emotionally disturbing work, they engaged in greater levels of negative work rumination, which in turn was associated with greater mental exhaustion and worse sleep quality, but not greater alcohol consumption. In addition, calling intensity moderated the indirect effect of emotionally disturbing work on both mental exhaustion and sleep quality, such that these indirect effects were stronger among those with higher (vs. lower) levels of calling intensity. These results provide evidence that employees who feel most called to their jobs may be particularly vulnerable to short-term negative outcomes associated with emotionally disturbing work. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The care of severely burned patients comes with unique requirements for specialized burn centers. The American Burn Association sets guidelines for burn centers and provides a voluntary program to verify their quality of care. However, not all burn centers are verified, and it is unclear which nonverified centers have met requirements set by their state health departments. To compile a complete database of all U.S. emergency departments in facilities with confirmed burn centers, we investigated state requirements to supplement data from the American Burn Association verification process. In 2020, only 13 states set requirements for burn centers; 3 states explicitly required American Burn Association verification, 4 used modified American Burn Association criteria, and 6 used alternate criteria. Only two states had separate requirements for pediatric burn centers. Based on adherence to state and American Burn Association criteria, we identified 90 confirmed burn centers in 2020, 85 of which had emergency departments. Of these 85, 45 (53%) were only verified, 17 (20%) were only state-confirmed, and 23 (27%) were both. Emergency departments in a confirmed burn center were more likely-than those without-to have higher adult and pediatric visit volumes, be academic, be a stroke or trauma (adult or pediatric) center, have a dedicated pediatric area, and have a pediatric emergency care coordinator. We compiled the first unified burn center database that incorporates state and American Burn Association lists. This database can be utilized in future health services research and is available to the public through a smartphone application., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: As the COVID-19 pandemic began, there were significant concerns for the strength and stability of the emergency medical services (EMS) workforce. These concerns were heightened with the closure of examination centers and the cessation of certification examinations. The impact of this interruption on the EMS workforce is unclear. Our objective was to evaluate the impact of COVID-19 on initial EMS certification in the United States. In addition, we evaluated mitigation measures taken to address these interruptions., Methods: This study was a cross-sectional evaluation of the National Certification Cognitive Examination administration and results for emergency medical technician (EMT) and paramedic candidates. We compared the number of examinations administered and first-attempt pass rates in 2020 (pandemic) to 2019 (control). Descriptive statistics and 2 one-sided tests of equivalence were used to assess if there was a relevant difference of ±5 percentage points., Results: Total number of examinations administered decreased by 15% (EMT, 14%; paramedic, 7%). Without the addition of EMT remote proctoring, the EMT reduction would have been 35%. First-time pass rates were similar in both EMT (-0.9%) and paramedic (-1.9%) candidates, which did not meet our threshold of a relevant difference., Conclusion: COVID-19 has had a measurable impact on examination administration for both levels of certification. First-time pass rates remained unaffected. EMT remote proctoring mitigated some of the impact of COVID-19 on examination administration, although a comparison with mitigation was not assessed. These reductions indicate a potential decrease in the newly certified workforce, but future evaluations will be necessary to assess the presence and magnitude of this impact., Competing Interests: These data were presented as a poster presentation at the 2020 National Association of EMS Physicians Annual Meeting (January 10, 2020; San Diego, CA). The authors report no additional conflict of interest., (© 2022 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Introduction: It is unclear how best to identify "high-risk" areas for out-of-hospital cardiac arrest (OHCA) and if neighborhood-level interventions improve bystander cardiopulmonary resuscitation (BCPR). Our objectives were to 1) identify and compare community characteristics between high and low-risk neighborhoods; and 2) examine change in BCPR after a targeted hands-only CPR intervention., Methods: This was a cross-sectional analysis of OHCA events in Franklin County, Ohio between 1/1/2010-12/31/2017. Adult (≥18 years) OHCAs in a non-healthcare setting with emergency medical services resuscitation attempted were included. High-risk neighborhoods based on OHCA incidence and BCPR rates were identified using global Empirical Bayes, Local Moran's I, and spatial scan statistic. We compared characteristics of high and low-risk neighborhoods and examined change in BCPR., Results: From the 3,841 included OHCAs, the mean adjusted OHCA incidence per census tract was 0.81 per 1,000, BCPR rate was 37.2%, and survival to hospital discharge was 11.5%. Of the 35 census tracts identified as high-risk, ten persisted from previous work. OHCA incidence was higher in high-risk neighborhoods (1.30 per 1,000 vs. 0.73, p < 0.001) and BCPR rates were lower (30.2% vs. 38.5%, p < 0.001). There were significant differences in characteristics between high and low-risk neighborhoods (e.g., Black population: 45.3% vs. 25.7%, p < 0.001). The neighborhoods targeted for the community education intervention had similar pre- and post-intervention BCPR rates., Conclusions: Demographic and socioeconomic characteristics differed between high- and low-risk neighborhoods. BCPR rates were lower in high-risk neighborhoods despite a targeted BCPR intervention. Educational interventions may be necessary, but not sufficient, to improve OHCA outcomes., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

Background: Optimal care for patients with stroke relies on timely recognition and rapid transport to appropriate treatment, often by emergency medical services (EMS). Our primary objective was to describe EMS time intervals for patients with suspected stroke in the United States. We also sought to quantify the variation in EMS time intervals by geographic location and urbanicity., Methods: We conducted a cross-sectional evaluation of EMS 9-1-1 activations (ie, calls for service) included in the 2018 and 2019 National EMS Information System datasets. We included ground or air EMS activations for a 9-1-1 scene response where a patient aged ≥18 years with suspected stroke was treated and transported by EMS. Time intervals for dispatch, response, scene, transport, and total prehospital time (ie, from dispatch to hospital arrival) were calculated, stratified by ground and air transport type., Results: A total of 410 187 activations for suspected stroke were included, of which 98% were a ground transport. The median total prehospital time for ground transports was 35 minutes (interquartile range, 27-45, 90th percentile 58). Median total prehospital time for air transports was substantially longer at 56 minutes (interquartile range, 43-70, 90th percentile 86). Times varied by Census division and urbanicity with the shortest ground total prehospital times in the East North Central division and urban areas and longest times in the East South Central and rural and frontier areas., Conclusions: Timely EMS response and transport is critical for optimizing care of patients with suspected stroke. Using a large, national dataset of EMS activations, we found variations by geographic location and urbanicity in total prehospital time for ground and air EMS activations for patients with stroke.

Objective: Evaluating organizational safety culture is critical for high-stress, high-risk professions such as prehospital emergency medical services (EMS). The aim of the study was to evaluate the psychometric properties of a safety culture instrument for EMS, based on the Agency for Healthcare Research and Quality's widely used Surveys on Patient Safety Culture (SOPS)., Methods: The final EMS-adapted instrument consisted of 37 items covering 11 safety culture domains including 10 domains from existing SOPS instruments and one new domain for communication while en route to an emergency call. The analysis sample included 23,029 nationally certified EMS providers. Domain structure was evaluated on two separate halves of the data set through confirmatory factor analysis using a polychoric correlation matrix for ordinal data. The reliability and validity of each domain were evaluated using Cronbach α and Pearson correlation coefficients., Results: The confirmatory factor analysis supported the 11-domain model. All items loaded above the 0.4 threshold (range = 0.508-0.984). Three composite domains exhibited factor variance below the 0.5 threshold: staffing (0.32), communication about incidents (0.26), and handoffs (0.26). Floor and ceiling effects were not detected. Inter-item consistency exceeded 0.6 for all subscales (α = 0.65-0.88). Predictive validity was supported as all domain composites were correlated with the outcome variables of overall safety rating (r = 0.44-0.72) and frequency of event reporting (r = 0.31-0.48)., Conclusions: Overall, the EMS-adapted tool demonstrated adequate psychometric properties consistent with those of existing SOPS instruments. Additional research is needed to evaluate the instrument's performance at the agency level and its correlation with safety outcomes in the prehospital setting., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Prehospital obstetric events encountered by emergency medical services (EMS) can be high-risk patient presentations for which suboptimal care can cause substantial morbidity and mortality. The frequency of prehospital obstetric events is unclear because existing descriptions have reported obstetric and gynecological conditions together, without delineating specific patient presentations. Our objective was to identify the types, frequency, and acuity of prehospital obstetric events treated by EMS personnel in the US., Methods: We conducted a cross-sectional analysis of EMS patient care records in the 2018 National EMS Information System dataset (n=22,532,890). We focused on EMS activations (i.e., calls for service) for an emergency scene response for patients aged 12-50 years with evidence of an obstetric event. Type of obstetric event was determined by examining patient symptoms, the treating EMS provider's impression (i.e., field diagnosis), and procedures performed. High patient acuity was ascertained by EMS documentation of patient status and application of the modified early obstetric warning system (MEOWS) criteria, with concordance assessed using Cohen's kappa. Descriptive statistics were calculated to describe the primary symptoms, impressions, and frequency of each type of obstetric event among these activations., Results: A total of 107,771 (0.6%) of EMS emergency activations were identified as involving an obstetric event. The most common presentation was early or threatened labor (15%). Abdominal complaints, including pain and other digestive/abdomen signs and symptoms, was the most common primary symptom (29%) and primary impression (18%). We identified 3,489 (3%) out-of-hospital deliveries, of which 1,504 were preterm. Overall, EMS providers documented 34% of patients as being high acuity, similar to the MEOWS criteria (35%); however, there were high rates of missing data for EMS documented acuity (19%), poor concordance between the two measures (Cohen's kappa=0.12), and acuity differences for specific conditions (e.g., high acuity of non-cephalic presentations, 77% in EMS documentation versus 53% identified by MEOWS)., Conclusion: Prehospital obstetric events were infrequently encountered by EMS personnel, and about one-third were high acuity. Additional work to understand the epidemiology and clinical care of these patients by EMS would help to optimize prehospital care and outcomes., (© 2021. The Author(s).)

Objective: Given the variability in crisis standards of care (CSC) guidelines during the COVID-19 pandemic, we investigated the racial and ethnic differences in prioritization between 3 different CSC triage policies (New York, Massachusetts, USA), as well as a first come, first served (FCFS) approach, using a single patient population., Methods: We performed a retrospective cohort study of patients with intensive care unit (ICU) needs at a tertiary hospital on its peak COVID-19 ICU census day. We used medical record data to calculate a CSC score under 3 criteria: New York, Massachusetts with full comorbidity list (Massachusetts1), and MA with a modified comorbidity list (Massachusetts2). The CSC scores, as well as FCFS, determined which patients were eligible to receive critical care under 2 scarcity scenarios: 50 versus 100 ICU bed capacity. We assessed the association between race/ethnicity and eligibility for critical care with logistic regression., Results: Of 211 patients, 139 (66%) were male, 95 (45%) were Hispanic, 23 (11%) were non-Hispanic Black, and 69 (33%) were non-Hispanic White. Hispanic patients had the fewest comorbidities. Assuming a 50 ICU bed capacity, Hispanic patients had significantly higher odds of receiving critical care services across all CSC guidelines, except FCFS. However, assuming a 100 ICU bed capacity, Hispanic patients had greater odds of receiving critical care services under only the Massachusetts2 guidelines (odds ratio, 2.05; 95% CI, 1.09 to 3.85)., Conclusion: Varying CSC guidelines differentially affect racial and ethnic minority groups with regard to risk stratification. The equity implications of CSC guidelines require thorough investigation before CSC guidelines are implemented., Competing Interests: None., (© 2021 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Background: The US older adult population (age ≥65 years) is increasing and may be at increased risk for severe anaphylaxis. Little is known about the health care use for acute allergic reactions (AAR), including anaphylaxis, among older adults., Objective: To characterize trends in emergency department (ED) visits and hospitalizations for AAR and anaphylaxis among US older adults from 2006 to 2014 and examine factors associated with severe anaphylaxis., Methods: We performed cross-sectional analyses of trends in ED visits and hospitalizations among older adults using data from the Nationwide Emergency Department Sample and the National (Nationwide) Inpatient Sample in 2006 to 2014. We used International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes to identify visits for AAR, including anaphylaxis. Multivariable logistic regression modeling was used to identify factors associated with severe anaphylaxis (cardiac arrest, intubation, and death)., Results: In 2006 to 2014, older adults experienced approximately 1,019,967 AAR-related ED visits, 173,844 AAR-related hospitalizations, 93,795 anaphylaxis-related ED visits, and 72,677 anaphylaxis-related hospitalizations. Whereas AAR-related ED visit and hospitalization rates remained stable (P = .28 and .16, respectively), anaphylaxis-related ED visit and hospitalization rates increased significantly over time (37 visits/100,000 in 2006 to 51 in 2014, P < .001; and from 13 hospitalizations/100,000 in 2006 to 23 in 2014, P < .001), especially hospitalization rates for drug-related anaphylaxis (47 hospitalizations/100,000 in 2006 to 85 in 2014; P < .001). Risk factors for anaphylaxis-related death included older age and drug-related trigger., Conclusions: In a nationally representative sample of US older adults, the rate of anaphylaxis-related ED visits and hospitalizations increased over time. Drug-related triggers represented a substantial portion of increased health care use and are a growing risk in this vulnerable population., (Copyright © 2021 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Objective: Understanding the pattern of population risk for coronavirus disease 2019 (COVID-19) is critically important for health systems and policy makers. The objective of this study was to describe the association between neighborhood factors and number of COVID-19 cases. We hypothesized an association between disadvantaged neighborhoods and clusters of COVID-19 cases., Methods: We analyzed data on patients presenting to a large health care system in Boston during February 5-May 4, 2020. We used a bivariate local join-count procedure to determine colocation between census tracts with high rates of neighborhood demographic characteristics (eg, Hispanic race/ethnicity) and measures of disadvantage (eg, health insurance status) and COVID-19 cases. We used negative binomial models to assess independent associations between neighborhood factors and the incidence of COVID-19., Results: A total of 9898 COVID-19 patients were in the cohort. The overall crude incidence in the study area was 32 cases per 10 000 population, and the adjusted incidence per census tract ranged from 2 to 405 per 10 000 population. We found significant colocation of several neighborhood factors and the top quintile of cases: percentage of population that was Hispanic, non-Hispanic Black, without health insurance, receiving Supplemental Nutrition Assistance Program benefits, and living in poverty. Factors associated with increased incidence of COVID-19 included percentage of population that is Hispanic (incidence rate ratio [IRR] = 1.25; 95% CI, 1.23-1.28) and percentage of households living in poverty (IRR = 1.25; 95% CI, 1.19-1.32)., Conclusions: We found a significant association between neighborhoods with high rates of disadvantage and COVID-19. Policy makers need to consider these health inequities when responding to the pandemic and planning for subsequent health needs.

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: Transition from pediatric to adult care is a vulnerable time for youth with chronic diseases. In youth with rheumatic disease, studies show high rates of loss to follow up and increased disease activity. However, mortality data are lacking. In this study, we assessed whether transitional age is a risk factor for inpatient mortality., Methods: We analyzed the 2012-2014 National Inpatient Sample database, a representative sample of discharges in the United States. Individuals with rheumatic diseases were identified by International Statistical Classification of Disease - 9 (ICD-9) codes at time of discharge. Youth were categorized into three age groups: pre-transitional (11-17), transitional (18-24) and post transitional (25-31). We fitted univariable and multivariable logistic regression models to assess whether transitional age was a risk factor for inpatient mortality., Results: There were 30,269 hospital discharges which met our inclusion criteria of diagnosis and age. There were 195 inpatient deaths (0.7%). The most common causes of death were infection (39.5%), pulmonary disease (13.8%), and cardiac disease (11.2%). The Odds ratio for inpatient mortality of a transitional-aged individual was 1.18 compared to controls (p = 0.3). Black race (OR = 1.4), male sex (OR = 1.75), and a diagnosis of systemic sclerosis (OR = 4.81) or vasculitis (OR = 2.85) were the greatest risk factors of inpatient mortality., Conclusion: Transitional age was not a risk factor for inpatient mortality in this study. We did identify other risk factors other than age. Further studies are required to assess if there is an increased risk of mortality in outpatients of the transitional age group.

Background: Retention in emergency medical services (EMS) is a concern. To evaluate workforce stability within EMS, it is critical to understand factors that may lead an emergency medical technician (EMT) or paramedic to leave the profession., Objective: We compared the most important factors influencing an EMT or paramedic's decision to leave EMS and determined whether these factors differed between the two certification levels., Methods: We performed a cross-sectional analysis of an electronic questionnaire deployed to EMTs and paramedics who did not renew National EMS Certification in 2017 and were no longer working in EMS. Chi-squared tests with Bonferroni adjustment were used to compare factors between the two groups., Results: Of the 5,093 responses, 53.1% (n=2,703) were no longer practicing in EMS and were included in the analyses. The most important factor for leaving EMS was pursuing education for EMTs (20.6%) and seeking better pay/benefits for paramedics (19.6%). Excluding those considering retirement, 32.4% of EMTs and 16.4% of paramedics (p<0.001) stated an intention to return to EMS., Conclusion: EMTs and paramedics leave EMS for different reasons, and fewer paramedics reported an intention to return. The need for better pay and benefits and lack of career advancement opportunity were common themes.

Background: Inconsistent use of seat belts in an ambulance may increase the risk of injury for emergency medical services (EMS) professionals and their patients. Our objectives were to: (1) describe the prevalence of seat belt usage based on patient acuity and seat location, and (2) assess the association between EMS-related characteristics and consistent use of a seat belt., Methods: We administered a cross-sectional electronic questionnaire to a random sample of 20,000 nationally-certified EMS professionals, measuring seat belt use in each seating location of an ambulance during transport of stable, critical, or no patients. We included practicing, non-military, emergency medical technicians or higher who reported working in ambulances. We used multivariable logistic regression models to estimate the odds of consistent (≥50% of the time) use of seat belts for the rear-facing jump seat and right-sided crew bench during transport of stable and critical patients., Results: A total of 1431 respondents were included in the analysis. Patient compartment seat belt use varied with the highest use in forward-facing seats when no patient was being transported (59.8%) and lowest use in the left-side "CPR" seat with a critical patient (9.4%). Only 40.2% of respondents reported an agency policy regarding seat belt use while riding in the patient compartment. In all multivariable logistic regression models, advanced life support level certification and fewer years of experience were associated with decreased odds of consistent seat belt use. An agency seat belt policy was strongly associated with increased odds of seat belt use in the patient compartment., Conclusions: Seat belt use was low and varied by seating location and patient acuity in the patient compartment of an ambulance. Practical Applications: EMS organizations should consider primary prevention approaches of provider education, improved ambulance designs, enactment and enforcement of policies to improve seat belt compliance and provider safety., (Copyright © 2019 National Safety Council and Elsevier Ltd. All rights reserved.)

While institutional and program accreditation has long been required for physician and nursing education, paramedic program accreditation was largely voluntary in the US until recently. Our objective was to assess whether program accreditation is associated with higher pass rates and cognitive ability performance. This was a cross-sectional evaluation of the National Registry of Emergency Medical Technicians' (NREMT) Paramedic Certification cognitive examination results for graduates of US paramedic pro¬grams. Individual first-attempt and cumulative third-attempt pass rates along with first-attempt cognitive mean ability estimates (MAE) for each content area were analyzed. In 2012, 8,404 paramedic program graduates attempted the cognitive examination. The first-attempt pass rate for accredited program graduates was higher than that of their non-accredited counterparts (75.6% vs. 67.3, p<0.001). The cumulative pass rate after three attempts also was higher for accredited program graduates than for non-accredited graduates (88.9% vs 81.9%, p<0.001). Paramedic students from accredited programs demonstrated higher cognitive ability in all clinical content areas (p<0.001). Accredited program graduates had greater success on the National Paramedic Certification examination with 51% greater odds of first-time success (OR 1.51, 95%CI 1.31-1.73, p<0.001). Collectively, these results support the need for universal paramedic program accreditation.

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., Competing Interests: No conflicts of interest were reported.

Background: Use 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., Methods: A 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., Results: A 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., Conclusion: This 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. Buckland DM , Crowe RP , Cash RE , Gondek S , Maluso P , Sirajuddin S , Smith ER , Dangerfield P , Shapiro G , Wanka C , Panchal AR , Sarani B . Ketamine in the prehospital environment: a national survey of paramedics in the United States. Prehosp Disaster Med. 2018;33(1):23-28.