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Objectives: To determine the prevalence and associated risk factors of workplace violence (WPV) experienced by emergency medical services (EMS) clinicians across a large, multistate ground/air EMS agency., Methods: We used a prospective cohort study design from 1 December 2022 to 30 November 2023. A checkbox was added within the electronic medical record (EMR) asking staff to indicate whether WPV occurred. Patient characteristics, encounter (run), and crew factors were abstracted. Potential risk factors for WPV were assessed using logistic regression, with the occurrence of any form of violence as the primary outcome of interest. Models were both univariable, assessing each risk factor individually, and multivariable, assessing all risk factors together to identify independent factors associated with higher risk of WPV. Multivariable model results were reported using adjusted odds ratios (aORs) and 95% confidence intervals., Results: A total of 102,632 runs were included, 95.7% ( n  = 98,234) included checkbox documentation. There were 843 runs (0.86 per 100 runs, 95% CI 0.80-0.92) identified by EMS clinicians as WPV having occurred, including verbal abuse ( n  = 482), physical assault ( n  = 142), and both abuse and assault ( n  = 219). Risk factors for violence included male patient gender (aOR 1.45, 95% CI 1.24-1.70, p  < 0.001), Richmond Agitation-Sedation Scale (RASS) > 1 (aOR 16.97, 95% CI 13.71-21.01, p  < 0.001), and 9-1-1 runs to include emergent (P1; aOR 1.75, 95% CI: 1.17-2.63, p  = 0.007) and urgent (P2; aOR 1.64, 95% CI 1.08-2.50, p  = 0.021) priority, compared to P3/scheduled transfer or P4/trip requests. Factors associated with lower risk for violence included older patients (aOR per 10 years = 0.95, 95% CI 0.91-0.98, p  = 0.007) and run time of day between 0601-1200 h compared to 0000-0600 h (aOR 0.67, 95% CI 0.51-0.88, p  = 0.004). Only 2.7% of violent runs captured through the EMR were reported through official processes., Conclusions: Verbal and/or physical violence is recognized in nearly 1% of EMS runs. We recommend prioritizing WPV prevention and mitigation strategies around identified risk factors and simplifying the WPV reporting process in order to reduce staff administrative burden and encourage optimal capturing of violent events.

Objectives: The objectives of this study were to: (1) understand the personal impact of workplace violence (WPV) on staff within a large multistate emergency medical services (EMS) agency, (2) describe the impact of WPV on subsequent patient interactions, examining how experiences of violence affect the quality of care provided by EMS clinicians, (3) examine the influence of WPV on perceived workplace safety among prehospital personnel and its correlation with retention in the EMS field, and (4) solicit recommendations from staff for the prevention and mitigation of WPV in the future., Methods: We conducted virtual focus groups and individual interviews with 22 prehospital personnel using a descriptive qualitative design within a large multistate Midwest EMS agency between 4/5/2023-6/20/2023. Data were analyzed using Thematic Analysis to identify common perceptions among and across participants., Results: Major themes of personal impact; impact on patient interactions; influence of WPV on career longevity/sustainability; and relationship between EMS culture and WPV were identified. Overall, participants shared the perception that WPV is "part of the job", and that verbal abuse was so common that they hadn't previously considered it as violence. Participants provided several examples of WPV and described how these experiences impacted them personally (e.g., hypervigilance) and impacted their subsequent interaction with patients (e.g., quicker to use restraints, loss of empathy). Participants shared the perception that EMS is no longer valued or respected by patients or communities. Several voiced concerns for the next generation of colleagues and nearly all participants reported the need for education and training in situational awareness, de-escalation, and self-defense tactics. Participants referenced desire for more coordination and communication with law enforcement, change in culture of abuse from patients without repercussions, and improved agency mental health support and peer support/mentoring following a violent event. Despite experiences with WPV, the majority reported plans to remain in EMS., Conclusions: Emergency Medical Services personnel are commonly traumatized by violence in their work and nonphysical violence is underappreciated. Despite its impact on staff and subsequent patient interactions, most participants reported plans to remain within EMS. Multi-faceted system-focused efforts are needed to shift toward and support a zero-tolerance culture for WPV.

Objective: Emergency Medical Services (EMS) clinicians desire performance feedback (PF) and patient outcome follow-up (POF). Within our agency, both a peer-review and feedback/outcome (PF/POF) process exist. Our objective was to determine whether receiving feedback and outcome data improved future clinical care amongst EMS, based upon peer-review scores., Methods: This retrospective cohort study took place between 1/1/2020 and 6/7/2023 within an EMS agency site with 22,000 average annual 9-1-1 calls. Requests for PF/POF were submitted on an individual basis beginning June 2020 and completed by a dedicated EMS nurse, EMS physician, or emergency medicine (EM) resident. Peer-review of select high-acuity cases were scored by two Quality Assurance (QA) specialists within the categories of assessment, treatment, disposition/outcome and process/administrative guidelines. Association between overall peer-review score and number of PF/POF requests at time of assessment was evaluated by linear regression., Results: A total of 378 PF/POF requests were received, with the most common patient complaints being cardiac ( n  = 105; 27.8%, including 49 (13.0%) out of hospital cardiac arrests), altered mental status/neurologic ( n  = 103; 27.2%), trauma ( n  = 61; 16.1%, including 2 (0.5%) traumatic arrests); and respiratory distress ( n  = 47; 12.4%). A total of 378 runs meeting QA criteria were peer-reviewed post-PF/POF process implementation, including 337 (89.2%) cardiac/respiratory arrests, 27 (7.1%) with difficult airway management, and 14 (3.7%) major trauma/traumatic arrests. The number of prior PF/POF requests made by the team leader was associated with higher overall peer-review scores. Team leaders with > 5 prior PF/POF requests had a peer-review score 0.39 points greater (95% CI: 0.16 - 0.62, p  = 0.001) than those with <5 prior requests. The number of prior PF/POF requests amongst the entire crew was also associated with higher peer-review scores. Crews that collectively had > 5 prior PF/POF requests had an increase in peer-review score 0.32 points greater (95% CI: 0.14 - 0.50, p  < 0.001) than those with <5 prior requests., Conclusion: Providing performance feedback and patient outcome follow-up to EMS is associated with improved peer-review scores of clinical performance. Future studies should assess if those that are submitting cases for feedback/outcome are higher performers at baseline or if the process of receiving feedback/outcome improves their performance.

Background: Emergency medicine (EM) trainee comfort level with lumbar puncture (LP) has decreased over time due to changing practice guidelines, particularly amongst pediatric patients. We implemented a "just in time" (JIT) brief educational video based on a previously published LP Performance Scoring Checklist to improve trainee efficiency and competence in LP performance., Methods: Our pilot quasi-experimental study took place January-June 2022 within a large, academic Midwestern emergency department (ED) with an established 3-year EM residency program. All 9 interns performed a timed diagnostic LP on an infant LP model in January, scored according to the LP Performance Scoring Checklist. In June, interns repeated the timed LP procedure directly after watching a brief educational video based on major checklist steps. The study was deemed exempt by the Institutional Review Board., Results: All interns completed both assessments. At baseline, interns had logged performance of median 2 (IQR 0-5) LPs and spent 12.9 (10.3-14.4) minutes performing the procedure. Post-intervention, interns had logged an additional median 2 (0-5) LPs and completed the procedure faster with an average time of 10.3 (9.7-11.3) minutes (p = 0.004). A median of 5 (4-7) major steps were missed at baseline, compared to 1 (1-2) at time of post-intervention assessment (p = 0.015)., Conclusion: Development of a brief educational video improved efficiency and competency amongst our intern class in performing an infant LP when viewed Just-In-Time. Similar efforts may improve education and performance of other rare (or decreasing in frequency) procedures within EM training., (© 2024. The Author(s).)

Patients in custody due to arrest or incarceration are a vulnerable population that present a unique ethical and logistical challenge for emergency physicians (EPs). People incarcerated in the United States have a constitutional right to health care. When caring for these patients, EPs must balance their ethical obligations to the patient with security and safety concerns. They should refer to their institutional policy for guidance and their local, state, and federal laws, when applicable. Hospital legal counsel and risk management also can be helpful resources. EPs should communicate early and openly with law enforcement personnel to ensure security and emergency department staff safety is maintained while meeting the patient's medical needs. Physicians should consider the least restrictive restraints necessary to ensure security while allowing for medical evaluation and treatment. They should also protect patient privacy as much as possible within departmental constraints, promote the patient's autonomous medical decision-making, and be mindful of ways that medical information could interact with the legal system., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Authors. Journal of the American College of Emergency Physicians Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Background: After officer-involved shootings (OIS), rapid delivery of emergency medical care is critical but may be delayed due to scene safety concerns. The purpose of this study was to describe medical care rendered by law enforcement officers (LEOs) after lethal force incidents., Methods: Retrospective analysis of open-source video footage of OIS occurring from February 15, 2013 through December 31, 2020. Frequency and nature of care provided, time until LEO and Emergency Medical Services (EMS) care, and mortality outcomes were evaluated. The study was deemed exempt by the Mayo Clinic Institutional Review Board., Results: Three hundred forty-two (342) videos were included in the final analysis; LEOs rendered care in 172 (50.3%) incidents. Average elapsed time from time-of-injury (TOI) to LEO-provided care was 155.8 (SD = 198.8) seconds. Hemorrhage control was the most common intervention performed. An average of 214.2 seconds elapsed between LEO care and EMS arrival. No mortality difference was identified between LEO versus EMS care (P = .1631). Subjects with truncal wounds were more likely to die than those with extremity wounds (P < .00001)., Conclusions: It was found that LEOs rendered medical care in one-half of all OIS incidents, initiating care on average 3.5 minutes prior to EMS arrival. Although no significant mortality difference was noted for LEO versus EMS care, this finding must be interpreted cautiously, as specific interventions, such as extremity hemorrhage control, may have impacted select patients. Future studies are needed to determine optimal LEO care for these patients.

Introduction: Healthcare workers, particularly those in the emergency department (ED), experience high rates of injuries caused by workplace violence (WPV)., Objective: Our goal was to establish the incidence of WPV among multidisciplinary ED staff within a regional health system and assess its impact on staff victims., Methods: We conducted a survey study of all multidisciplinary ED staff at 18 Midwestern EDs encompassing a larger health system between November 18-December 31, 2020. We solicited the incidence of verbal abuse and physical assault experienced and witnessed by respondents over the prior six months, as well as its impact on staff., Results: We included responses from 814 staff (24.5% response rate) for final analysis with 585 (71.9%) indicating some form of violence experienced in the preceding six months. A total of 582 (71.5%) respondents indicated experiencing verbal abuse, and 251 (30.8%) indicated experiencing some form of physical assault. All disciplines experienced some type of verbal abuse and nearly all experienced some type of physical assault. One hundred thirty-five (21.9%) respondents indicated that being the victim of WPV has affected their ability to perform their job, and nearly half (47.6%) indicated it has changed the way they interact with or perceive patients. Additionally, 132 (21.3%) indicated experiencing symptoms of post-traumatic stress, and 18.5% reported they have considered leaving their position due to an incident., Conclusion: Emergency department staff suffer violence at a high rate, and there is no discipline that is spared. As health systems seek to prioritize staff safety in violence-prone areas such as the ED, it is imperative to recognize that the entire multidisciplinary team is impacted and requires targeted efforts for improvement in safety.

Violence in the emergency department (ED) remains underreported. Patient factors are often cited as a source of confusion in determining the culpability of perpetrators and whether to proceed with incident reporting. This study’s objective was to determine how ED staff at one academic medical center perceive certain clinical scenarios and how this compares to local law enforcement officers (LEO). An anonymous survey with 4 scenarios was sent to multidisciplinary ED staff at our academic medical center, as well as local LEO and inquired whether respondents considered any of the scenarios to be reportable as a crime. Chi-square analysis was used for comparison. The study was deemed exempt by the Institutional Review Board. A total of 261 ED staff and 77 LEO completed the survey. Both groups were equally likely to believe that a reportable crime occurred in Scenario 1, where a patient with dementia punches a nurse (LEO: 26.0% vs. ED: 31.4%, p = 0.44), and in Scenario 2, where an intoxicated patient spits at a phlebotomist (LEO: 97.4% vs. ED: 95.0%, p = 0.56). However, the two groups differed in Scenario 3, in which a patient with delirium makes verbal threats to a doctor (LEO: 20.8% vs. ED: 42.9%, p < 0.001), and Scenario 4, in which a patient’s parent throws a chair at a medical student (LEO: 66.2% vs. ED: 81.2%, p = 0.009). As health systems seek to improve workplace safety, it is important to consider the barriers to reporting violent incidents, including staff’s understanding of what acts may constitute reportable violence, as well as LEO understanding of the unique ED environment and patient responsibilities.

Objective: Performance feedback on clinical care and patient outcomes is a cornerstone of medical education, yet it remains lacking in the prehospital environment. Research seeking to establish the quantity of feedback provided to Emergency Medical Services (EMS) has been limited and studies focused on complimentary feedback or how feedback relates to EMS job satisfaction are lacking. The objectives of this study were to measure the frequency and nature of feedback received by EMS agencies and to identify the importance of receiving feedback as it relates to EMS job satisfaction., Methods: This was an anonymous, survey-based study of twenty-nine Basic Life Support (BLS) and fifteen Advanced Life Support (ALS) agencies located in Southeastern Minnesota (USA). Descriptive statistics and Fisher exact tests were used. The study was deemed exempt by the Mayo Clinic Institutional Review Board., Results: Ninety-four responses were included from nineteen different EMS agencies, including sixty-one (64.9%) paramedics and thirty-three (35.1%) emergency medical technicians (EMTs). One-half of all respondents reported that they had not received any type of feedback in the past 30 days, while another 43.6% of respondents indicated that they had only received feedback one to three times in the same time period. Twenty (60.6%) EMTs reported receiving no feedback in the past 30 days, compared with twenty-seven (44.3%) paramedics (P = .123). Of respondents receiving feedback, 65.9% reported never or rarely receiving positive reinforcing feedback and 60.6% reported never or rarely receiving constructive criticism or feedback regarding something that did not go well with patient care or transport. The majority of respondents were dissatisfied with the quantity (86.1%) and quality (73.4%) of feedback received. An overwhelming majority (93.6%) indicated that feedback on patient care or outcomes was important in influencing their overall job satisfaction. This high importance was maintained across all demographic groups., Conclusion: Within the cohort of survey respondents, a paucity of feedback received by EMS personnel is a source of dissatisfaction for EMS providers. Feedback on patient care strongly relates to overall job satisfaction. These findings suggest system-wide opportunities for structured feedback processes, focusing upon both quality and quantity of delivered feedback, to improve both patient care and staff satisfaction.

Background: Tactical Emergency Medical Support (TEMS) providers may encounter severe traumatic injuries, with associated hemorrhagic shock, coagulopathy, and hyperfibrinolysis. Tranexamic acid (TXA) administration represents a potential intervention in this operational environment. This study evaluated TXA availability and use among US tactical medical personnel supporting law enforcement tactical teams., Methods: An anonymous on-line survey of the American College of Emergency Physicians (ACEP) Tactical Emergency Medicine (TEM) section was administered., Results: Fifty respondents were included in the final study. Fifty-four percent reported TXA availability, with 14% reporting its use at least once in the past year. Additional available resuscitative products included crystalloids (88%) and packed red blood cells (6%). Twenty-five respondents reported managing ≥ 1 patient(s) with hemorrhagic shock in the past year. Resuscitative measures included crystalloids (96%), TXA (68%), and blood products (16%). Overall, 88% of respondents were supportive of TXA use. Full-time teams, those with = 3 monthly callouts, and teams that carried blood products were more likely to have TXA., Conclusions: Half of respondents reported managing a patient with hemorrhagic shock in the past year. Although 88% were supportive of TXA use, only 54% reported availability. Tactical teams with higher call volume and more resources were more likely to carry TXA. Further studies evaluating TEMS patient wounding patterns and barriers to TXA utilization are required., (2021.)

Introduction: Workplace violence in the emergency department (ED) is a serious threat to staff and is likely to go unreported. We sought to identify the incidence of violence among staff at our academic ED over a six-month period., Methods: An anonymous survey was sent to all ED staff, asking whether respondents had experienced verbal abuse or physical assault over the prior six months and whether they had reported it. Those working in the department <6 months were excluded from analysis. We used chi-squared comparison to analyze the results., Results: We analyzed 242 responses. Overall, 208 (86%) respondents indicated being verbally abused in the preceding six months, and 90 (37%) indicated being physically assaulted. Security officers had the highest incidence of verbal abuse (98%), followed by nursing (95%), patient care assistants (PCA) (90%) and clinicians (90%), phlebotomists (75%), care team assistants (73%), registration staff (50%) and electrocardiogram (ECG)/radiology technicians (50%). Security also had the highest incidence of physical assault (73%), followed by nursing (49%), PCAs (30%), clinicians (24%), phlebotomists (17%), and ECG/radiology technicians (13%). A total of 140 (69%) non-security personnel indicated that they never report incidents of violence., Conclusion: Our results indicate that violence in the ED affects more than just nurses and doctors. As health systems seek to improve the safety of their employees in violence-prone areas, it is imperative that they direct initiatives to the entire healthcare team as no one group is immune.

Background: Although first responders (FRs) represent a high-risk group for exposure, little information is available regarding their risk of coronavirus disease 2019 (COVID-19) infection. The purpose of the current study was to determine the serological prevalence of past COVID-19 infection in a cohort of municipal law enforcement (LE) and firefighters (FFs)., Methods: Descriptive analysis of a de-identified data reporting Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) immunoglobulin G (IgG), or COR2G, serology results for municipal FRs. As part of the serology process, FRs were surveyed for COVID-19-like symptoms since February 2020 and asked to report any prior COVID-19 nasal swab testing. Descriptive statistics and two-sided Chi Square tests with Yates correction were used to compare groups., Results: Of 318 FRs, 225 (80.2%) underwent serology testing (LE: 163/207 [78.7%]; FF: 92/111 [82.9%]). The prevalence of positive serology for all FRs tested was 3/255 (1.2%). Two LE (1.2%) and one FF (1.1%) had positive serology (P = 1.0). Two hundred and twenty-four FRs responded to a survey regarding prior symptoms and testing. Fifty-eight (25.9%) FRs (44 LE; 14 FFs) reported the presence of COVID-19-like symptoms. Of these, only nine (15.5%) received reverse transcriptase - polymerase chain reaction (RT-PCR) testing; none were positive. Two of the three FRs with positive serology reported no COVID-19-like symptoms and none of these responders had received prior nasal RT-PCR swabs. The overall community positive RT-PCR rate was 0.36%, representing a three-fold higher rate of positive seroprevalence amongst FRs compared with the general population (P = .07)., Conclusions: Amongst a cohort of municipal FRs with low community COVID-19 prevalence, the seroprevalence of SARS-CoV-19 IgG Ab was three-fold greater than the general community. Two-thirds of positive FRs reported a lack of symptoms. Only 15.5% of FRs with COVID-19-like symptoms received RT-PCR testing. In addition to workplace control measures, increased testing availability to FRs is critical in limiting infection spread and ensuring response capability.