Identifying the critical physical demanding tasks of paramedic work: Towards the development of a physical employment standard

Identifying and validating perceived workload metrics for emergency medical services

The most common workload surrogates used by Emergency Medical Services (EMS)- overall call volume (CV) and unit hour utilization (UHU)-have not been validated. This study investigates the relationship between EMS operational metrics and perceived workload, measured through the NASA task load index (TLX) survey. We paired crew member survey responses with the operational metrics based on dispatch data. Linear regression was used to evaluate the influence of each metric on perceived workload. Logistic regression was used to identify values of workload indicating a fair day's work. We found that the overall CV (p < 0.001, R2=0.32) and UHU (p < 0.001, R2=0.22) explained less variability in perceived workload than a priority (P)-stratified CV (p < 0.001, R2=0.41). However, we found no clear fair day's workload threshold. We conclude that a priority-stratified CV is a better workload surrogate than a CV and UHU.

Work-, lifestyle-, and health-related factors among women and men working in the emergency medical services

Objectives. This study aimed to describe work-, lifestyle-, and health-related factors among ambulance personnel, and to analyse differences between women and men. Methods. The cross-sectional study (N = 106) included self-reported and objective measures of work, lifestyle, and health in 10 Swedish ambulance stations. The data collection comprised clinical health examination, blood samples, tests of physical capacity, and questionnaires. Results. A high proportion of the ambulance personnel reported heavy lifting, risk of accidents, threats and violence at work. A low level of smoking and alcohol use, and a high level of leisure-time physical activity were reported. The ambulance personnel had, on average, good self-rated health, high work ability and high physical capacity. However, the results also showed high proportions with risk factors for cardiovascular disease (CVD), e.g., high blood pressure, and high levels of blood lipids. More women than men reported high work demands. Furthermore, women performed better in tests of physical capacity and had a lower level of CVD risk factors. Conclusions. Exposure to work-related factors that might affect health was common among ambulance personnel. Lifestyle- and health-related factors were somewhat contradictory, with a low proportion reporting lifestyle-related risk factors, but a high proportion having risk factors for CVD.

Factors influencing the likelihood of females passing the Ottawa paramedic physical ability test

The Ottawa Paramedic Physical Ability Test (OPPAT) was launched in Ontario as a physical employment standard for front-line paramedics. When considering pass rates based on sex, males had a higher likelihood of passing than females. To help understand how to improve pass rates among females we aimed to understand if factors such as participant demographics, college type, employment status and/or peak heart rate (a surrogate of fitness level) were related to OPPAT pass rates. Females who were employed, who were educated in a public paramedic college, and who had higher body mass were more likely to successfully complete the OPPAT. Those educated in a public paramedic college were more than twice as likely to pass relative to those educated in a private college program. This may underscore a need to further explore different modes of paramedic education to understand why public college program trained students are more likely to pass.

Occupation-Induced Fatigue and Impacts on Emergency First Responders: A Systematic Review

Fatigue in emergency first responders (EFRs) is known to affect performance abilities and safety outcomes for both patients and EFRs. The primary aim of this review was to determine the main contributors to occupation-induced fatigue in EFRs and its subsequent impacts. Following the PRIMSA checklist, academic databases (Medline, Embase, CINAHL, and SPORTDiscus) were searched using key terms with results subjected to inclusion and exclusion criteria. Populations of interest were firefighters, paramedics, or emergency call centre personnel. Of the 5633 records identified, 43 studies, which reported on 186 unique measures from a total population of 6373 participants, informed the review. Synthesis revealed fatigue was caused by lack of sleep during the shift and consistent poor sleep quality which negatively impacted cognitive function, alertness, and physical and mental health while increasing safety-compromising behaviours and injuries. Both subjective and objective assessments of fatigue are necessary for effective risk management in EFRs. EFRs that are consistently fatigued are at a greater risk of poor physical and mental health, reduced cognitive function, and increased injuries. No studies reported on fatigue in emergency call centre personnel, highlighting a literature gap. Funding was provided by the Australian Capital Territory Emergency Services Agency. Preregistration was filed in OSF: osf.io/26f3s.

Identifying the critical physically demanding tasks performed by personal support workers in Canada

Due to increased work demands, personal support workers (PSWs) are experiencing more work-related injuries. However, little is known about PSW work tasks and their corresponding physical demand. The purpose of this study was to identify critical tasks that are physically demanding and completed frequently as identified by PSWs. Additionally, we identified contextual factors (i.e., environmental-, situational-, patient-related) that influenced physical demands. We surveyed 443 community-based PSWs working in Canada who rated the physical demand associated with client care tasks and identified contextual factors that can increase task specific physical demands. Transferring/repositioning patients, dressing, and bathing were perceived as most demanding. Patient weight and mobility influenced the level of physical demand required for most tasks. These data provide a foundation to develop physical employment standards and task specific education and training to prevent PSW injuries.

The bookmark method to establish minimum performance standards for intensive care flight paramedics performing helicopter winch rescue

We aimed to use the bookmark method to establish minimum standards for selecting intensive care flight paramedics. Two subject matter expert (SME) focus groups reviewed nine videos of decreasing duration showing land and water helicopter rescue tasks. Focus Group 1 (FG1, n = 10) viewed videos individually off-site, whilst Focus Group 2 (FG2, n = 9) attended a face-to-face session. All SMEs selected the video they judged as the appropriate pace for the task then reviewed feedback. For both groups, the process was repeated until 80% agreement was achieved, or three rounds were completed (whichever occurred first). FG1 and FG2 achieved agreement after two rounds for the land task. For the water task, FG1 did not reach agreement. FG2 reached consensus after two rounds. The selected task durations were similar. The bookmark method is valuable to determine performance standards for performing winch rescue, and SMEs are more likely to reach consensus when face-to-face.

Comparison of physical demanding paramedic work tasks between an Australian and Canadian ambulance service

Ambulance services require candidates to pass physical employment tests (PETs) to be deemed suitable for the paramedic role. Whilst some research has been undertaken to improve to relevance of these tests, they are often arbitrary and not based on research. The first phase in developing PETs is to generate a list of job tasks. To examine the utility of universal physical tasks tests for ambulance work, we conducted a cross-sectional study, utilising the results from previous work in a Canadian ambulance service to create a physical tasks checklist. These lists were then used by paramedics working for an Australian Service to identify physical tasks in their workplace, and the results from the two services were compared. Patient transfer tasks were similar in frequency and description for both services. Stretcher handling and manoeuvring was identified by Canadian paramedics as highly strenuous, (mean rating of perceived exertion (RPE) 7/10) but were rated mean RPE <3/10 by AV paramedics. Although some tasks between these two services were similar, the ambulance services in this study differed sufficiently with regard to equipment, training and policies mean that similarly titled jobs are not comparable, cross-nationally. Service specific job task analysis is required to develop PETs that ensure employees are specifically selected to meet the requirements of that service.

Does the fit of personal protective equipment affect functional performance? A systematic review across occupational domains

OBJECTIVE

To explore the effect of personal protective equipment (PPE) fit on functional performance across a range of occupational domains.

BACKGROUND

PPE introduces an ergonomic, human systems integration, and mass burden to the wearer, and these factors are thought to be amplified if PPE is ill-fitting. However, few studies have considered the role of fit (static, dynamic, and cognitive) when evaluating PPE-related performance detriments in occupational settings.

METHOD

A systematic literature review was conducted to identify relevant studies, which were then critically appraised based on methodological quality and collated to compare key findings and present evidence-based recommendations for future research directions across a range of occupational domains.

RESULTS

16 published studies met the inclusion criteria, 88% of which found that the fit of PPE had a statistically significant effect on occupational performance. Poorly sized PPE resulted in slower or increased reaction time; decreased range of motion or mobility; decreased endurance or tolerance; decreased pulmonary function; and altered muscle activation. Limited research met the inclusion criteria and those that did had risks of bias in methodology quality.

CONCLUSION

Future research evaluating the effect of PPE on performance in occupational settings should aim to recruit a more representative population; consider sex as a covariate; quantify and evaluate PPE fit and performance when integrated with all relevant equipment items; include outcome measures related to all three categories of fit (static, dynamic, cognitive); and assess performance of operationally relevant tasks.

Use of the Airstretcher with dragging may reduce rescuers’ physical burden when transporting patients down stairs

Transporting patients down stairs by carrying is associated with a particularly high fall risk for patients and the occurrence of back pain among emergency medical technicians. The present study aimed to verify the effectiveness of the Airstretcher device, which was developed to reduce rescuers’ physical burden when transporting patients by dragging along the floor and down stairs. Forty-one paramedical students used three devices to transport a 65-kg manikin down stairs from the 3rd to the 1st floor. To verify the physical burden while carrying the stretchers, ratings of perceived exertion were measured using the Borg CR10 scale immediately after the task. Mean Borg CR10 scores (standard deviation) were 3.6 (1.7), 4.1 (1.8), 5.6 (2.4), and 4.2 (1.8) for the Airstretcher with dragging, Airstretcher with lifting, backboard with lifting, and tarpaulin with lifting conditions, respectively (p < 0.01). Multiple comparisons revealed that the Airstretcher with dragging condition was associated with significantly lower Borg CR10 scores compared with the backboard with lifting condition (p < 0.01). When the analysis was divided by handling position, estimated Borg CR10 values (standard error) for head position were 4.4 (1.3), 2.9 (0.9), 3.2 (0.8), and 4.0 (1.1) for the Airstretcher with dragging, Airstretcher with lifting, backboard with lifting, and tarpaulin with lifting conditions, respectively, after adjusting for participant and duration time (F = 1.4, p < 0.25). The estimated Borg CR10 value (standard error) for toe position in the Airstretcher with dragging condition was 2.0 (0.8), and the scores for the side position were 4.9 (0.4), 6.1 (0.3), and 4.7 (0.4) for the Airstretcher with lifting, backboard with lifting, and tarpaulin with lifting conditions, respectively, after adjusting for participant and duration time (F = 3.6, p = 0.02). Transferring a patient down stairs inside a house by dragging using the Airstretcher may reduce the physical burden for rescuers.

The influence of sex and strength capacity on normalized low-back exposure during lifting: Insights from a joint power analysis

OBJECTIVE

Investigate the influence of sex, strength capacity, and relative load mass on low-back exposure and lower extremity joint power generation in backboard lifting.

BACKGROUND

Sex and strength have been shown to influence lifting strategy, but without load mass being scaled to strength it is unknown which factor influences low-back exposures, and whether there are interactions with load mass.

METHODS

Motion capture and force plate data from 28 participants were collected during backboard lifting at load masses scaled to strength capacity. Differences in normalized peak low-back moment, peak knee-to-hip power magnitude ratio and timing were tested as a function of sex, strength, and load mass.

RESULTS

Stronger participants had lower normalized peak low-back moments (average 32% change from low-capacity across all load masses), with no significant sex effect (p = 0.582). As load mass increased, normalized peak low-back moment, peak knee-to-hip power magnitude and synchronicity decreased.

CONCLUSION

Training to both increase strength capacity and hip-joint power generation may be a strategy to reduce low-back exposure in backboard lifting.

A comparison of augmented feedback and didactic training approaches to reduce spine motion during occupational lifting tasks

Manual handling training may be improved if it relied on the provision of individualized, augmented feedback about key movement features. The purpose of this study was to compare the reduction in sagittal spine motion during manual lifting tasks following two training approaches: didactic (DID) and augmented feedback (AUG). Untrained participants (n = 26) completed lifting tests (box, medication bag, and paramedic backboard) and a randomly-assigned intervention involving 50 practice box lifts. Lifting tests were performed immediately before and after training, and one-week after interventions. Both groups exhibited reductions in spine motions immediately and one-week after the interventions. However, the AUG intervention group elicited significantly greater reductions in 5 of 12 between-group comparisons (3 tasks × 4 spine motion variables). The results of the current study support the use of augmented feedback-based approaches to manual handling training over education-based approaches.

Development of physical employment standards of specialist paramedic roles in the National Ambulance Resilience Unit (Naru)

AIM

To develop evidence-based role-specific physical employment standards and tests for National Ambulance Resilience Unit (NARU) specialist paramedics.

METHODS

Sixty-two (53 men, 9 women) paramedics performed an array of (1) realistic reconstructions of critical job-tasks (criterion job performance); (2) simplified, easily-replicable simulations of those reconstructions and; (3) fitness tests that are portable and/or practicable to administer with limited resources or specialist equipment. Pearson's correlations and ordinary least products regression were used to assess relationships between tasks and tests. Performance on reconstructions, subject-matter expert and participant ratings were combined to derive minimum acceptable job performance levels, which were used to determine cut-scores on appropriate correlated simulations and tests.

RESULTS

The majority of performance times were highly correlated with their respective simulations (range of r: 0.73-0.90), with the exception of those replicating water rescue (r range: 0.28-0.47). Regression compatibility intervals provided three cut-scores for each job-task on an appropriate simulation and fitness test.

CONCLUSION

This study provides a varied and easily-implementable physical capability assessment for NARU personnel, empirically linked to job performance, with flexible options depending on organisational requirements.

The efficacy of a lifting strap as an ergonomic intervention for EMS providers: Does it make it easier to raise a supine patient to an upright sitting posture?

Patient handling related musculoskeletal injuries are prevalent among Emergency Medical Service (EMS) providers. The first step in many patient handling situations is where a supine patient on the floor is brought to a sitting position. This study investigated whether a strap, placed under the patient's torso and long enough that EMS providers can perform the patient raising task in a standing posture, reduced muscular effort. Fifteen participants raised a simulated patient, with the help of an assistant, using the strap method and a traditional method (grasping the shoulders) in an open area, a restricted space, and in a bathtub. Torso postures improved in all location conditions when using the strap. The muscle activation data showed mixed results. While EMG responses from the latissimus dorsi muscles were reduced, EMG activity of the erector spinae muscles increased when the strap was used. Perceived effort assessments supported the use of the strap.

Defining the characteristics of physically demanding winch rescue in helicopter search and rescue operations

Helicopter emergency medical service search and rescue (HEMS SAR) paramedics perform physically demanding winch rescues. Rescue organisations require valid physical employment standards (PES) to ensure personnel can adequately perform duties. There are no studies describing validated PES for HEMS SAR. We convened a subject matter expert (SME) focus group to review historical case data and generate task descriptions for land and water winch rescue as the basis for development of task simulations to assess physiological workload. Sixteen helicopter rescue paramedics with a mean age of 47 (range, 36-52) years and 8 (2-20) years' experience in helicopter rescue participated in a SME focus group. When provided with data from historical cases, SMEs achieved consensus (≥80%) when generating descriptions of winch rescue. This method may be useful to develop simulations for assessment of physiological demands of winch rescue and similar tasks, and to enhance validity and reliability of PES for rescue organisations.

Review of methods to identify the critical job-tasks undertaken by the emergency services

BACKGROUND:

The roles of the emergency services are challenging and often physically demanding. Readiness to meet these challenges and demands is a fundamental requirement for staff to deliver their roles safely and effectively. Furthermore, employers are required by law to demonstrate every reasonable effort to protect their staff from undue risk of work-related injury. Implementing Physical Employment Standards (PES) enables employers to assign staff to roles for which they are physically-suited whilst contributing to such duty-of-care. However, for PES to be successful and legally-defendable, standards must reflect the demands of those job-tasks which are truly critical to the readiness of these services.

OBJECTIVE:

To determine whether a standardised approach to identifying critical job-tasks exists in the development of PES for the emergency services.

METHODS:

Studies which conducted analysis of job-tasks to develop PES within the emergency services were reviewed.

RESULTS:

Forty-two reported studies (i.e. records) met the inclusion criteria. Methods to determine job-tasks varied but were typically criteria-based incorporating one, or all, of 9 reported techniques. Methods were subjective and based upon reference to past or present job-task performance.

CONCLUSION:

Correctly determining critical job-tasks is essential for effective, legally-defendable PES. A standardised method to define job-tasks remains to be established.

Self-preservation comes at a cost: Why British National Health Service paramedics might be choosing a healthier, but poorer, retirement

Objectives:

To explore and portray the perspectives of National Health Service Ambulance personnel related to the latest rise in the National Health Service occupational pension age.

Methods:

Data gathering took the form of 35 in-depth interviews. A thematic analysis was used to characterise and articulate key concepts and meanings. The analysis applied interpretive techniques, as views expressed were from personal experiences, and allowed for an in-depth analysis of shared meanings.

Results:

The themes reported captured the desire of many Ambulance personnel to exit their employment well in advance of their retirement age, despite satisfaction gained from patient care. This early exit is being driven by increased worry that the work demands of the job are unsustainable, especially for older workers, as clinical responsibilities increase and their social support diminishes. Also, Ambulance personnel feel betrayed by their employers, because their retirement is being delayed further by another change in their pensionable age.

Conclusion:

There is an increased orientation for ‘living for today’ and indications of a willingness to sacrifice salary and pension income in order to protect their health in older age, which has implications for long-term financial and general well-being in retirement.

Paramedic equipment bags: How their position during out-of-hospital cardiopulmonary resuscitation (CPR) affect paramedic ergonomics and performance

This study investigates how the positions of paramedic equipment bags affect paramedic performance and biomechanical loads during out-of-hospital Cardiopulmonary Resuscitation (CPR). An experiment was conducted in which 12 paramedic teams (each including two paramedics) performed in-situ simulations of a cardiac-arrest scenario. CPR quality was evaluated using five standard resuscitation measures (i.e., pre- and post-shock pauses, and compression rate, depth and fraction). The spinal loads while lifting, pulling and pushing the equipment bags were assessed using digital human modeling software (Jack) and prediction equation from previous studies. The results highlight where paramedics are currently choosing to position their equipment. They also demonstrate that the positions of the equipment bags affect CPR quality as well as the paramedics' work efficiency, physiological effort and biomechanical loads. The spinal loads ranged from 1901 to 4030N; furthermore, every occasion on which an equipment bag was lifted resulted in spinal forces higher than 3400N, thus exceeding the maximum threshold stipulated by the National Institute for Occupational Safety and Health. 72% of paramedics' postures were categorized as high or very high risk for musculoskeletal disorders by the Rapid Entire Body Assessment. Guidelines related to bag positioning and equipment handling might improve CPR quality and patient outcomes, and reduce paramedics' risk of injury.

The Ottawa Paramedic Physical Ability Test: test-retest reliability and analysis of sex-based performance differences

The Ottawa Paramedic Physical Ability Test (OPPAT) is a physical employment standard (PES) that candidates must pass as a pre-hire requirement and that incumbents may have to pass prior to returning to work after absence, to demonstrate their physical capabilities as required to safely meet the demands of paramedic work. Consistent with best practice guidelines for PES development, it is important to establish reliability and to investigate sex-based performance differences. Active duty paramedics completed the OPPAT twice while candidates completed the OPPAT six times. Across all participants, a median improvement of 76.0 s was observed in OPPAT performance (922.0-846.0 s) between trial 1 and trial 2. Among candidates, OPPAT performance stabilised by the fourth trial confirming reliability. Sex-based analyses revealed median differences in OPPAT performance time of 39.0 and 63.0 s between males and females during the first and second trials respectively. Practitioner summary: Active duty paramedics and candidates performed the Ottawa Paramedic Physical Ability Test (OPPAT) faster following familiarisation. Among candidates, performance time stabilised by the fourth trial. Performance time was slower among females, but this had less impact on females' ability to meet the OPPAT standard.

Evaluating the effect of a strength and conditioning program to improve paramedic candidates' physical readiness for duty

BACKGROUND

The Ottawa Paramedic Physical Ability Test (OPPAT™) is a physical employment standard for the paramedic sector. If a candidate is unsuccessful in meeting the OPPAT™ performance standard they should be provided with an appropriate accommodation, such as a strength and conditioning program, to improve performance.

OBJECTIVE

Develop, implement and evaluate the effectiveness of a 4-week strength and conditioning program on improving OPPAT™ performance and associated fitness measures in paramedic candidates.

METHODS

A 4-week strength and conditioning program was developed to focus on strength and power improvements. Based on initial OPPAT™ performance, participants were divided into high and low performing groups; only the low performing group received the training intervention. OPPAT™ completion times and relevant fitness measures were compared pre- to post- intervention and between groups.

RESULTS

Over the 4-weeks, peak lower body power and grip strength did not significantly improve in the intervention group, however OPPAT™ performance improved by 10%. The control group had significantly lower OPPAT™ completion times both pre- and post-intervention (19% and 11% lower respectively), as well as greater grip strength and peak lower body power.

CONCLUSIONS

Implementation of a targeted strength and conditioning program successfully improved OPPAT™ performance in low performing candidates.

Overall risk index for patient transfers in total assistance mode executed by emergency medical technician-paramedics in real work situations

Few studies have quantified the risk of musculoskeletal disorders during patient transfers in total assistance mode in real-life prehospital emergency care situations. An index to assess the overall risk of patient transfers was created; it makes it possible to quantify risk based on the patient's position and the height of the patient's location. An analysis of 71 transfers executed by paramedics in actual work situations showed that moving a patient from the ground was characterized by acute sagittal flexions and axial rotations, respectively, 42% and 12% of the time. When the patient was lying on a raised surface, the lifting index and perceived exertion were the lowest (2.55; easy). According to the overall risk index, patient transfers from the ground are the riskiest. Paramedics execute many risky lifts even in favorable patient handling contexts.

Comparing the biomechanical and psychophysical demands imposed on paramedics when using manual and powered stretchers

The aim of this investigation was to compare the effect of three different stretchers (two powered and one manual) on the biomechanical and psychophysical demands experienced by paramedics when performing routine stretcher handling activities. Eight experienced paramedics performed stretcher raising, lowering, unloading and loading tasks. Video data of task performance and static force requirements were recorded and input into a posture matching program with a quasi-static linked segment model (3DMatch) to compute peak and cumulative L4/L5 compression and shear forces and shoulder moments during each activity. Ratings of perceived exertion (RPE) were recorded from paramedics upon the completion of each task. Use of powered stretchers with load assist functionality reduced the demands on paramedics. Peak L4/L5 forces were reduced by 13-62% and 58-93% for compression and shear respectively when using powered stretchers to perform routine stretcher handling activities. Shoulder flexor moments and RPE scores were reduced by 16-95% and 29-60% respectively when using the powered stretchers compared to the manual stretcher. However, cumulative forces showed mixed results. Although powered stretcher use decreased peak forces, loading and unloading a powered stretcher took 1.5 to 3.4 times longer then when using the manual stretcher, which may explain the mixed results regarding cumulative forces. Based on the RPE scores, paramedics preferred power stretchers relative to the manual stretcher. This study demonstrates that powered stretchers can reduce peak biomechanical and psychophysical exposures associated with the development of musculoskeletal disorder (MSD) during routine stretcher handling activities with minimal increases in cumulative exposures.