Disparities in Feedback Provision to Emergency Medical Services Professionals

A Qualitative Analysis of Barriers to Evidence-Based Care in the Prehospital Management of Patients with Suspected Acute Coronary Syndrome

OBJECTIVES: Prehospital electrocardiogram (ECG) and administration of aspirin are evidence-based strategies for patients with acute coronary syndrome (ACS). However, emergency medical services (EMS) compliance in patients with suspected ACS varies widely. We sought to understand the barriers to prehospital ECG acquisition and aspirin administration for patients with suspected ACS.METHODS: In this qualitative study, we interviewed EMS clinicians at three geographically-diverse United States (U.S.)-based EMS agencies. We interviewed practicing clinicians and quality and operations leaders at these agencies. Based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, interviews were recorded, transcribed, and analyzed using a grounded qualitative approach with open coding. The Systems Engineering Initiative for Patient Safety (SEIPS) framework and a constant comparison technique were used to identify and refine themes.RESULTS: Twenty-five paramedics and 20 additional agency personnel participated. Median age was 41 (IQR: 34-51) years and 13 (29%) were female. Themes were organized using SEIPS and longitudinally through four phases of an EMS call. During the pre-arrival phase, staffing challenges, training quality, and dispatch may anchor EMS clinicians on a diagnosis. During the diagnosis and treatment phase, safety and communication barriers may take priority over care delivery. Additionally, EMS clinicians must allocate assets (e.g., whether to send an advanced life support unit) and financial resources; veteran EMS clinicians identified their experience whereas newer clinicians cited their recent education when making these decisions. Also, diagnostic uncertainty due to increasing patient complexity and atypical presentations contributed to diagnostic error. During the response and transport phase, scope of practice limits use and interpretation of the ECG, with clinicians reporting that liberal use of ECG led to more rapid decision-making. Finally, in the after phase, personnel reported the "psychologically taxing" nature of the job contributing to biases, bad habits, and burnout. Performance feedback was desired for personal development, though currently perceived as infrequent and punitive.CONCLUSIONS: Multiple, interrelated themes underscored the complexities of delivering evidence-based care to prehospital patients with ACS. Education in ECG interpretation, resource allocation, and bias, and enhancing feedback may serve as strategies to address the identified barriers.

Emergency Medical Service Agency Practices and Cardiac Arrest Survival

Importance

Survival for out-of-hospital cardiac arrest (OHCA) varies widely across emergency medical service (EMS) agencies in the US. However, little is known about which EMS practices are associated with higher agency-level survival.

Objective

To identify resuscitation practices associated with favorable neurological survival for OHCA at EMS agencies.

Design, Setting, and Participants

This cohort study surveyed EMS agencies participating in the Cardiac Arrest Registry to Enhance Survival (CARES) with 10 or more OHCAs annually during January 2015 to December 2019; data analyses were performed from April to October 2023.

Exposure

Survey of resuscitation practices at EMS agencies.

Main Outcomes and Measures

Risk-standardized rates of favorable neurological survival for OHCA at each EMS agency were estimated using hierarchical logistic regression. Multivariable linear regression then examined the association of EMS practices with rates of risk-standardized favorable neurological survival.

Results

Of 577 eligible EMS agencies, 470 agencies (81.5%) completed the survey. The mean (SD) rate of risk-standardized favorable neurological survival was 8.1% (1.8%). A total of 7 EMS practices across 3 domains (training, cardiopulmonary resuscitation [CPR], and transport) were associated with higher rates of risk-standardized favorable neurological survival. EMS agencies with higher favorable neurological survival rates were more likely to use simulation to assess CPR competency (β = 0.54; P = .05), perform frequent reassessment (at least once every 6 months) of CPR competency in new staff (β = 0.51; P = .04), use full multiperson scenario simulation for ongoing skills training (β = 0.48; P = .01), perform simulation training at least every 6 months (β = 0.63; P < .001), and conduct training in the use of mechanical CPR devices at least once annually (β = 0.43; P = .04). EMS agencies with higher risk-standardized favorable neurological survival were also more likely to use CPR feedback devices (β = 0.58; P = .007) and to transport patients to a designated cardiac arrest or ST-segment elevation myocardial infarction receiving center (β = 0.57; P = .003). Adoption of more than half (≥4) of the 7 practices was more common at EMS agencies in the highest quartile of favorable neurological survival rates (70 of 118 agencies [59.3%]) vs the lowest quartile (42 of 118 agencies [35.6%]) (P < .001).

Conclusions and Relevance

In a national registry for OHCA, 7 practices associated with higher rates of favorable neurological survival were identified at EMS agencies. Given wide variability in neurological survival across EMS agencies, these findings provide initial insights into EMS practices associated with top-performing EMS agencies in OHCA survival. Future studies are needed to validate these findings and identify best practices for EMS agencies.

Closing the Loop: The Value of Outcome Letters for Prehospital Pediatric Care

OBJECTIVES

Providing emergency care to acutely ill or injured children is stressful and requires a high level of training. Paramedics who provide prehospital care are typically not involved in the circle of care and do not receive patient outcome information. The aim of this quality improvement project was to assess paramedics' perceptions of standardized outcome letters pertaining to acute pediatric patients that they had treated and transported to an emergency department.

METHODS

Between December 2019 and December 2020, 888 outcome letters were distributed to paramedics who provided care for 370 acute pediatric patients transported to the Children's Hospital of Eastern Ontario in Ottawa, Canada. All paramedics who received a letter (n = 470) were invited to participate in a survey that collected their perceptions and feedback about the letters, as well as their demographic information.

RESULTS

The response rate was 37% (172/470). Approximately half of the respondents were Primary Care Paramedics and half Advanced Care Paramedics. The respondents' median age was 36 years, median years of service was 12 years, and 64% identified as male. Most agreed that the outcome letters contained information pertinent to their practice (91%), allowed them to reflect on care they had provided (87%), and confirmed clinical suspicions (93%). Respondents indicated that they found the letters useful for 3 reasons: 1) increases capacity to link differential diagnoses, prehospital care, or patient outcomes; 2) contributes to a culture of continuous learning and improvement; and 3) gives closure, reduces stress, or provides answers for difficult cases. Suggestions for improvement included providing more information, provision of letters on all patients transported, faster turnaround time between call and receipt of letter and inclusion of recommendations or interventions/assessments.

CONCLUSIONS

Paramedics appreciated receiving hospital-based patient outcome information after their provision of care and reported that the letters offered opportunities for closure, reflection, and learning.

Enhancing Patient Safety in Prehospital Environment: Analyzing Patient Perspectives on Non-Transport Decisions With Natural Language Processing and Machine Learning

OBJECTIVE

This research explored the experiences and perspectives of patients declining hospital transportation after receiving prehospital emergency care using advanced computational techniques.

METHOD

Between 15th June and 1st August 2023, 210 patients in Qatar, treated by Hamad Medical Corporation Ambulance Service (HMCAS) but refusing transportation to hospital, were interviewed. Key outcome variables stratified by demographics included "reasons for refusing transport," "satisfaction with HMCAS service," and "postrefusal actions." Responses underwent sentiment analysis and topic modeling using latent Dirichlet allocation. Machine learning models, such as Naïve Bayes, K-nearest neighboring, random forest, and support vector machine, were used to predict patients' subsequent actions.

RESULTS

Participants had an average age of 38.61 ± 19.91 years. The chief complaints were primarily chest and abdominal pains (18.49%; n = 39). Sentiment Analysis revealed a generally favorable perception of HMCAS-provided service. Latent Dirichlet allocation identified two main topics pertaining to refusal reasons and service satisfaction. Naïve Bayes and support vector machine algorithms were most effective in predicting postrefusal actions with an accuracy rate of 81.58%.

CONCLUSIONS

This study highlighted the utility of Natural Language Processing and ML in enhancing our understanding of patient behaviors and sentiments in prehospital settings. These advanced computational methodologies allowed for a nuanced exploration of patient demographics and sentiments, providing insights for Quality Improvement initiatives. The study also advocates for continuously integrating automated feedback mechanisms to improve patient-centered care in the prehospital context. Continuous integration of automated feedback systems is recommended to improve prehospital patient-centered care.

Rural Emergency Medical Services Clinicians' Perceptions and Preferences in Receiving Clinical Feedback From Hospitals: A Qualitative Needs Assessment

OBJECTIVE

Emergency medical services (EMS) clinicians experience dissatisfaction with the quality and quantity of clinical feedback from hospitals. Satisfaction is further diminished by the lack of a standardized systems approach. The purpose of this study was to identify rural clinicians' perceptions and preferences regarding clinical feedback received from hospitals, the delivery mechanisms, and its impact on their relationships with health care organizations.

METHODS

This was a qualitative study focused on EMS clinicians involved in rural prehospital care at a single Midwestern academic medical center. Using a phenomenological framework, semi-structured interviews were conducted with medical directors, service directors, fire captains, air medical personnel, emergency medical responders, emergency medical technicians, advanced emergency medical technicians, and paramedics, all of whom were selected through purposive sampling. Interviews were recorded, transcribed, and independently coded by two trained reviewers.

RESULTS

Twenty participants (11 frontline clinicians and 9 administrative staff members) with a wide range of clinical experience from 14 air and ground EMS agencies were interviewed. Emerging themes included: (1) the value or usefulness of feedback; (2) desired feedback system characteristics; (3) barriers to receiving feedback; (4) utilization and application of feedback; and (5) the feedback's impact on the relationship with health care organizations. Participants felt that clinical feedback from hospitals was especially important as a method of improving quality of care, though was rarely provided. Professional development was seen as a major benefit of receiving clinical feedback from hospitals.

CONCLUSION

Our results suggest that consistent clinical feedback provided by hospitals was valued. Establishing a culture of providing organized feedback to practicing rural EMS clinicians is important for professional development and can strengthen the relationships between EMS clinicians and hospitals. These study findings can assist in the development and implementation of a standardized feedback instrument to benefit rural EMS clinicians, patients, and the health care system as a whole.

Survey of resuscitation practices at emergency medical service agencies in the U.S

Background

Survival for out-of-hospital cardiac arrest (OHCA) varies across emergency medical service (EMS) agencies. Yet, little is known about resuscitation response and quality improvement activities at EMS agencies. We describe herein a novel survey to EMS agencies in a U.S. registry for OHCA.

Methods

Using data from the Cardiac Arrest Registry to Enhance Survival (CARES), we identified 577 EMS agencies with ≥10 OHCA cases annually between 2015 and 2019 that remained active in CARES. We administered a survey to EMS directors regarding agency characteristics, cardiac arrest response, relationships with first responders and dispatchers, quality improvement activities and perceived barriers in the community.

Results

Of eligible EMS agencies, 470 (81.5%) completed the survey. The high completion rate was likely due to frequent personalized emails and phone calls, liaising with CARES state coordinators to encourage survey response, and multiple periodic drawings of an automated external defibrillator during the survey period for participating EMS agencies. The survey examined rates of resuscitation training modalities; use of resuscitation equipment and devices in the field; frequency of simulation; non-EMS stakeholder response to OHCA (dispatchers, fire, police); quality improvement; and community factors affecting bystander response to OHCA.

Conclusions

In this study design paper on the RED-CASO survey, we provide summary data on EMS agency characteristics in the U.S. Upon linkage to CARES patient-level data, this survey will provide critical insights into 'best practices' at EMS agencies with the highest OHCA survival rates as well as provide insights into current disparities in outcomes.

Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta-analysis

BACKGROUND

Extensive research has been conducted into the effects of feedback interventions within many areas of healthcare, but prehospital emergency care has been relatively neglected. Exploratory work suggests that enhancing feedback and follow-up to emergency medical service (EMS) staff might provide staff with closure and improve clinical performance. Our aim was to summarise the literature on the types of feedback received by EMS professionals and its effects on the quality and safety of patient care, staff well-being and professional development.

METHODS

A systematic review and meta-analysis, including primary research studies of any method published in peer-reviewed journals. Studies were included if they contained information on systematic feedback to emergency ambulance staff regarding their performance. Databases searched from inception were MEDLINE, Embase, AMED, PsycINFO, HMIC, CINAHL and Web of Science, with searches last updated on 2 August 2022. Study quality was appraised using the Mixed Methods Appraisal Tool. Data analysis followed a convergent integrated design involving simultaneous narrative synthesis and random effects multilevel meta-analyses.

RESULTS

The search strategy yielded 3183 articles, with 48 studies meeting inclusion criteria after title/abstract screening and full-text review. Interventions were categorised as audit and feedback (n=31), peer-to-peer feedback (n=3), postevent debriefing (n=2), incident-prompted feedback (n=1), patient outcome feedback (n=1) or a combination thereof (n=4). Feedback was found to have a moderate positive effect on quality of care and professional development with a pooled effect of d=0.50 (95% CI 0.34, 0.67). Feedback to EMS professionals had large effects in improving documentation (d=0.73 (0.00, 1.45)) and protocol adherence (d=0.68 (0.12, 1.24)), as well as small effects in enhancing cardiac arrest performance (d=0.46 (0.06, 0.86)), clinical decision-making (d=0.47 (0.23, 0.72)), ambulance times (d=0.43 (0.12, 0.74)) and survival rates (d=0.22 (0.11, 0.33)). The between-study heterogeneity variance was estimated at σ2=0.32 (95% CI 0.22, 0.50), with an I2 value of 99% (95% CI 98%, 99%), indicating substantial statistical heterogeneity.

CONCLUSION

This review demonstrated that the evidence base currently does not support a clear single point estimate of the pooled effect of feedback to EMS staff as a single intervention type due to study heterogeneity. Further research is needed to provide guidance and frameworks supporting better design and evaluation of feedback interventions within EMS.

PROSPERO REGISTRATION NUMBER

CRD42020162600.

Feedback for Emergency Ambulance Staff: A National Review of Current Practice Informed by Realist Evaluation Methodology

Research suggests that feedback in Emergency Medical Services (EMS) positively affects quality of care and professional development. However, the mechanisms by which feedback achieves its effects still need to be better understood across healthcare settings. This study aimed to understand how United Kingdom (UK) ambulance services provide feedback for EMS professionals and develop a programme theory of how feedback works within EMS, using a mixed-methods, realist evaluation framework. A national cross-sectional survey was conducted to identify feedback initiatives in UK ambulance services, followed by four in-depth case studies involving qualitative interviews and documentary analysis. We used qualitative content analysis and descriptive statistics to analyse survey responses from 40 prehospital feedback initiatives, alongside retroductive analysis of 17 interviews and six documents from case study sites. Feedback initiatives mainly provided individual patient outcome feedback through "pull" initiatives triggered by staff requests. Challenges related to information governance were identified. Our programme theory of feedback to EMS professionals encompassed context (healthcare professional and organisational characteristics), mechanisms (feedback and implementation characteristics, psychological reasoning) and outcomes (implementation, staff and service outcomes). This study suggests that most UK ambulance services use a range of feedback initiatives and provides 24 empirically based testable hypotheses for future research.

Conflict in the EMS Workforce: An Analysis of an Open-Ended Survey Question Reveals a Complex Assemblage of Stress, Burnout, and Pandemic-Related Factors Influencing Well-Being

Emergency Medical Services (EMS) clinicians provide patient care within a high-stakes, unpredictable, and complex work environment in which conflict is inevitable. Our objective was to explore the extent to which added stressors of the pandemic exacerbated EMS workplace conflict. We administered our survey to a sample of U.S. nationally certified EMS clinicians during the COVID-19 pandemic in April 2022. Out of 1881 respondents, 46% (n = 857) experienced conflict and 79% (n = 674) provided free-text descriptions of their experience. The responses were analyzed for themes using qualitative content analysis, and they were then sorted into codes using word unit sets. Code counts, frequencies, and rankings were tabulated, enabling quantitative comparisons of the codes. Of the fifteen codes to emerge, stress (a precursor of burnout) and burnout-related fatigue were the key factors contributing to EMS workplace conflict. We mapped our codes to a conceptual model guided by the National Academies of Sciences, Engineering, and Medicine (NASEM) report on using a systems approach to address clinician burnout and professional well-being to explore implications for addressing conflict within that framework. Factors attributed to conflict mapped to all levels of the NASEM model, lending empirical legitimacy to a broad systems approach to fostering worker well-being. Our findings lead us to propose that active surveillance (enhanced management information and feedback systems) of frontline clinicians' experiences during public health emergencies could increase the effectiveness of regulations and policies across the healthcare system. Ideally, the contributions of the occupational health discipline would become a mainstay of a sustained response to promote ongoing worker well-being. The maintenance of a robust EMS workforce, and by extension the health professionals in its operational sphere, is unquestionably essential to our preparedness for the likelihood that pandemic threats may become more commonplace.

Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care

Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.

Prehospital Stroke Care, Paramedic Training Needs, and Hospital-Directed Feedback in Lithuania

Background: Emergency medical services (EMS) are the first health care contact for the majority of stroke patients. However, there is a lack of data on the current paramedics’ hospital-directed feedback and training needs across different health care settings. We aimed to evaluate paramedics’ prehospital stroke care knowledge, training needs, and current status of feedback on suspected stroke patients. Methods: We surveyed paramedics from the Vilnius region from September to November 2019 and compared the answers between the city and the district agencies. The questionnaire content included questions on paramedics’ demographic characteristics, prehospital stroke care self-assessment, knowledge on stroke mimics, stroke training needs, and the importance of hospital-directed feedback on suspected stroke patients. Results: A total number of 161 paramedics (or 49.4% of all paramedics from our stroke care network) were surveyed, with more district paramedics rating their prehospital stroke care knowledge as inadequate (44.8% (95% confidence interval (CI) 32.8−57.6) vs. 28.1% (95% CI 20.1−27.8), p = 0.028). In addition, more district paramedics indicated a need for additional stroke training (83.1% (95% CI 71.5−90.5) vs. 69.8% (60.0−78.1), p = 0.043). However, respondents reported being the most confident while dealing with stroke (71.3%, 95% CI 63.8−77.7) compared to other time-critical conditions (p < 0.001). Vertigo (60.8%, 95% CI 53.0−68.0), brain tumors (56.3%, 95% CI 48.5−63.8), and seizures (54.4%, 95% CI 46.7−62.0) were indicated as the most common stroke mimics. Only 6.2% (95% CI 3.4−11.1) of respondents received formal feedback on the outcome of suspected stroke patients brought to the emergency department. Conclusions: A high proportion of paramedics self-perceive having inadequate stroke knowledge and an urgent need for further stroke training. The EMS staff indicate receiving insufficient feedback on suspected stroke patients, even though its usefulness is perceived as paramount.

Trauma-Specific Performance Improvement Activities for Emergency Medical Services Providers: A Statewide Perspective

INTRODUCTION

Trauma-specific performance improvement (PI) activities are highly variable among Emergency Medical Services (EMS) providers. This study assesses the perception of the trauma PI activities of EMS providers in the state of Ohio and identifies potential barriers to conducting a successful program.

METHODS

An institutional review board-approved, voluntary, and anonymous Qualtrics survey was disseminated to all EMS agencies registered under the Ohio Department of Public Safety throughout the 88 counties of Ohio. It included questions regarding what agencies considered trauma-specific PI activities, how frequently they completed those activities, and barriers related to conducting such PI activities. There were both open-ended and closed-ended questions in the survey, along with a follow-up interview. The data were descriptively and thematically analyzed.

RESULTS

From the recorded responses (341), most the respondents (98.5%) either agreed or strongly agreed that trauma-specific PI activities improve performance of EMS providers, while only 63.8% (218) of the agencies performed them. Some activities considered as trauma PI and conducted at least once a month included (1) record keeping (74.6%), (2) confirmation on the use of correct triage protocols (66.9%), (3) measuring response time on trauma calls (60.0%), (4) PI reviews of trauma cases (56.9%), and (5) obtaining feedback from the receiving facility and or authorizing physicians (48.5%). Primary barriers to performing trauma PI activities included a lack of interest and financial resources, followed by system-level reasons such as unavailability of training centers and a lack of regional/state support. Thematic analysis of the data suggested that improved communication and awareness of trauma PI, sharing statewide data on trauma PI, better synchronization among EMS agencies and trauma centers, and enhanced EMS funding could potentially improve trauma-specific PI programs at the EMS level.

CONCLUSIONS

Our results showed variability in the perception, execution, and availability of trauma-specific PI activities among EMS agencies in the state. Common barriers could potentially be mitigated by collaboration between agencies, trauma centers, and state-led initiatives. With the increased frequency of mass shootings and other large-scale trauma disasters, it is imperative from a state and regional level to address these inconsistencies and further elucidate effective measures of trauma PI for the EMS community.

Ambulance nurses' experiences of using prehospital guidelines for patients with acute chest pain - A qualitative study

BACKGROUND

Ambulance nurses have an important role in early recognition and treatment often being the first medical contact for patients with acute chest pain. However, there is sparse knowledge on the experiences of ambulance nurses with regard to use of Prehospital Guidelines for patients with Acute Chest Pain.

AIM

To explore ambulance nurses' experiences of using prehospital guidelines for patients with acute coronary syndrome.

METHOD

A qualitative descriptive study design. Semi-structured interviews with 22 ambulance nurses recruited through purposive sampling strategy. The material was transcribed and analysed using content analysis.

RESULTS

Two main categories emerged from the results. The first category Sense of professional obligation included experiences of having an important role in caring for patients with acute chest pain. Understanding this role and the collaboration in the chain of care prompted ambulance nurses to adhere to the guidelines. However, not receiving enough feedback on the provided care made them uncertain whether to use guidelines. The second category Clinical difficulties using guidelines consisted of experiences of being surrounded by practical challenges while using guidelines. Ambulance nurses meet these challenges by relying on their clinical experience, which sometimes led to them deviating from the guidelines.

CONCLUSIONS

The ambulance nurses experienced a mixture of feeling secure and insecure when using the guidelines. Foremost, when encountering patients with unspecific chest pain, they felt a lack of feedback and an insufficient collaboration within the chain of care, which made them deviate from guidelines. To increase adherence in guidelines, post-registration education to update the knowledge and skills about guidelines for acute chest pain is needed followed by formal inter-disciplinary feedback on the care provided.

The role of feedback in emergency ambulance services: a qualitative interview study

BACKGROUND

Several international studies suggest that the feedback that emergency ambulance service (EMS) personnel receive on the care they have delivered lacks structure, relevance, credibility and routine implementation. Feedback in this context can relate to performance or patient outcomes, can come from a variety of sources and can be sought or imposed. Evidence from health services research and implementation science, suggests that feedback can change professional behavior, improve clinical outcomes and positively influence staff mental health. The current study aimed to explore the experience of EMS professionals regarding current feedback provision and their views on how feedback impacts on patient care, patient safety and staff wellbeing.

METHODS

This qualitative study was conducted as part of a wider study of work-related wellbeing in EMS professionals. We used purposive sampling to select 24 frontline EMS professionals from one ambulance service in the United Kingdom and conducted semi-structured interviews. The data was analyzed in iterative cycles of inductive and deductive reasoning using Abductive Thematic Network Analysis. The analysis was informed by psychological theory, as well as models from the wider feedback effectiveness and feedback-seeking behavior literature.

RESULTS

Participants viewed current feedback provision as inadequate and consistently expressed a desire for increased feedback. Reported types of prehospital feedback included patient outcome feedback, patient-experience feedback, peer-to-peer feedback, performance feedback, feedforward: on-scene advice, debriefing and investigations and coroners' reports. Participants raised concerns that inadequate feedback could negatively impact on patient safety by preventing learning from mistakes. Enhancing feedback provision was thought to improve patient care and staff wellbeing by supporting personal and professional development.

CONCLUSIONS

In line with previous research in this area, this study highlights EMS professionals' strong desire for feedback. The study advances the literature by suggesting a typology of prehospital feedback and presenting a unique insight into the motives for feedback-seeking using psychological theory. A logic model for prehospital feedback interventions was developed to inform future research and development into prehospital feedback.

An Opportunity to Understand Concerns about COVID-19 Vaccination: Perspectives from EMS Professionals

Some healthcare professionals, including emergency medical service (EMS) professionals, remain hesitant about receiving COVID-19 vaccines. This study sought to understand EMS professionals’ perspectives regarding COVID-19 vaccination. Using open-ended comments from a national survey deployed electronically to over 19,000 EMS professionals in April of 2021, we examined perspectives about acceptance of and hesitancy toward COVID-19 vaccines. Survey comments revealed differences in perspectives between vaccinated and unvaccinated EMS professionals regarding their personal role in improving public health through COVID-19 vaccination as well as vaccine benefits and the protection conferred by vaccination. Unvaccinated individuals also expressed concerns over the research and development of the COVID-19 vaccines that led to their decision not to get vaccinated. Individuals who were vaccinated suggested ways to increase uptake of the vaccine including having healthcare professionals serve as leaders for vaccination and educating individuals about COVID-19 vaccination through credible resources. Vaccine hesitancy remains a challenge to achieving herd immunity to COVID-19 through vaccination, even among healthcare professionals. Understanding the perspectives of those who have chosen not to be vaccinated can help direct strategies to reduce confusion and concerns. The perspectives of vaccinated individuals may also be valuable in identifying opportunities to promote vaccination in the professional setting.

Quality Management of Prehospital Pediatric Respiratory Distress and Airway Programs: An NAEMSP Position Statement and Resource Document

The unique challenges of pediatric respiratory and airway emergencies require the development and maintenance of a prehospital quality management program that includes pediatric-focused medical oversight and clinical care expertise, data collection, operational considerations, focused education, and clinician competency evaluation.NAEMSP recommends:Medical director oversight must include a focus on pediatric airway and respiratory management and integrate pediatric-specific elements in guideline development, competency assessment, and skills maintenance efforts.EMS agencies are encouraged to collaborate with medical professionals who have expertise in pediatric emergency care to provide support for quality management initiatives in pediatric respiratory distress and airway management.EMS agencies should define quality indicators for pediatric-specific elements in respiratory distress and airway management and benchmark performance based on regional and national standards.EMS agencies should implement both quantitative (objective) and qualitative (subjective) measures of performance to assess competency in pediatric respiratory distress and airway management.EMS agencies choosing to incorporate pediatric endotracheal intubation or supraglottic airway insertion must use pediatric-specific quality management benchmarks and perform focused review of advanced airway management.

COVID-19 Vaccinations in EMS Professionals: Prevalence and Predictors

Background:

Immunizations for emergency medical services (EMS) professionals during pandemics are an important tool to increase the safety of the workforce as well as their patients. The purpose of this study was to better understand EMS professionals’ decisions to receive or decline a COVID-19 vaccine.

Methods:

We conducted a cross-sectional analysis of nationally certified EMS professionals (18–85 years) in April 2021. Participants received an electronic survey asking whether they received a vaccine, why or why not, and their associated beliefs using three validated scales: perceived risk of COVID-19, medical mistrust, and confidence in the COVID-19 vaccine. Data were merged with National Registry dataset demographics. Analyses included descriptive analysis and multivariable logistic regression (OR, 95% CI). Multivariate imputation by chained equations was used for missingness.

Results:

A total of 2,584 respondents satisfied inclusion criteria (response rate = 14%). Overall, 70% of EMS professionals were vaccinated. Common reasons for vaccination among vaccinated respondents were to protect oneself (76%) and others (73%). Common reasons for non-vaccination among non-vaccinated respondents included concerns about vaccine safety (53%) and beliefs that vaccination was not necessary (39%). Most who had not received the vaccine did not plan to get it in the future (84%). Hesitation was most frequently related to wanting to see how the vaccine was working for others (55%). Odds of COVID-19 vaccination were associated with demographics including age (referent <28 years; 39–50 years: 1.56, 1.17–2.08; >51 years: 2.22, 1.64–3.01), male sex (1.26, 1.01–1.58), residing in an urban/suburban area (referent rural; 1.36, 1.08–1.70), advanced education (referent GED/high school and below; bachelor’s and above: 1.72, 1.19–2.47), and working at a hospital (referent fire-based agency; 1.53, 1.04–2.24). Additionally, vaccination odds were significantly higher with greater perceived risk of COVID-19 (2.05, 1.68–2.50), and higher vaccine confidence (2.84, 2.40–3.36). Odds of vaccination were significantly lower with higher medical mistrust (0.54, 0.46–0.63).

Conclusion:

Despite vaccine availability, not all EMS professionals had been vaccinated. The decision to receive a COVID-19 vaccine was associated with demographics, beliefs regarding COVID-19 and the vaccine, and medical mistrust. Efforts to increase COVID-19 vaccination rates should emphasize the safety and efficacy of vaccines.

It's Time to Talk to Prehospital Providers: Feedback Disparities among Ground-Based Emergency Medical Services Providers and its Impact on Job Satisfaction

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.

Methods and Implementation of the 2019 EMS Practice Analysis

Background: The EMS Practice Analysis provides a vision of current prehospital care by defining the work performed by EMS professionals. In this manuscript, we present the National Advanced Life Support (ALS) EMS Practice Analysis for the advanced EMT (AEMT) and paramedic levels of certification. The goal of the 2019 EMS Practice Analysis is to define the work performed by EMS professionals and present a new template for future practice analyses. Methods: The project was executed in three phases. Phase 1 defined the types/frequency of EMS clinical presentations using the 2016 National Emergency Medical Services Information System (NEMSIS) dataset. Phase 2 defined the criticality or potential for harm of these clinical presentations through a survey of a random sample of nationally certified EMS professionals and medical directors. Phase 3 defined the tasks and the associated knowledge, skills, and abilities (KSA) that encompass EMS care through focus groups of subject matter experts. Results: In Phase 1, the most common EMS adult impressions were traumatic injury, abdominal pain/problems, respiratory distress/arrest, behavioral/psychiatric disorder, and syncope/fainting. The most common pediatric impressions were traumatic injury, behavioral/psychiatric disorder, respiratory distress/arrest, seizure, and abdominal pain/problems. Criticality was defined in Phase 2 with the highest risk of harm for adults being airway obstruction, respiratory distress/arrest, cardiac arrest, hypovolemia/shock, allergic reaction, or stroke/CVA. In comparison, pediatric patients presenting with airway obstruction, respiratory distress/arrest, cardiac arrest, hypovolemia/shock, allergic reaction, stroke/CVA, and inhalation injury had the highest potential for harm. Finally, in Phase 3, task statements were generated for both paramedic and AEMT certification levels. A total of 425 tasks and 1,734 KSAs were defined for the paramedic level and 405 tasks and 1,636 KSAs were defined for the AEMT level. Conclusion: The 2019 ALS Practice Analysis describes prehospital practice at the AEMT and paramedic levels. This approach allows for a detailed and robust evaluation of EMS care while focusing on each task conducted at each level of certification in EMS. The data can be leveraged to inform the scope of practice, educational standards, and assist in validating the ALS levels of the certification examination.

What influences safety in paramedicine? Understanding the impact of stress and fatigue on safety outcomes

OBJECTIVE

The purpose of this study was to build on extant research linking fatigue to safety outcomes in paramedicine by assessing the influence of a multiplicity of workplace stressors, including chronic and critical incident stresses on safety outcomes.

METHODS

A cross-sectional survey was deployed to 10 paramedic services in Ontario. Validated survey instruments measured operational and organizational chronic stress, critical incident stress, post-traumatic stress symptomatology (PTSS), fatigue, safety outcomes, and demographics. Analysis of covariance assessed associations of workplace stresses with safety outcomes and corroborated findings using hierarchical linear model and generalized estimating equations (GEE) by taking into account paramedic service when assessing the proposed associations. A non-responder survey was conducted to asses for demographic differences in those who did and did not complete the survey.

RESULTS

This survey had a response rate of 40.5% (n = 717/1767); 80% of paramedics reported an injury or exposure to pathogen, 95% reported safety compromising behaviors, and 76% reported medical errors. In the GEE analyses, paramedic injury was significantly related to fatigue (0.13, SE = 0.06, P = 0.020), critical incident stress (0.03, SE = 0.01, P < 0.01), and PTSS (0.03, SE = 0.01, P < 0.01). Safety compromising behaviors were significantly associated with fatigue (0.37, SE = 0.06, P < 0.01), organizational stress (0.06, SE = 0.01, P < 0.01), and critical incident stress (0.01. SE = 0.01, P = 0.017). Medication errors were significantly related to fatigue (0.12, SE = 0.05, P < 0.01). Finally, the bivariate analysis showed increased stress factors and fatigue was associated with increased safety outcomes.

CONCLUSION

These findings illustrate that a host of different stressors may influence safety-related behaviors. For those interested in safety, these findings point to the need for a holistic focus on fatigue and stress in paramedicine.

The Association of Death Notification and Related Training with Burnout among Emergency Medical Services Professionals

INTRODUCTION

Death notification is a difficult task commonly encountered during prehospital care and may lead to burnout among EMS professionals. Lack of training could potentiate the relationship between death notification and burnout. The first objective of this study was to describe EMS professionals' experience with death notification and related training. The secondary objective was to assess the associations between death notification delivery, training, and burnout. Methods: We administered an electronic questionnaire to a random sample of nationally-certified EMS professionals. Work-related burnout was measured using the validated Copenhagen Burnout Inventory. Analysis was stratified by certification level to basic life support (BLS) and advanced life support (ALS). The association between the number of adult (≥18 years) patient death notifications delivered in the prior 12 months and burnout was assessed using multivariable logistic regression to adjust for confounding variables. Multivariable logistic regression modeling was used to assess the adjusted association between training and burnout among those who reported delivering at least one death notification in the prior 12 months. Adjusted odds ratios (aOR) and 95% confidence intervals are reported (95% CI). Results: We received 2,333/19,330 (12%) responses and 1,514 were included in the analysis. Most ALS respondents (77%) and one-third of BLS respondents (33%) reported at least one adult death notification in the past year. Approximately half of respondents reported receiving death notification training as part of their initial EMS education program (51% BLS; 52% ALS) and fewer reported receiving continuing education (30% BLS; 44% ALS). Delivering a greater number of death notifications was associated with increased odds of burnout. Among those who delivered at least one death notification, continuing education was associated with reduced odds of burnout. Conclusion: Many EMS professionals reported delivering at least one death notification within the past year. Yet, fewer than half reported training related to death notification during initial EMS education and even fewer reported receiving continuing education. More of those who delivered death notifications experienced burnout, while continuing education was associated with reduced odds of burnout. Future work is needed to develop and evaluate death notification training specifically for EMS professionals.

Exploring paramedic perceptions of feedback using a phenomenological approach

Objectives:

Despite widespread advocacy of a feedback culture in healthcare, paramedics receive little feedback on their clinical performance. Provision of ‘outcome feedback’, or information concerning health-related patient outcomes following incidents that paramedics have attended, is proposed, to provide paramedics with a means of assessing and developing their diagnostic and decision-making skills. To inform the design of feedback mechanisms, this study aimed to explore the perceptions of paramedics concerning current feedback provision and to discover their attitudes towards formal provision of patient outcome feedback.

Methods:

Convenience sampling from a single ambulance station in the United Kingdom (UK) resulted in eight paramedics participating in semi-structured interviews. Interpretative phenomenological analysis was employed to generate descriptive and interpretative themes related to both current and potential feedback provision.

Results:

The perception that only exceptional incidents initiate feedback, and that often the required depth of information supplied is lacking, resulted in some participants describing an isolation of their daily practice. Barriers and limitations of the informal processes currently employed to access feedback were also highlighted. Formal provision of outcome feedback was anticipated by participants to benefit the integration and progression of the paramedic profession as a whole, in addition to facilitating the continued development and well-being of the individual clinician. Participants anticipated feedback to be delivered electronically to minimise resource demands, with delivery initiated by the individual clinician. However, a level of support or supervision may also be required to minimise the potential for harmful consequences.

Conclusions:

Establishing a just feedback culture within paramedic practice may reduce a perceived isolation of clinical practice, enabling both individual development and progression of the profession. Carefully designed formal outcome feedback mechanisms should be initiated and subsequently evaluated to establish resultant benefits and costs.

The association of job demands and resources with burnout among emergency medical services professionals

OBJECTIVE

Although burnout has been linked to negative workplace-level effects, prior studies have primarily focused on individuals rather than job-related characteristics. This study sought to evaluate variation in burnout between agencies and to quantify the relationship between burnout and job-related demands/resources among emergency medical services (EMS) professionals.

METHODS

An electronic questionnaire was sent to all licensed, practicing EMS professionals in South Carolina. Work-related burnout was measured using the Copenhagen Burnout Inventory. Multivariable generalized estimating equations were used to estimate odds ratios (ORs) for specific job demands and resources while adjusting for confounding variables. Composite scores were used to simultaneously assess the relationship between burnout and job-related demands and resources.

RESULTS

Among 1271 EMS professionals working at 248 EMS agencies, the median agency-level burnout was 35% (interquartile range [IQR]: 13% to 50%). Job-related demands, including time pressure, were associated with increased burnout. Traditional job-related resources, including pay and benefits, were associated with reduced burnout. Less tangible job resources, including autonomy, clinical performance feedback, social support, and adequate training demonstrated strong associations with reduced burnout. EMS professionals facing high job demands and low job resources demonstrated nearly a 10-fold increase in odds of burnout compared with those exposed to low demands and high resources (adjusted OR [aOR]: 9.50, 95% confidence interval [CI]: 6.39-14.10). High job resources attenuated the impact of high job demands.

CONCLUSION

The proportion of EMS professionals experiencing burnout varied substantially across EMS agencies. Job resources, including those reflective of organizational culture, were associated with reduced burnout. Collectively, these findings suggest an opportunity to address burnout at the EMS agency level.

Treat me nice! -a cross-sectional study examining support during the first year in the emergency medical services

Background

Working in the emergency medical service (EMS) can be extremely varying and sometimes physically and psychologically demanding. Being new in this context can be a great challenge. This study aim to describe what ambulance nurses consider to be important support during the first year in the EMS.

Methods

Three hundred and eighty-nine eligible participants that had graduated from the prehospital emergency care program were identified via university registrations office in Sweden. The eligible participants received a study specific questionnaire via mail consisting of 70 statements about support during the first year. The perceived importance of each statement were graded on a 7-point Likert scale. The gradings were analysed using descriptive statistics and frequencies, mean and SD were calculated.

Results

Two hundred and thirty questionnaires were returned fully completed, giving a response rate of 59%. Fourteen statements regarding desirable support were rated with mean values > 6.00 and SD < 1.00 and considered as being the most important during the first year in the EMS. The important supports regarded; colleagues and work environment, management and organisation, experience-based knowledge, introduction period, practical support, and theoretical support. Most statements regarded culture and climate and the way the newcomers wanted to be treated.

Conclusion

It was concluded that an important way to support newcomers in the EMS is to treat them ‘nice’. This can be achieved by creating an open climate and a welcoming culture where the new professionals feel trusted and treated with respect, created ways to work structurally, have applicable medical guidelines, and for newcomers to receive feedback on their actions.