Effect of cognitive rehabilitation on outcomes for persons with traumatic brain injury: A systematic review

We evaluated evidence for the effectiveness of cognitive rehabilitation methods to improve outcomes for persons with traumatic brain injury (TBI). A search of MEDLINE, HealthSTAR, CINAHL, PsycINFO, and the Cochrane Library produced 600 potential references. Thirty-two studies met predetermined inclusion criteria and were abstracted; data from 24 were placed into evidence tables. Two randomized controlled trials and one observational study provided evidence that specific forms of cognitive rehabilitation reduce memory failures and anxiety, and improve self-concept and interpersonal relationships for persons with TBI. The durability and clinical relevance of these findings is not established. Future research utilizing control groups and multivariate analysis must incorporate subject variability and must include standard definitions of the intervention and relevant outcome measures that reflect health and function.

The effect of post-operative mechanical axis alignment on the survival of primary total knee replacements after a follow-up of 15 years

Correct positioning and alignment of components during primary total knee replacement (TKR) is widely accepted to be an important predictor of patient satisfaction and implant durability. This retrospective study reports the effect of the post-operative mechanical axis of the lower limb in the coronal plane on implant survival following primary TKR. A total of 501 TKRs in 396 patients were divided into an aligned group with a neutral mechanical axis (± 3°) and a malaligned group where the mechanical axis deviated from neutral by > 3°. At 15 years' follow-up, 33 of 458 (7.2%) TKRs were revised for aseptic loosening. Kaplan-Meier survival analysis showed a weak tendency towards improved survival with restoration of a neutral mechanical axis, but this did not reach statistical significance (p = 0.47). We found that the relationship between survival of a primary TKR and mechanical axis alignment is weaker than that described in a number of previous reports.

Pre-eclampsia is associated with an excess of proliferative immature intermediate trophoblast

Pre-eclampsia/toxemia (PET) is an idiopathic hypertensive disorder of pregnancy elicited in susceptible mothers by exposure to placental trophoblast. Three facts regarding the placenta in PET are known: an association with large placentas (excessive trophoblast), a tendency for superficial implantation, and inappropriate trophoblastic immaturity, as assessed by ultrastructural and biochemical criteria. A unitary hypothesis is that PET is related to a maturation defect leading to excessive accumulation of inappropriately immature intermediate trophoblast in the placental implantation site. We studied the implantation site of PET and control placentas from three gestational age groups (25 to 30, 30 to 35, and 36 to 40 weeks old [five per group]) by morphometry and immunohistochemistry using antibodies to three phenotypic markers (cytokeratin, human placental lactogen (HPL), and beta 2-microglobulin) and two markers of cell dynamics (proliferating cell nuclear antigen [PCNA] and bcl-2]). Implantation sites in the PET group had increased amounts of intermediate trophoblast (cell number and longitudinal extent) with an increased proliferative index (percentage of PCNA positive) and evidence of phenotypic immaturity (HPL negative). Intermediate trophoblast from both groups was uniformly bcl-2 negative and beta 2-microglobulin positive. Based on these data and the findings of other investigators, we propose that the diagnostic term "atypical implantation site" be added to acute atherosis, villous infarction, and increased syncytial knotting as a characteristic of placentas from pre-eclamptic pregnancies.

Association between poor sleep, fatigue, and safety outcomes in emergency medical services providers

OBJECTIVE

To determine the association between poor sleep quality, fatigue, and self-reported safety outcomes among emergency medical services (EMS) workers.

METHODS

We used convenience sampling of EMS agencies and a cross-sectional survey design. We administered the 19-item Pittsburgh Sleep Quality Index (PSQI), 11-item Chalder Fatigue Questionnaire (CFQ), and 44-item EMS Safety Inventory (EMS-SI) to measure sleep quality, fatigue, and safety outcomes, respectively. We used a consensus process to develop the EMS-SI, which was designed to capture three composite measurements of EMS worker injury, medical errors and adverse events (AEs), and safety-compromising behaviors. We used hierarchical logistic regression to test the association between poor sleep quality, fatigue, and three composite measures of EMS worker safety outcomes.

RESULTS

We received 547 surveys from 30 EMS agencies (a 35.6% mean agency response rate). The mean PSQI score exceeded the benchmark for poor sleep (6.9, 95% confidence interval [CI] 6.6, 7.2). More than half of the respondents were classified as fatigued (55%, 95% CI 50.7, 59.3). Eighteen percent of the respondents reported an injury (17.8%, 95% CI 13.5, 22.1), 41% reported a medical error or AE (41.1%, 95% CI 36.8, 45.4), and 90% reported a safety-compromising behavior (89.6%, 95% CI 87, 92). After controlling for confounding, we identified 1.9 greater odds of injury (95% CI 1.1, 3.3), 2.2 greater odds of medical error or AE (95% CI 1.4, 3.3), and 3.6 greater odds of safety-compromising behavior (95% CI 1.5, 8.3) among fatigued respondents versus nonfatigued respondents.

CONCLUSIONS

In this sample of EMS workers, poor sleep quality and fatigue are common. We provide preliminary evidence of an association between sleep quality, fatigue, and safety outcomes.

Low serum antimycobacterial drug levels in non-HIV-infected tuberculosis patients

BACKGROUND

Despite the use of directly observed therapy (DOT) by tuberculosis control programs, patient treatment failure, relapse, and acquired drug resistance remain problematic in a small number. We investigated serum drug levels in non-HIV-infected tuberculosis patients who were receiving DOT by the health department and did not respond to treatment as expected.

METHODS

The indications for checking levels were as follows: (1) slow clinical response or failure to convert the sputum culture within 12 weeks; (2) treatment failure, early disease relapse < 13 months since being declared cured; (3) relapse, late disease reactivation > or = 13 months since being declared cured; and (4) acquired drug resistance while receiving DOT. Baseline characteristics of control subjects who responded to therapy as expected were compared. Venous blood for analysis was obtained at 2 h after directly observed ingestion and measured by high-performance liquid chromatography.

RESULTS

Twenty-four patients receiving daily or twice-weekly standard therapy with isoniazid (INH, 300 or 900 mg) and rifampin (RMP, 600 mg) were identified; 22 had drug levels evaluated at 2 h. For INH, 15 of 22 patients (68%) had levels less than the reported target range. For RMP, 14 of 22 patients (64%) had low levels. Among the 14 patients receiving INH, 900 mg, and RMP, 600 mg, 4 (29%) had very low levels of both. Use of a combination INH/RMP tablet was associated with lower INH levels (p=0.04); however, RMP levels were higher (p<0.02). Alcohol use was associated with significantly higher RMP (p<0.01) serum concentrations.

CONCLUSIONS

Important questions remain concerning the utility and timing of serum drug measurements. However, if a patient is not responding to therapy as expected and one is assured that the Mycobacterium tuberculosis organism is susceptible to the drugs given and that the patient is taking the medication as prescribed, drug level monitoring should be considered.

Summary report: evidence for the effectiveness of rehabilitation for persons with traumatic brain injury

We evaluated the evidence for effectiveness of rehabilitation methods throughout the phases of recovery from traumatic brain injury (TBI) in adults. MEDLINE, HealthSTAR, CINAHL, PsycINFO, and the Cochrane Library were searched, and a total of 3,098 abstracts were reviewed. The strongest studies were critically appraised and their data placed in evidence tables. Results showed that to determine the effectiveness of rehabilitation interventions for persons with TBI, a commitment must be made to population-based studies, strong controlled research design, standardization of measures, adequate statistical analysis, and specification of health outcomes of importance to persons with TBI and their families.

The relationship between shift work, sleep, and cognition in career emergency physicians

OBJECTIVES

The 24-hour physician coverage of the emergency department (ED) requires shift work, which can result in desynchronosis and cognitive decline. We measured changes in cognition and sleep disturbance in attending emergency physicians (EPs) before and after day and overnight shifts.

METHODS

Thirteen EPs were tested before and after day and overnight shifts using the Paced Auditory Serial Addition Test (PASAT), the University of Southern California Repeatable Episodic Memory Test (REMT), the Trail Making Test (TMT), and the Stroop Color-Word Test. Sleep quality and fatigue were assessed using the Pittsburgh Sleep Quality Index (PSQI) and Chalder Fatigue Questionnaire (CFQ). Saliva samples were collected from each physician immediately before and after day shifts and night shifts for neurohormonal assays.

RESULTS

Significantly fewer words were recalled on the REMT after both day (-2.4, 95% confidence interval [CI] = -4.4 to -0.4) and overnight shifts (-4.6, 95% CI = -6.4 to -2.8). There was a significant postshift increase in words recalled from the last third of the REMT list after overnight shifts (6.6, 95% CI = 2.8 to 10.4). Sleep quality was worse in EPs (mean PSQI = 4.8, SD ± 2.5) compared to the normal population, with 31% of subjects reporting poor sleep quality. Postshift fatigue was correlated with the perceived difficulty of the shift. Salivary cortisol and melatonin demonstrated diurnal variation consistent with normal circadian rhythms. Morning cortisol peak was decreased or delayed in samples from physicians after a night shift.

CONCLUSIONS

These data indicate that short-term memory appears to decline after day and overnight shifts and confirms the high incidence of disturbed sleep in this population.

In vitro study of foot kinematics using a dynamic walking cadaver model

There is a dearth of information on navicular, cuboid, cuneiform and metatarsal kinematics during walking and our objective was to study the kinematic contributions these bones might make to foot function. A dynamic cadaver model of walking was used to apply forces to cadaver feet and mobilise them in a manner similar to in vivo. Kinematic data were recorded from 13 cadaver feet. Given limitations to the simulation, the data describe what the cadaver feet were capable of in response to the forces applied, rather than exactly how they performed in vivo. The talonavicular joint was more mobile than the calcaneocuboid joint. The range of motion between cuneiforms and navicular was similar to that between talus and navicular. Metatarsals four and five were more mobile relative to the cuboid than metatarsals one, two and three relative to the cuneiforms. This work has confirmed the complexity of rear, mid and forefoot kinematics. The data demonstrate the potential for often-ignored foot joints to contribute significantly to the overall kinematic function of the foot. Previous emphasis on the ankle and sub talar joints as the principal articulating components of the foot has neglected more distal articulations. The results also demonstrate the extent to which the rigid segment assumptions of previous foot kinematics research have over simplified the foot.

Sleep quality and fatigue among prehospital providers

BACKGROUND

Fatigue is common among medical professionals and has been linked to poor performance and medical error. Objective. To characterize sleep quality and its association with severe fatigue in emergency medical services (EMS) providers.

METHODS

We studied a convenience sample of EMS providers who completed three surveys: the Pittsburgh Sleep Quality Index (PSQI), the Chalder Fatigue Questionnaire (CFQ), and a demographic survey. We used established measures to examine survey psychometrics and performed t-tests, analysis of variance (ANOVA), and chi-square tests to identify differences in PSQI and CFQ scores.

RESULTS

One hundred nineteen surveys were completed. The eight-hour shift was most commonly reported (35.4%). A majority of subjects were overweight (41.9%) or obese (42.7%), and 59.6% had been diagnosed with one or more health conditions (e.g., diabetes). Results from psychometric tests were positive. The mean (+/- standard deviation) PSQI score was 9.2 (+/- 3.7). A CFQ score > or =4, indicating severe mental and physical fatigue, was present in 44.5% of the subjects. The mean PSQI score was higher among those reporting severe fatigue (11.3 +/- 3.2) than among those not reporting fatigue (7.5 +/- 3.0, p < 0.0001).

CONCLUSIONS

The results from this study suggest that the sleep quality and fatigue status of EMS workers are at unhealthy levels. The health and safety of the EMS worker and patient population should be considered in light of these results.

Measuring nurse attitudes towards deliberate self-harm: the Self-Harm Antipathy Scale (SHAS)

Most mental health nurses engage at some point with clients who harm themselves and these nurses often experience strong negative emotional reactions. Prolonged engagement with relapsing clients can lead to antipathy, and 'malignant alienation'. The study reported here has the aim of developing a brief, robust instrument for assessing nurse attitudes in this area. The Self-Harm Antipathy Scale, developed here on a sample of 153 healthcare professionals, has 30 attitudinal items with six factors. It has acceptable face validity, good internal consistency and some evidence of good test-retest reliability. It discriminates effectively between criterion groups. Overall this is evidence for the complexity of nurses' responses to this client group but such complex attitudes can still be assessed using a relatively brief structured instrument.

Cannabis use and age at onset of symptoms in subjects at clinical high risk for psychosis

OBJECTIVE

Numerous studies have found a robust association between cannabis use and the onset of psychosis. Nevertheless, the relationship between cannabis use and the onset of early (or, in retrospect, prodromal) symptoms of psychosis remains unclear. The study focused on investigating the relationship between cannabis use and early and high-risk symptoms in subjects at clinical high risk for psychosis.

METHOD

Prospective multicenter, naturalistic field study with an 18-month follow-up period in 245 help-seeking individuals clinically at high risk. The Composite International Diagnostic Interview was used to assess their cannabis use. Age at onset of high risk or certain early symptoms was assessed retrospectively with the Interview for the Retrospective Assessment of the Onset of Schizophrenia.

RESULTS

Younger age at onset of cannabis use or a cannabis use disorder was significantly related to younger age at onset of six symptoms (0.33 < r(s) < 0.83, 0.004 < P < 0.001). Onset of cannabis use preceded symptoms in most participants.

CONCLUSION

Our results provide support that cannabis use plays an important role in the development of psychosis in vulnerable individuals. Cannabis use in early adolescence should be discouraged.

Paramedic determinations of medical necessity: a meta-analysis

INTRODUCTION

Reducing unnecessary ambulance transports may have operational and economic benefits for emergency medical services (EMS) agencies and receiving emergency departments. However, no consensus exists on the ability of paramedics to accurately and safely identify patients who do not require ambulance transport. Objective. This systematic review and meta-analysis evaluated studies reporting U.S. paramedics' ability to determine medical necessity of ambulance transport.

METHODS

PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library databases were searched using Cochrane Prehospital and Emergency Care Field search terms combined with the Medical Subject Headings (MeSH) terms "triage"; "utilization review"; "health services misuse"; "severity of illness index," and "trauma severity indices." Two reviewers independently evaluated each title to identify relevant studies; each abstract then underwent independent review to identify studies requiring full appraisal. Inclusion criteria were original research; emergency responses; determinations of medical necessity by U.S. paramedics; and a reference standard comparison. The primary outcome measure of interest was the negative predictive value (NPV) of paramedic determinations. For studies reporting sufficient data, agreement between paramedic and reference standard determinations was measured using kappa; sensitivity, specificity, and positive predictive value (PPV) were also calculated.

RESULTS

From 9,752 identified titles, 214 abstracts were evaluated, with 61 studies selected for full review. Five studies met the inclusion criteria (interrater reliability, kappa = 0.75). Reference standards included physician opinion (n = 3), hospital admission (n = 1), and a composite of physician opinion and patient clinical circumstances (n = 1). The NPV ranged from 0.610 to 0.997. Results lacked homogeneity across studies; meta-analysis using a random-effects model produced an aggregate NPV of 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported complete 2 x 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

CONCLUSION

The results of the few studies evaluating U.S. paramedic determinations of medical necessity for ambulance transport vary considerably, and only two studies report complete data. The aggregate NPV of the paramedic determinations is 0.91, with a lower confidence limit of 0.71. These data do not support the practice of paramedics' determining whether patients require ambulance transport. These findings have implications for EMS systems, emergency departments, and third-party payers.

Variation in emergency medical services workplace safety culture

INTRODUCTION

Workplace attitude, beliefs, and culture may impact the safety of patient care. This study characterized perceptions of safety culture in a nationwide sample of emergency medical services (EMS) agencies.

METHODS

We conducted a cross-sectional survey involving 61 advanced life support EMS agencies in North America. We administered a modified version of the Safety Attitudes Questionnaire (SAQ), a survey instrument measuring dimensions of workplace safety culture (Safety Climate, Teamwork Climate, Perceptions of Management, Job Satisfaction, Working Conditions, and Stress Recognition). We included full-time and part-time paramedics and emergency medical technicians. We determined the variation in safety culture scores across EMS agencies. Using hierarchical linear models, we determined associations between safety culture scores and individual and EMS agency characteristics.

RESULTS

We received 1,715 completed surveys from 61 EMS agencies (mean agency response rate 47%; 95% confidence interval [CI] 10%, 83%). There was wide variation in safety culture scores across EMS agencies [mean (minimum, maximum)]: Safety Climate 74.5 (min 49.9, max 89.7), Teamwork Climate 71.2 (min 45.1, max 90.1), Perceptions of Management 67.2 (min 31.1, max 92.2), Job Satisfaction 75.4 (min 47.5, max 93.8), Working Conditions 66.9 (min 36.6, max 91.4), and Stress Recognition 55.1 (min 31.3, max 70.6). Air medical EMS agencies tended to score higher across all safety culture domains. Lower safety culture scores were associated with increased annual patient contacts. Safety Climate domain scores were not associated with other individual or EMS agency characteristics.

CONCLUSION

In this sample, workplace safety culture varies between EMS agencies.

Effects of Napping During Shift Work on Sleepiness and Performance in Emergency Medical Services Personnel and Similar Shift Workers: A Systematic Review and Meta-Analysis

BACKGROUND

Scheduled napping during work shifts may be an effective way to mitigate fatigue-related risk. This study aimed to critically review and synthesize existing literature on the impact of scheduled naps on fatigue-related outcomes for EMS personnel and similar shift worker groups.

METHODS

A systematic literature review was performed of the impact of a scheduled nap during shift work on EMS personnel or similar shift workers. The primary (critical) outcome of interest was EMS personnel safety. Secondary (important) outcomes were patient safety; personnel performance; acute states of fatigue, alertness, and sleepiness; indicators of sleep duration and/or quality; employee retention/turnover; indicators of long-term health; and cost to the system. Meta-analyses were performed to evaluate the impact of napping on a measure of personnel performance (the psychomotor vigilance test [PVT]) and measures of acute fatigue.

RESULTS

Of 4,660 unique records identified, 13 experimental studies were determined relevant and summarized. The effect of napping on reaction time measured at the end of shift was small and non-significant (SMD 0.12, 95% CI -0.13 to 0.36; p = 0.34). Napping during work did not change reaction time from the beginning to the end of the shift (SMD -0.01, 95% CI -25.0 to 0.24; p = 0.96). Naps had a moderate, significant effect on sleepiness measured at the end of shift (SMD 0.40, 95% CI 0.09 to 0.72; p = 0.01). The difference in sleepiness from the start to the end of shift was moderate and statistically significant (SMD 0.41, 95% CI 0.09 to 0.72; p = 0.01).

CONCLUSIONS

Reviewed literature indicated that scheduled naps at work improved performance and decreased fatigue in shift workers. Further research is required to identify the optimal timing and duration of scheduled naps to maximize the beneficial outcomes.

Levels of unmet needs and distress amongst adolescents and young adults (AYAs) impacted by familial cancer

OBJECTIVE

To describe levels of, and relationships between, distress and psychosocial unmet needs in adolescents and young adults (AYAs) with a family member with cancer.

METHODS

Adolescents and young adults (12-24 years old) with a living sibling or parent with cancer participated. Participants completed demographics, the Kessler 10 (K10) distress scale and the Sibling or Offspring Cancer Needs Instruments. Descriptive statistics were obtained for all measures, item-level frequencies were examined to identify common unmet needs, and relationships between distress and unmet needs were explored.

RESULTS

Average sibling (N = 106) and offspring (N = 256) distress levels were in the high range (K10total = 22-30), with 29.6% and 31.6% in the very high range (K10total = 31-50), respectively. Siblings had mean = 19.7 unmet needs (range 0-45), 66% had ≥10 unmet needs, and 44% of the 45 needs were unmet on average. Offspring had mean = 22.4 unmet needs (range 0-47), 77% had ≥10 unmet needs, and 48% of the 47 needs were unmet on average. Strong positive correlations were found between K10 distress and the number of sibling/offspring unmet needs (r = 0.599 and r = 0.522, respectively, P = .00).

CONCLUSIONS

Australian AYA siblings and offspring impacted by familial cancer experience high levels and numbers of unmet needs and substantial distress. Strong associations were found between increased distress and more unmet needs. Distress levels were comparable to AYAs seeking treatment for mental health issues. Insights into the type and number of needs experienced by AYA siblings and offspring will facilitate development and delivery of targeted, age-appropriate interventions, and resources for these vulnerable and underserved young people.

The emergency medical services safety attitudes questionnaire

To characterize safety culture in emergency medical services (EMS), the authors modified a validated safety culture instrument, the Safety Attitudes Questionnaire (SAQ). The pilot instrument was administered to 3 EMS agencies in a large metropolitan area. The authors characterized safety culture across 6 domains: safety climate, teamwork climate, perceptions of management, job satisfaction, working conditions, and stress recognition. The feasibility of characterizing safety culture in EMS was evaluated by examining response rate, item missingness, EMS chief administrators' perceptions of the EMS-SAQ, as well as psychometric properties.The results confirm feasibility with a high response rate, acceptable internal consistency, and model fit validity. However, some agencies voiced concerns about respondent burden and the wording and face validity of several EMS-SAQ items. Variation in safety culture scores across EMS agencies within a single geographic area, as well as variation across respondent characteristics, warrants further investigation.

Prediction of psychosis in clinical high-risk patients by the Schizotypal Personality Questionnaire. Results of the EPOS project

OBJECTIVE

Schizotypal features indicate proneness to psychosis in the general population. It is also possible that they increase transition to psychosis (TTP) among clinical high-risk patients (CHR). Our aim was to investigate whether schizotypal features predict TTP in CHR patients.

METHODS

In the EPOS (European Prediction of Psychosis Study) project, 245 young help-seeking CHR patients were prospectively followed for 18 months and their TTP was identified. At baseline, subjects were assessed with the Schizotypal Personality Questionnaire (SPQ). Associations between SPQ items and its subscales with the TTP were analysed in Cox regression analysis.

RESULTS

The SPQ subscales and items describing ideas of reference and lack of close interpersonal relationships were found to correlate significantly with TTP. The co-occurrence of these features doubled the risk of TTP.

CONCLUSIONS

Presence of ideas of reference and lack of close interpersonal relations increase the risk of full-blown psychosis among CHR patients. This co-occurrence makes the risk of psychosis very high.

Testing the effectiveness of an educational intervention aimed at changing attitudes to self-harm

Nurses' attitudes toward service users who repeatedly self-harm can be negative and may interfere with the user's willingness to engage with services. The effectiveness of an educational intervention aimed at improving nurses' attitudes in this area was tested in this study. The intervention consisted of attendance on an accredited course on self-harm over a period of 15 weeks and the outcome of interest was attitudes as measured by the Self Harm Antipathy Scale. When deployed in a before-and-after design with two non-randomly allocated groups, there was evidence of a 20% reduction in antipathy toward self-harm among course attenders maintained over a period of at least 18 months (compared with a 9% reduction in a comparison group). Three of the six Self Harm Antipathy Scale attitude dimensions showed significant short-term change with some further long-term effects. This is preliminary evidence for the effectiveness of the chosen intervention in reducing overall antipathy toward self-harm clients and enhancing a sense of competence, a valuing of the care process and an awareness of the factors contributing to self-harm.

COVID-19 Vaccine Uptake and Intent Among Emergency Healthcare Workers: A Cross-Sectional Survey

OBJECTIVE

Vaccine hesitancy limits population protection from SARS-CoV (coronavirus disease [COVID-19]). Vaccine hesitancy among healthcare workers (HCW) could put patients and coworkers at risk.

METHODS

We surveyed 475 emergency department and emergency medical service workers from January to February 2021 to determine vaccine intent/uptake, perceived COVID-19 vulnerability, and factors associated with vaccine intent/uptake.

RESULTS

Although 79% of HCWs received or had plans to receive the COVID-19 vaccine, 21% had no intent/were unvaccinated; intent/uptake was lower among females (odds ratio [OR] = 0.34) and those with a history of COVID-19 infection (OR = 0.55), and higher among those with advanced degrees (OR = 3.53) and high perceived COVID-19 vulnerability (OR = 1.99).

CONCLUSIONS

This study provides a timely assessment of vaccination status among frontline HCWs and highlights subgroups who may be at high risk of exposure and transmission.

The longitudinal study of turnover and the cost of turnover in emergency medical services

BACKGROUND

Few studies have examined employee turnover and associated costs in emergency medical services (EMS).

OBJECTIVE

To quantify the mean annual rate of turnover, total median cost of turnover, and median cost per termination in a diverse sample of EMS agencies.

METHODS

A convenience sample of 40 EMS agencies was followed over a six-month period. Internet, telephone, and on-site data-collection methods were used to document terminations, new hires, open positions, and costs associated with turnover. The cost associated with turnover was calculated based on a modified version of the Nursing Turnover Cost Calculation Methodology (NTCCM). The NTCCM identified direct and indirect costs through a series of questions that agency administrators answered monthly during the study period. A previously tested measure of turnover to calculate the mean annual rate of turnover was used. All calculations were weighted by the size of the EMS agency roster. The mean annual rate of turnover, total median cost of turnover, and median cost per termination were determined for three categories of agency staff mix: all-paid staff, mix of paid and volunteer (mixed) staff, and all-volunteer staff.

RESULTS

The overall weighted mean annual rate of turnover was 10.7%. This rate varied slightly across agency staffing mix (all-paid = 10.2%, mixed = 12.3%, all-volunteer = 12.4%). Among agencies that experienced turnover (n = 25), the weighted median cost of turnover was $71,613.75, which varied across agency staffing mix (all-paid = $86,452.05, mixed = $9,766.65, and all-volunteer = $0). The weighted median cost per termination was $6,871.51 and varied across agency staffing mix (all-paid = $7,161.38, mixed = $1,409.64, and all-volunteer = $0).

CONCLUSIONS

Annual rates of turnover and costs associated with turnover vary widely across types of EMS agencies. The study's mean annual rate of turnover was lower than expected based on information appearing in the news media and EMS trade magazines. Findings provide estimates of two key workforce measures--turnover rates and costs--where previously none have existed. Local EMS directors and policymakers at all levels of government may find the results and study methodology useful toward designing and evaluating programs targeting the EMS workforce.

Comparison of public safety provider injury rates

INTRODUCTION

During normal operations, public safety personnel may become injured, leading them to seek medical care and possible time off. Examining the nature and patterns of injury may help to identify preventive health measures for all public safety personnel and address specific needs of each discipline based on actual risk. Objective. To determine the types and severity of injuries encountered by public safety personnel during routine work conditions within a single urban population.

METHODS

De-identified workers' compensation data for emergency medical services (EMS), fire, and police providers from one urban center between January 1, 2005, and May 31, 2007, were examined. Data included type of injury, severity of injury, and date of event. Severity was categorized as follows: lost time (type 1), medical evaluation (type 2), report only (type 3), restricted duty (type 4), and not reported (type 5). Analysis of variance (ANOVA) and a pairwise t-test between groups with a Bonferroni correction was performed to determine the relative risk of injuries between groups.

RESULTS

During the 29-month interval, an average workforce of 850 firefighters, 194 EMS providers, and 850 police officers were employed. A total of 1,295 workers' compensation events were documented, with 243 (18%) reported from EMS, 477 (36%) from fire, and 608 (46%) from police. Type 1 injuries were more common in fire (39%) and police (38%) than EMS (23%). EMS had higher rates of lost work (type 1) and medical evaluations (type 2) than both fire and police. Workers' compensation events common to all bureaus were minor trauma (76%) and exposures to blood-borne pathogens (12%). Minor traumatic injuries, mostly associated with axial musculoskeletal strains and extremity injuries, were responsible for the majority of injuries resulting in missed work. Injuries more common in a specific bureau included motor vehicle crashes and gunshot wounds (police) and cardiovascular disease, burns, and heat illness (fire).

CONCLUSION

Public safety personnel are affected by both profession-specific and non-profession-specific injuries. Overall, EMS has higher rates of missed time and medical evaluations than both fire and police. These data highlight the need to make direct comparisons of various public safety personnel bureaus using a common time interval and locale in order to rationally plan interventions and apply resources.

An observational study of shift length, crew familiarity, and occupational injury and illness in emergency medical services workers

OBJECTIVES

Emergency medical services (EMS) clinicians are shift workers deployed in two-person teams. Extended shift duration, workplace fatigue, poor sleep and lack of familiarity with teammates are common in the EMS workforce and may contribute to workplace injury. We sought to examine the relationship between shift length and occupational injury while controlling for relevant shift work and teamwork factors.

METHODS

We obtained 3 years of shift schedules and occupational injury and illness reports were from 14 large EMS agencies. We abstracted shift length and additional scheduling and team characteristics from shift schedules. We matched occupational injury and illness reports to shift records and used hierarchical logistic regression models to test the relationship between shift length and occupational injury and illness while controlling for teammate familiarity.

RESULTS

The cohort contained 966,082 shifts, 4382 employees and 950 outcome reports. Risk of occupational injury and illness was lower for shifts ≤8 h in duration (RR 0.70; 95% CI 0.51 to 0.96) compared with shifts >8 and ≤12 h. Relative to shifts >8 and ≤12 h, risk of injury was 60% greater (RR 1.60; 95% CI 1.22 to 2.10) for employees that worked shifts >16 and ≤24 h.

CONCLUSIONS

Shift length is associated with increased risk of occupational injury and illness in this sample of EMS shift workers.