The Longitudinal Study of Turnover and the Cost of Turnover in Emergency Medical Services

Few studies have examined employee turnover and associated costs in emergency medical services (EMS). The purpose of this study was 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

Paramedic Out-of-hospital Cardiac Arrest Case Volume Is a Predictor of Return of Spontaneous Circulation

Introduction: Many factors contribute to the survival of out-of-hospital cardiac arrest (OHCA). One such factor is the quality of resuscitation efforts, which in turn may be a function of OHCA case volume. However, few studies have investigated the OHCA case volume-survival relationship.  Consequently, we sought to develop a model describing the likelihood of return of spontaneous circulation (ROSC) as a function of paramedic cumulative OHCA experience.Methods: We conducted a statewide retrospective study of cardiac arrest using the North Carolina Prehospital Care Reporting System. Adult patients suffering a witnessed, non-traumatic cardiac arrest between January 2012 and June 2014 were included. Using logistic regression, we calculated an adjusted odds ratio (OR) for the influence of the preceding five-year paramedic OHCA case volume on ROSC while controlling for the potentially confounding variables identified a priori as patient age, gender, and non-Caucasian race; shockable presenting rhythm; layperson/first responder cardiopulmonary resuscitation (CPR); and emergency medical services (EMS) response time.  Results: Of the 6,405 patients meeting inclusion criteria, 3,155 (49.3%) experienced ROSC. ROSC was more likely among patients treated by paramedics with ≥ 15 OHCA experiences during the preceding five years (OR [1.21], p<0.01). ROSC was also more likely among patients with shockable initial rhythms (OR [2.35], p<0.01) and who received layperson/first responder CPR (OR [1.77], p<0.01). Increasing patient age (OR [0.996], p=0.02), male gender (OR [0.742], p<0.01), and increasing EMS response time (OR [0.954], p<0.01) were associated with a decreased likelihood of ROSC. Non-Caucasian race was not an independent predictor of ROSC.Conclusion: We found that a paramedic five-year OHCA case volume of ≥ 15 is significantly associated with ROSC. Further study is needed to determine the specific actions of these more experienced paramedics who are responsible for the increased likelihood of ROSC, as well as the influence of case volume on the longer-term outcome measures of hospital discharge and neurological function

Estimated Cost Effectiveness of Influenza Vaccination for Emergency Medical Services Professionals

Introduction: Because of their frequent contact with compromised patients, vaccination against influenza is recommended for all healthcare workers. Recent studies suggest that vaccination decreases influenza transmission to patients and reduces worker illness and absenteeism. However, few emergency medical services (EMS) agencies provide annual vaccination, and the vaccination rate among EMS personnel remains low. Reticence among EMS agencies to provide influenza vaccination to their employees may be due in part to the unknown fiscal consequences of implementing a vaccination program. In this study, we sought to estimate the cost effectiveness of an employer-provided influenza vaccination program for EMS personnel. Methods: Using data from published reports on influenza vaccination, we developed a cost-effectiveness model of vaccination for a hypothesized EMS system of 100 employees. Model inputs included vaccination costs, vaccination rate, infection rate, costs associated with absenteeism, lost productivity due to working while ill (presenteeism), and medical care for treating illness. To assess the robustness of the model we performed a series of sensitivity analyses on the input variables. Results: The proportion of employees contracting influenza or influenza-like illness (ILI) was estimated at 19% among vaccinated employees compared to 26% among non-vaccinated employees. The costs of the vaccine, consumables, and employee time for vaccination totaled $44.19 per vaccinated employee, with a total system cost of$4,419. Compared to no vaccination, a mandatory vaccination program would save $20,745 in lost productivity and medical costs, or$16,325 in net savings after accounting for vaccination costs. The savings were 3.7 times the cost of the vaccination program and were derived from avoided absenteeism ($7,988), avoided presenteeism productivity losses ($10,303), and avoided medical costs of treating employees with influenza/ILI ($2,454). Through sensitivity analyses the model was verified to be robust across a wide range of input variable assumptions. The net monetary benefits were positive across all ranges of input assumptions, but cost savings were most sensitive to the vaccination uptake rate, ILI rate, and presenteeism productivity losses. Conclusion: This cost-effectiveness analysis suggests that an employer-provided influenza vaccination program is a financially favorable strategy for reducing costs associated with influenza/ILI employee absenteeism, presenteeism, and medical care.&nbsp

Paramedic Out-of-hospital Cardiac Arrest Case Volume Is a Predictor of Return of Spontaneous Circulation

Introduction: Many factors contribute to the survival of out-of-hospital cardiac arrest (OHCA). One such factor is the quality of resuscitation efforts, which in turn may be a function of OHCA case volume. However, few studies have investigated the OHCA case volume-survival relationship. Consequently, we sought to develop a model describing the likelihood of return of spontaneous circulation (ROSC) as a function of paramedic cumulative OHCA experience. Methods: We conducted a statewide retrospective study of cardiac arrest using the North Carolina Prehospital Care Reporting System. Adult patients suffering a witnessed, non-traumatic cardiac arrest between January 2012 and June 2014 were included. Using logistic regression, we calculated an adjusted odds ratio (OR) for the influence of the preceding five-year paramedic OHCA case volume on ROSC while controlling for the potentially confounding variables identified a priori as patient age, gender, and non-Caucasian race; shockable presenting rhythm; layperson/first responder cardiopulmonary resuscitation (CPR); and emergency medical services (EMS) response time. Results: Of the 6,405 patients meeting inclusion criteria, 3,155 (49.3%) experienced ROSC. ROSC was more likely among patients treated by paramedics with ≥ 15 OHCA experiences during the preceding five years (OR [1.21], p<0.01). ROSC was also more likely among patients with shockable initial rhythms (OR [2.35], p<0.01) and who received layperson/first responder CPR (OR [1.77], p<0.01). Increasing patient age (OR [0.996], p=0.02), male gender (OR [0.742], p<0.01), and increasing EMS response time (OR [0.954], p<0.01) were associated with a decreased likelihood of ROSC. Non-Caucasian race was not an independent predictor of ROSC. Conclusion: We found that a paramedic five-year OHCA case volume of ≥ 15 is significantly associated with ROSC. Further study is needed to determine the specific actions of these more experienced paramedics who are responsible for the increased likelihood of ROSC, as well as the influence of case volume on the longer-term outcome measures of hospital discharge and neurological function

Predictors of COVID-19 Vaccination Among EMS Personnel

Introduction: Unvaccinated emergency medical services (EMS) personnel are at increased risk of contracting coronavirus disease 2019 (COVID-19) and potentially transmitting the virus to their families, coworkers, and patients. Effective vaccines for the severe acute respiratory syndrome coronavirus 2 virus exist; however, vaccination rates among EMS professionals remain largely unknown. Consequently, we sought to document vaccination rates of EMS professionals and identify predictors of vaccination uptake.Methods: We conducted a cross-sectional survey of North Carolina EMS professionals after the COVID-19 vaccines were widely available. The survey assessed vaccination status as well as beliefs regarding COVID-19 illness and vaccine effectiveness. Prediction of vaccine uptake was modeled using logistic regression.Results: A total of 860 EMS professionals completed the survey, of whom 74.7% reported receiving the COVID-19 vaccination. Most respondents believed that COVID-19 is a serious threat to the population, that they are personally at higher risk of infection, that vaccine side effects are outweighed by illness prevention, and the vaccine is safe and effective. Despite this, only 18.7% supported mandatory vaccination for EMS professionals. Statistically significant differences were observed between the vaccinated and unvaccinated groups regarding vaccine safety and effectiveness, recall of employer vaccine recommendation, perceived risk of infection, degree of threat to the population, and trust in government to take actions to limit the spread of disease. Unvaccinated respondents cited reasons such as belief in personal health and natural immunity as protectors against infection, concerns about vaccine safety and effectiveness, inadequate vaccine knowledge, and lack of an employer mandate for declining the vaccine. Predictors of vaccination included belief in vaccine safety (odds ratio [OR] 5.5, P=&lt;0.001) and effectiveness (OR 4.6, P=&lt;0.001); importance of vaccination to protect patients (OR 15.5, P=&lt;0.001); perceived personal risk of infection (OR 1.8, P=0.04); previous receipt of influenza vaccine (OR 2.5, P=0.003); and sufficient knowledge to make an informed decision about vaccination (OR 2.4,&nbsp; P=0.024).Conclusion: In this survey of EMS professionals, over a quarter remained unvaccinated for COVID-19. Given the identified predictors of vaccine acceptance, EMS systems should focus on countering misinformation through employee educational campaigns as well as on developing policies regarding workforce immunization requirements

A meta-analysis of prehospital airway techniques part 1: orotracheal and nasotracheal intubation success rates

Background: Airway management is a key component of prehospital care for seriously ill and injured patients. Although endotracheal intubation has been a commonly performed prehospital procedure for nearly three decades, the safety and efficacy profile of prehospital intubation has been challenged in the last decade. Reported intubation success rates vary widely, and established benchmarks are lacking. \ud \ud Objective: We sought to determine pooled estimates for oral endotracheal intubation (OETI) and nasotracheal intubation (NTI) placement success rates through a meta-analysis of the literature. \ud \ud Methods: We performed a systematic literature search for all English-language articles reporting placement success rates for prehospital intubation. Studies of field procedures performed by prehospital personnel from any nation were included. All titles were reviewed independently by two authors using prespecified inclusion criteria. Pooled estimates of success rates for each airway technique, including drug-facilitated intubation (DFI) and rapid-sequence intubation (RSI), were calculated using a random-effects model. Historical trends were evaluated using meta-regression. \ud \ud Results: Of 2,005 identified titles reviewed, 117 studies addressed OETI and 23 addressed NTI, encompassing a total of 57,132 prehospital patients. There was substantial interrater reliability in the review process (kappa = 0.81). The pooled estimates (and 95% confidence intervals [CIs]) for intervention success for nonphysician clinicians were as follows: overall non-RSI/non-DFI OETI success rate: 86.3% (82.6%-89.4%); OETI for non-cardiac arrest patients: 69.8% (50.9%-83.8%); DFI 86.8% (80.2%-91.4%); and RSI 96.7% (94.7%-98.0%). For pediatric patients, the paramedic OETI success rate was 83.2% (55.2%-95.2%). The overall NTI success rate for nonphysician clinicians was 75.9% (65.9%-83.7%). The historical trend of OETI reflects a 0.49% decline in success rates per year. \ud \ud Conclusions: We provide pooled estimates of placement success rates for prehospital airway interventions. For some patient and clinician characteristics, OETI has relatively low success rates. For nonarrest patients, DFI and RSI appear to increase success rates. Across all clinicians, NTI has a low rate of success, raising questions about the safety and efficacy of this procedure

A meta-analysis of prehospital airway control techniques part II: alternative airway devices and cricothyrotomy success rates

Background: Airway management is a key component of prehospital care for seriously ill and injured patients. Oral endotracheal intubation (OETI) is the definitive airway of choice in most emergency medical services (EMS) systems. However, OETI may not be an approved skill for some clinicians or may prove problematic in certain patients because of anatomic abnormalities, trauma, or inadequate relaxation. In these situations alternative airways are frequently employed. However, the reported success rates for these devices vary widely, and established benchmarks are lacking. \ud \ud Objective: We sought to determine pooled estimates of the success rates of alternative airway devices (AADs) and needle cricothyrotomy (NCRIC) and surgical cricothyrotomy (SCRIC) placement through a meta-analysis of the literature. \ud \ud Methods: We performed a systematic literature search for all English-language articles reporting success rates for AADs, SCRIC, and NCRIC. Studies of field procedures performed by prehospital personnel from any nation were included. All titles were reviewed independently by two authors using prespecified inclusion criteria. Pooled estimates of success rates for each airway technique were calculated using a random-effects meta-analysis model. \ud \ud Results: Of 2,005 prehospital airway titles identified, 35 unique studies were retained for analysis of AAD success rates, encompassing a total of 10,172 prehospital patients. The success rates for SCRIC and NCRIC were analyzed across an additional 21 studies totaling 512 patients. The pooled estimates (and 95% confidence intervals [CIs]) for intervention success across all clinicians and patients were as follows: esophageal obturator airway–esophageal gastric tube airway (EOA-EGTA) 92.6% (90.1%–94.5%); pharyngeotracheal lumen airway (PTLA) 82.1% (74.0%–88.0%); esophageal-tracheal Combitube (ETC) 85.4% (77.3%–91.0%); laryngeal mask airway (LMA) 87.4% (79.0%–92.8%); King Laryngeal Tube airway (King LT) 96.5% (71.2%–99.7%); NCRIC 65.8% (42.3%–83.59%); and SCRIC 90.5% (84.8%–94.2%). \ud \ud Conclusions: We provide pooled estimates for prehospital AAD, NCRIC, and SCRIC airway interventions. Of the AADs, the King LT demonstrated the highest insertion success rate (96.5%), although this estimate is based on limited data, and data regarding its ventilatory effectiveness are lacking; more data are available for the ETC and LMA. The ETC, LMA, and PTLA all had similar—but lower—success rates (82.1%–87.4%). NCRIC has a low rate of success (65.8%); SCRIC has a much higher success rate (90.5%) and should be considered the preferred percutaneous rescue airway

Emergency Medical Services Professionals’ Attitudes About Community Paramedic Programs

Introduction: The number of community paramedic (CP) programs has expanded to mitigatethe impact of increased patient usage on emergency services. However, it has not beendetermined to what extent emergency medical services (EMS) professionals would be willing toparticipate in this model of care. With this project, we sought to evaluate the perceptions of EMSprofessionals toward the concept of a CP program.Methods: We used a cross-sectional study method to evaluate the perceptions of participatingEMS professionals with regard to their understanding of and willingness to participate in a CPprogram. Approximately 350 licensed EMS professionals currently working for an EMS servicethat provides coverage to four states (Missouri, Arkansas, Kansas, and Oklahoma) were invitedto participate in an electronic survey regarding their perceptions toward a CP program. Weanalyzed interval data using the Mann-Whitney U test, Kruskal-Wallis one-way analysis ofvariance, and Pearson correlation as appropriate. Multivariate logistic regression was performedto examine the impact of participant characteristics on their willingness to perform CP duties.Statistical significance was established at p ≤ 0.05.Results: Of the 350 EMS professionals receiving an invitation, 283 (81%) participated. Of thoseparticipants, 165 (70%) indicated that they understood what a CP program entails. One hundredthirty-five (58%) stated they were likely to attend additional e ducation in order to becomea CP, 152 (66%) were willing to perform CP duties, and 175 (75%) felt that their respective communities would be in favor of a local CP program. Using logistic regression with regard towillingness to perform CP duties, we found that females were more willing than males (OR =4.65; p = 0.03) and that those participants without any perceived time on shift to commit to CPduties were less willing than those who believed their work shifts could accommodate additionalduties (OR = 0.20; p &lt; 0.001).Conclusion: The majority of EMS professionals in this study believe they understand CPprograms and perceive that their communities want them to provide CP-level care. While fewerin number, most are willing to attend additional CP education and/or are willing to perform CP duties