Management of Patients With Cardiac Arrest Requiring Interfacility Transport: A Scientific Statement From the American Heart Association.

People who experience out-of-hospital cardiac arrest often require care at a regional center for continued treatment after resuscitation, but many do not initially present to the hospital where they will be admitted. For patients who require interfacility transport after cardiac arrest, the decision to transfer between centers is complex and often based on individual clinical characteristics, resources at the presenting hospital, and available transport resources. Once the decision has been made to transfer a patient after cardiac arrest, there is little direct guidance on how best to provide interfacility transport. Accepting centers depend on transferring emergency departments and emergency medical services professionals to make important and nuanced decisions about postresuscitation care that may determine the efficacy of future treatments. The consequences of early care are greater when transport delays occur, which is common in rural areas or due to inclement weather. Challenges of providing interfacility transfer services for patients who have experienced cardiac arrest include varying expertise of clinicians, differing resources available to them, and nonstandardized communication between transferring and receiving centers. Although many aspects of care are insufficiently studied to determine implications for specific out-of-hospital treatment on outcomes, a general approach of maintaining otherwise recommended postresuscitation care during interfacility transfer is reasonable. This includes close attention to airway, vascular access, ventilator management, sedation, cardiopulmonary monitoring, antiarrhythmic treatments, blood pressure control, temperature control, and metabolic management. Patient stability for transfer, equity and inclusion, and communication also must be considered. Many of these aspects can be delivered by protocol-driven care.

2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Cardiac arrest is common and deadly, affecting up to 700 000 people in the United States annually. Advanced cardiac life support measures are commonly used to improve outcomes. This "2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support" summarizes the most recent published evidence for and recommendations on the use of medications, temperature management, percutaneous coronary angiography, extracorporeal cardiopulmonary resuscitation, and seizure management in this population. We discuss the lack of data in recent cardiac arrest literature that limits our ability to evaluate diversity, equity, and inclusion in this population. Last, we consider how the cardiac arrest population may make up an important pool of organ donors for those awaiting organ transplantation.

Temperature Management for Comatose Adult Survivors of Cardiac Arrest: A Science Advisory From the American Heart Association.

Targeted temperature management has been a cornerstone of post-cardiac arrest care for patients remaining unresponsive after return of spontaneous circulation since the initial trials in 2002 found that mild therapeutic hypothermia improves neurological outcome. The suggested temperature range expanded in 2015 in response to a large trial finding that outcomes were not better with treatment at 33° C compared with 36° C. In 2021, another large trial was published in which outcomes with temperature control at 33° C were not better than those of patients treated with a strategy of strict normothermia. On the basis of these new data, the International Liaison Committee on Resuscitation and other organizations have altered their treatment recommendations for temperature management after cardiac arrest. The new American Heart Association guidelines on this topic will be introduced in a 2023 focused update. To provide guidance to clinicians while this focused update is forthcoming, the American Heart Association's Emergency Cardiovascular Care Committee convened a writing group to review the TTM2 trial (Hypothermia Versus Normothermia After Out-of-Hospital Cardiac Arrest) in the context of other recent evidence and to present an opinion on how this trial may influence clinical practice. This science advisory was informed by review of the TTM2 trial, consideration of other recent influential studies, and discussion between cardiac arrest experts in the fields of cardiology, critical care, emergency medicine, and neurology. Conclusions presented in this advisory statement do not replace current guidelines but are intended to provide an expert opinion on novel literature that will be incorporated into future guidelines and suggest the opportunity for reassessment of current clinical practice.

Association between EMS Workforce Density and Population Health Outcomes in the U.S.

BACKGROUND: The prehospital care provided by emergency medical services (EMS) personnel is a critical component of the public health, public safety, and health care systems in the U.S.; however, the population-level value of EMS care is often overlooked. No studies have examined how the density of EMS personnel relates to population-level health outcomes. Our objectives were to examine the geographic distribution and density of EMS personnel in the U.S.; and quantify the association between EMS personnel density and population-level health outcomes. METHODS: We conducted a cross-sectional evaluation of county-level EMS personnel density using estimates from the National Registry of Emergency Medical Technicians in nine states that require continuous national certification (Alabama, Louisiana, Massachusetts, Minnesota, New Hampshire, North Dakota, South Carolina, Vermont, and Washington, D.C.). Outcomes of interest included life expectancy, all-cause mortality, and cardiac arrest mortality. We used quantile regression models to examine the association between a 10-person increase in EMS personnel density and each outcome at the 10th, 50th (median), and 90th percentiles, controlling for population characteristics and area health resources. RESULTS: There were 356 counties included, with a mean EMS density of 223 EMS personnel per 100,000 population. Density was higher in rural compared to urban counties (247 versus 186 per 100,000 population; p = 0.001). In unadjusted models, there was a significant association between increase in EMS personnel density and an increase in life expectancy at each examined percentile (e.g., 50th percentile, increase of 52.9 days; 95% CI 40.2, 65.5; p < 0.001), decrease in all-cause mortality at each examined percentile, and decrease in cardiac arrest mortality at the 50th and 90th percentiles. These associations were not statistically significant in the adjusted models. CONCLUSIONS: EMS personnel density differs between urban and rural areas, with higher density per population in rural areas. There were no statistically significant associations between EMS density and population-level health outcomes after controlling for population characteristics and other health resources. The best approach to quantifying the community-level value that EMS care may or may not provide remains unclear.

Mobile Integrated Health Care Roles of US EMS Clinicians: A Descriptive Cross-Sectional Study.

OBJECTIVE: Mobile integrated health care (MIH) leverages emergency medical services (EMS) clinicians to perform local health care functions. Little is known about the individual EMS clinicians working in this role. We sought to describe the prevalence, demographics, and training of EMS clinicians providing MIH in the United States (US). METHODS: This is a cross-sectional study of US-based, nationally certified civilian EMS clinicians who completed the National Registry of Emergency Medical Technicians (NREMT) recertification application during the 2021-2022 cycle and completed the voluntary workforce survey. Workforce survey respondents self-identified their job roles within EMS, including MIH. If an MIH role was selected, additional questions clarified the primary role in EMS, type of MIH provided, and hours of MIH training received. We merged the workforce survey responses with the individual's NREMT recertification demographic profile. The prevalence of EMS clinicians with MIH roles and data on demographics, clinical care provided, and MIH training were calculated using descriptive statistics, including proportions with associated binomial 95% confidence intervals (CI). RESULTS: Of 38,960 survey responses, 33,335 met inclusion criteria and 490 (1.5%; 95%CI 1.3-1.6%) EMS clinicians indicated MIH roles. Of these, 62.0% (95%CI 57.7-66.3%) provided MIH as their primary EMS role. EMS clinicians with MIH roles were present in all 50 states and certification levels included emergency medical technician (EMT) (42.8%; 95%CI 38.5-47.2%), advanced emergency medical technician (AEMT) (3.5%; 95%CI 1.9-5.1%), and paramedic (53.7%; 95%CI 49.3-58.1%). Over one-third (38.6%; 95%CI 34.3-42.9%) of EMS clinicians with MIH roles received bachelor's degrees or above, and 48.4% (95%CI 43.9%-52.8%) had been in their MIH roles for less than 3 years. Nearly half (45.6%; 95%CI 39.8-51.6%) of all EMS clinicians with primary MIH roles received less than 50 hours (h) of MIH training; only one-third (30.0%; 95%CI 24.7-35.6%) received more than 100 h of training. CONCLUSION: Few nationally certified US EMS clinicians perform MIH roles. Only half of MIH roles were performed by paramedics; EMT and AEMT clinicians performed a substantial proportion of MIH roles. The observed variability in certification and training suggest heterogeneity in preparation and performance of MIH roles among US EMS clinicians.

Medical Directors, Facilities, and Finances: Resource Deficiencies in Accredited Paramedic Programs.

BACKGROUND: Initial paramedic education must have sufficient rigor and appropriate resources to prepare graduates to provide lifesaving prehospital care. Despite required national paramedic accreditation, there is substantial variability in paramedic pass rates that may be related to program infrastructure and clinical support. Our objective was to evaluate US paramedic program resources and identify common deficiencies that may affect program completion. METHODS: We conducted a cross-sectional mixed methods analysis of the 2018 Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions annual report, focusing on program Resource Assessment Matrices (RAM). The RAM is a 360-degree evaluation completed by program personnel, advisory committee members, and currently enrolled students to identify program resource deficiencies affecting educational delivery. The analysis included all paramedic programs that reported graduating students in 2018. Resource deficiencies were categorized into ten categories: faculty, medical director, support personnel, curriculum, financial resources, facilities, clinical resources, field resources, learning resources, and physician interaction. Descriptive statistics of resource deficiency categories were conducted, followed by a thematic analysis of deficiencies to identify commonalities. Themes were generated from evaluating individual deficiencies, paired with program-reported analysis and action plans for each entry. RESULTS: Data from 626 programs were included (response rate = 100%), with 143 programs reporting at least one resource deficiency (23%). A total of 406 deficiencies were identified in the ten categories. The largest categories (n = 406) were medical director (14%), facilities (13%), financial resources (13%), support personnel (11%), and physician interaction (11%). The thematic analysis demonstrated that a lack of medical director engagement in educational activities, inadequate facility resources, and a lack of available financial resources affected the educational environment. Additionally, programs reported poor data collection due to program director turnover. CONCLUSION: Resource deficiencies were frequent for programs graduating paramedic students in 2018. Common themes identified were a need for medical director engagement, facility problems, and financial resources. Considering the pivotal role of EMS physicians in prehospital care, a consistent theme throughout the analysis involved challenges with medical director and physician interactions. Future work is needed to determine best practices for paramedic programs to ensure adequate resource availability for initial paramedic education.

Measuring the Implementation Preferences of Emergency Medical Services Clinicians Using Discrete Choice Experiments.

INTRODUCTION: Prehospital research and evidence-based guidelines (EBGs) have grown in recent decades, yet there is still a paucity of prehospital implementation research. While recent studies have revealed EMS agency leadership perspectives on implementation, the important perspectives and opinions of frontline EMS clinicians regarding implementation have yet to be explored in a systematic approach. The objective of this study was to measure the preferences of EMS clinicians for the process of EBG implementation and whether current agency practices align with those preferences. METHODS: This study was a cross-sectional survey of National Registry of Emergency Medical Technicians registrants. Eligible participants were certified paramedics who were actively practicing EMS clinicians. The survey contained discrete choice experiments (DCEs) for three EBG implementation scenarios and questions about rank order preferences for various aspects of the implementation process. For the DCEs, we used multinomial logistic regression to analyze the implementation preference choices of EMS clinicians, and latent class analysis to classify respondents into groups by their preferences. RESULTS: A total of 183 respondents completed the survey. Respondents had a median age of 39 years, were 74.9% male, 89.6% White, and 93.4% of non-Hispanic ethnicity. For all three DCE scenarios, respondents were significantly more likely to choose options with hospital feedback and individual-level feedback from EMS agencies. Respondents were significantly less likely to choose options with email/online only education, no feedback from hospitals, and no EMS agency feedback to clinicians. In general, respondents' preferences favored classroom-based training over in-person simulation. For all DCE questions, most respondents (66.2%-77.1%) preferred their survey DCE choice to their agency's current implementation practices. In the rank order preferences, most participants selected "knowledge of the underlying evidence behind the change" as the most important component of the process of implementation. CONCLUSIONS: In this study of EMS clinicians' implementation preferences using DCEs, respondents preferred in-person education, feedback on hospital outcomes, and feedback on their individual performance. However, current practice at EMS agencies rarely matched those expressed EMS clinician preferences. Collectively, these results present opportunities for improving EMS implementation from the EMS clinician perspective.

Comparison of the Scope of Practice of the Army Combat Medic Specialist and Civilian National EMS Certification Levels.

INTRODUCTION: The transition of Army Combat Medic Specialists (Military Occupational Specialty Code: 68W) from military to civilian emergency medical services (EMS) is challenging, and the pathway is not clearly defined. Our objective was to evaluate the current military requirements for 68W and how they compare to the 2019 EMS National Scope of Practice Model (SoPM) for the civilian emergency medical technician (EMT) and advanced emergency medical technician (AEMT). METHODS: This was a cross-sectional evaluation of the 68W skill floor as defined by the Soldier's Manual and Trainer's Guide Healthcare Specialist and Medical Education and Demonstration of Individual Competence in comparison to the 2019 SoPM, which categorizes EMS tasks into seven skill categories. Military training documents were reviewed and extracted for specific information on military scope of practice and task-specific training requirements. Descriptive statistics were calculated. RESULTS: Army 68Ws were noted to perform all (59/59) tasks that coincide with the EMT SoPM. Further, Army 68W practiced above scope in the following skill categories: airway/ventilation (3 tasks); medication administration route (7 tasks); medical director approved medication (6 tasks); intravenous initiation maintenance fluids (4 tasks); and miscellaneous (1 task). Army 68W perform 96% (74/77) of tasks aligned with the AEMT SoPM, excluding tracheobronchial suctioning of an intubated patient, end-tidal CO2 monitoring or waveform capnography, and inhaled nitrous oxide monitoring. Additionally, the 68W scope included six tasks that were above the SoPM for AEMT; airway/ventilation (2 tasks); medication administration route (2 tasks); and medical director approved medication (2 tasks). CONCLUSIONS: The scope of practice of U.S. Army 68W Combat Medics aligns well with the civilian 2019 Scope of Practice Model for EMTs and AEMTs. Based on the comparative scope of practice analysis, transitioning from Army 68W Combat Medic to civilian AEMT would require minimal additional training. This represents a promising potential workforce to assist with EMS workforce challenges. Although aligning the scope of practice is a promising first step, future research is needed to assess the relationship of Army 68Ws training with state licensure and certification equivalency to facilitate this transition.

State-Based Evaluation of the Workforce Pipeline from Paramedic Program Enrollment to Agency Affiliation.

OBJECTIVES: The strength and stability of the paramedic workforce is dependent on the continual flow of EMS clinicians into the field. Workforce entry requires three distinct steps: program completion, certification attainment, and affiliation with an EMS agency. At each of these steps, future EMS clinicians may be lost to the workforce but the contribution of each is unknown. Our objective was to evaluate these inflection points using a state-based registry of EMS clinicians from their point of entry into the EMS education system to eventual EMS agency affiliation. METHODS: This is a retrospective cohort evaluation of paramedic students in the Commonwealth of Virginia. We included any student who enrolled in a paramedic program in 2017 or 2018. Data were provided by the Virginia Office of Emergency Medical Services, who tracks the development of EMS clinicians from the point of entry into an educational program through their affiliation with an EMS agency upon employment. Our primary outcomes include proportions of enrolled students who complete a program, graduating students who attain national/state certification, and nationally certified EMS clinicians who affiliate with an EMS agency. Proportions were calculated at each step and compared to the overall population of students enrolled. RESULTS: In 2017 and 2018, 775 and 603 students were enrolled in paramedic programs, respectively. Approximately a quarter of students did not complete their paramedic program (2017: 25% [192/775]; 2018: 28% [170/603]). Of those who graduated, the proportion of students not gaining certification was lower (2017: 11% [62/583]; 2018: 17% [75/433]). Of those who certified, those not affiliating was similarly low (2017: 15% [77/521]; 2018: 13% [46/358]). Evaluating the effect of each of these steps on the total entry into the workforce, nearly half of those who originally enrolled did not join the workforce through agency affiliation (2017: 43% [331/775]; 2018: 48% [291/603]). CONCLUSIONS: There are multiple areas to enhance retention of potential EMS trainees from program enrollment to EMS agency affiliation. This analysis suggests that educational attrition has a larger impact on the availability of new paramedics than certification examinations or agency affiliation decisions, though is limited to a singular state evaluation.

Clinical Judgment Item Development for Emergency Medical Service Clinicians.

OBJECTIVES: While clinical judgment is vital for all clinicians, it is not clearly assessed in initial or continuing emergency medical services (EMS) education due to unclear definitions. Recently, clarity of this concept has been provided through the development of a theoretical framework for clinical judgment in EMS that considers the broad and evolving nature of prehospital care delivery. To facilitate standardization of clinical judgment assessments, in this educational practice review we present a template for item development leveraging the new framework. METHODS: We developed this template with input from EMS clinicians, educators, and subject matter experts from the nursing field with experience in clinical judgment item development. This template includes the basic cognitive steps of EMS clinical judgment, including recognizing cues, analyzing cues, defining a hypothesis, generating solutions, taking action, and evaluating the outcomes of those actions. RESULTS: We provide a transparent and reproducible template for item generation for clinical judgment assessments evaluating the six basic cognitive reasoning steps. Further, we provide a fully developed example of template application using a hypoglycemic patient case. This template can be used to support item generation for specific event phases (e.g., en route, scene, and post scene) in a clinical scenario. CONCLUSIONS: This template allows for generation of items for each EMS event phase that can be repeated serially for any combination of prehospital clinical situations.

Evaluating the Application of an EMS Clinical Judgment Theoretical Framework.

OBJECTIVES: Clinical judgment (CJ) encompasses clinical reasoning (process of evaluating a problem) and clinical decision-making (choice made). A theoretical model to better define emergency medical services (EMS) CJ has been developed but its use has not been evaluated in EMS training and assessments. Our objective was to evaluate the performance of this EMS CJ model to assess clinical reasoning and decision-making in a simulated environment. METHODS: In this evaluation, EMS clinician teams (2-3 members) were directed to care for a simulated older adult patient in their home following a fall. Simulations were video recorded, clinician team actions coded, and evaluated for whether proper CJ reasoning and decisions were made. We evaluated CJ in two ways: 1) EMS medical directors' (MD) determination of whether the CJ questions were addressed (MD score) and 2) objective rubric evaluation of CJ questions using the EMS CJ model focused on recognition of appropriate cues, performance of actions, and revaluation after action (rubric score). The CJ questions addressed in this simulation included: 1) Is the patient stable/unstable?, 2) Are interventions necessary before movement?, 3) How should the patient be transferred from the floor?, and 4) Does the cause of the fall require hospital evaluation? Descriptive statistics were calculated, and concordance between the two assessments was evaluated (mean, 95% CI). Percent concordance was calculated with a validity threshold set at 70%. RESULTS: Four EMS MDs reviewed 20 videos addressing 80 clinical judgment decisions. Overall concordance between MD score and rubric score for CJ decisions was above the threshold at 88.1% (85.0, 91.2). Concordance between MD score and rubric score for each CJ decision was 92.0% (87.3, 96.7) for question 1, 79.9% (71.5, 88.3) for question 2, 95.0% (90.4, 99.6) for question 3, and 85.4% (79.5, 91.2) for question 4. CONCLUSION: An objective evaluation of CJ decisions using a rubric derived from an EMS CJ theoretical framework demonstrated high concordance to subjective evaluations of CJ made by EMS MDs. This approach may allow for reproducible and objective CJ evaluations that could be used for competency assessment in EMS.

Examining the Reliability and Validity of the ALS Certification Examinations with the Inclusion of Clinical Judgment: An Update on the ALS Examination Redesign.

OBJECTIVES: Clinical judgment describes the process an emergency medical service clinician uses to evaluate problems and make decisions in the out-of-hospital setting. As part of the redesign of the Advanced Life Support (ALS) certification examinations, the National Registry of Emergency Medical Technicians is developing and evaluating items that measure clinical judgment, with the intention of assessing these as a new domain in the ALS certification examinations. In this study, we provide evidence around the redesign by evaluating the reliability and validity of the advanced emergency medical technician (AEMT) and paramedic certification examinations when clinical judgment is included as a sixth domain along with the five current domains. METHODS: Pretest (i.e., pilot, unscored) clinical judgment items were included as a new sixth clinical judgment domain. We then used the combination of operational (i.e., scored) and pretest items for all six domains and scored the redesigned AEMT and paramedic certification examinations. We evaluated the psychometric properties of these ALS examinations within the Rasch measurement framework with multiple assessments of reliability and validity including item-level statistics (e.g., mean-square infit and outfit, local dependence) and examination-level statistics (e.g., person reliability, item reliability, item separation, decision consistency, decision accuracy). Wright Maps were produced to evaluate whether the examination item difficulty statistics aligned with the candidate ability continuum. RESULTS: The total population of all examination forms included were 20,136 (AEMT 4,983; paramedic 15,153). The Rasch-based statistics for the redesigned AEMT and paramedic examinations, for both item and examination-level statistics, were well within the psychometric standard values. Wright maps demonstrated that the developed items fall along the candidate ability continuum for both examinations. Further, the distribution of clinical judgment item difficulties fell within the current item distribution, providing evidence that these new items are of similar difficulty to the items measuring the five current domains. CONCLUSION: We demonstrate strong reliability and validity evidence to support that the integrity of the examinations is upheld with the addition of clinical judgment items, while also providing a more robust candidate evaluation. Most importantly, the pass/fail decisions that candidates receive accurately reflect their level of ALS knowledge at the entry-level.

Evidence-Based Guidelines for Prehospital Airway Management: Methods and Resources Document.

INTRODUCTION: Emergency airway management is a common and critical task EMS clinicians perform in the prehospital setting. A new set of evidence-based guidelines (EBG) was developed to assist in prehospital airway management decision-making. We aim to describe the methods used to develop these EBGs. METHODS: The EBG development process leveraged the four key questions from a prior systematic review conducted by the Agency for Healthcare Research and Quality (AHRQ) to develop 22 different population, intervention, comparison, and outcome (PICO) questions. Evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework and tabulated into the summary of findings tables. The technical expert panel then used a rigorous systematic method to generate evidence to decision tables, including leveraging the PanelVoice function of GRADEpro. This process involved a review of the summary of findings tables, asynchronous member judging, and online facilitated panel discussions to generate final consensus-based recommendations. RESULTS: The panel completed the described work product from September 2022 to April 2023. A total of 17 summary of findings tables and 16 evidence to decision tables were generated through this process. For these recommendations, the overall certainty in evidence was "very low" or "low," data for decisions on cost-effectiveness and equity were lacking, and feasibility was rated well across all categories. Based on the evidence, 16 "conditional recommendations" were made, with six PICO questions lacking sufficient evidence to generate recommendations. CONCLUSION: The EBGs for prehospital airway management were developed by leveraging validated techniques, including the GRADE methodology and a rigorous systematic approach to consensus building to identify treatment recommendations. This process allowed the mitigation of many virtual and electronic communication confounders while managing several PICO questions to be evaluated consistently. Recognizing the increased need for rigorous evidence evaluation and recommendation development, this approach allows for transparency in the development processes and may inform future guideline development.

Evidence-Based Guideline for Prehospital Airway Management.

Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel made specific recommendations on the different PICO (population, intervention, comparison, outcome) questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations. The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.

Emergency Medical Services and Public Health Perspectives on Alternative Emergency Response Models.

CONTEXT: New approaches to emergency response are a national focus due to evolving needs and growing demands on the system, but perspectives of first responders and potential partners have not been evaluated. OBJECTIVE: This project aimed to inform the development and implementation of alternative emergency response models, including interdisciplinary partnerships, by identifying the perspectives of the frontline workforce regarding their evolving roles. DESIGN: An electronic survey was sent, querying respondents about their perceived roles in emergency response, interdisciplinary partnerships, and resources needed. SETTING: This study took place in a metropolitan, midwestern county with participants from 2 public health agencies and 1 emergency medical services (EMS) agency. PARTICIPANTS: The survey was completed by 945 EMS clinicians and 58 public health workers. MAIN OUTCOME MEASURES: The main outcome measures were agreement levels on each group's roles in prevention, response, and recovery after emergencies, as well as general feedback on new models. RESULTS: Overall, 97% of EMS clinicians and 42% of public health workers agreed that they have a role in immediate response to 9-1-1 emergencies. In mental health emergencies, 87% of EMS clinicians and 52% of public health workers agreed that they have a role, compared to 87% and 30%, respectively, in violent emergencies. Also, 84% of respondents felt multidisciplinary models are a needed change. However, 35% of respondents felt their agency has the resources necessary for changes. CONCLUSIONS: We observed differences between EMS clinicians and public health workers in their perceived roles during emergency response and beliefs about the types of emergencies within their scope. There is strong support for alternative approaches and a perception that this model may improve personal well-being and job satisfaction, but a need for additional resources to develop and implement.

Prehospital Stroke Care Part 2: On-Scene Evaluation and Management by Emergency Medical Services Practitioners.

The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.

National examination of occupational hazards in emergency medical services.

OBJECTIVE: Emergency medical services (EMS) clinicians operate in environments that predispose them to occupational hazards. Our objective was to evaluate the frequency of occupational hazards and associations with mitigation strategies in a national dataset. METHODS: We performed a cross-sectional analysis of currently working, nationally certified civilian EMS clinicians aged 18-85 in the USA. After recertifying their National EMS Certification, respondents were invited to complete a survey with questions regarding demographics, work experience and occupational hazards. Three multivariable logistic regression models (OR, 95% CI) were used to describe associations between these hazards and demographics, work characteristics and mitigation strategies. Models were adjusted for age, sex, minority status, years of experience, EMS agency type, service type and EMS role. RESULTS: A total of 13 218 respondents met inclusion criteria (response rate=12%). A high percentage of EMS clinicians reported occupational injuries (27%), exposures (38%) and violence (64%) in the past 12 months. Odds of injury were lower with the presence of a lifting policy (0.73, 0.67-0.80), lift training (0.74, 0.67-0.81) and always using a powered stretcher (0.87, 0.78-0.97). Odds of exposure decreased with chemical, biological and nuclear exposure protection training (0.75, 0.69-0.80). Training in de-escalation techniques was associated with lower odds of experiencing violence (0.87, 0.79-0.96). CONCLUSIONS: Occupational hazards are commonly experienced among EMS clinicians. Common mitigation efforts are associated with lower odds of reporting these hazards. Mitigation strategies were not widespread and associated with lower odds of occupational hazards. These findings may present actionable items to reduce occupational hazards for EMS clinicians.

Differences in Out-of-Hospital Cardiac Arrest Management and Outcomes across Urban, Suburban, and Rural Settings.

BACKGROUND: Rural prehospital care settings are underrepresented in the out-of-hospital cardiac arrest (OHCA) literature. This study aimed to describe treatment patterns and the odds of a favorable patient outcome (e.g., return of spontaneous circulation (ROSC) or being presumptively alive at the end of the incident) among rural OHCA patients in the U.S. METHODS: Using the 2018 National Emergency Medical Services Informational System (NEMSIS) dataset, we analyzed OHCA incidents where an emergency medical services (EMS) unit provided cardiopulmonary resuscitation (CPR) and either terminated the resuscitation or completed transport. We excluded traumatic injuries, pediatric patients, and incidents with response time >60 minutes. The primary outcome was ROSC at any time during the EMS incident. The secondary outcome was a binary end-of-event indicator previously described for use in NEMSIS to estimate longer-term outcomes. Multivariable logistic regression was performed for each outcome measure comparing rural, suburban, and urban settings while controlling for key factors. RESULTS: A total of 64,489 OHCA incidents were included, with 5,601 (8.9%) in rural settings. Among the full sample of OHCA incidents, ROSC was achieved in 20,578 (33.6%) cases, including 29.2% in rural settings and 34.1% in urban or suburban settings (p < 0.001). Advanced life support units responded to 95.3% of all calls, and a greater proportion of rural OHCA incidents were managed by basic life support units (7.4% vs. 4.2%, p < 0.001). Rural OHCA incidents had longer response times (7.5 vs. 5.9 minutes, p < 0.001), and rural patients were less likely to receive epinephrine (69.3% vs. 73.3%, p < 0.001). Further, EMS clinicians in rural areas were more likely to use mechanical CPR (29.5% vs. 27.6%, p < 0.01) and were less likely to perform advanced airway management (48.5% vs. 54.2%, p < 0.001). Rural patients had lower odds of achieving ROSC than urban patients after controlling for other factors (OR 0.81, 95% CI: 0.75-0.87). Rural patients also had lower odds of having a positive end-of-event outcome (i.e., presumptively alive) after controlling for other factors (OR 0.86, 95% CI: 0.79-0.93). CONCLUSION: In this national sample of EMS-treated OHCAs, rural patients had lower odds of a favorable outcome (e.g., ROSC or presumptively alive) compared to those in urban settings.

A Proposed Theoretical Framework for Clinical Judgment in EMS.

In the prehospital setting, EMS clinicians are challenged by the need to assess and treat patients who are clinically undifferentiated with a large constellation of possible medical problems. In addition to possessing a large and diverse set of knowledge, skills, and abilities, EMS clinicians must integrate a plethora of environmental, patient, and event specific cues in their clinical decision-making processes. To date, there is no theoretical framework to capture the complex process that characterizes the prehospital experience from dispatch to handoff, the interface between cues and on-scene information and assessments, while incorporating the importance of leadership and communication. To fill this gap, we propose a theoretical framework for clinical judgment in the prehospital setting that builds upon previously defined methodologies and applies them to the clinical practice of EMS clinicians throughout the EMS experience.

Deriving National Continued Competency Priorities for Emergency Medical Services Clinicians.

OBJECTIVE: Continued competency is poorly defined in emergency medical services (EMS), with no established method for verifying continued competency at a national level. The objective of this project was to refine understanding of continued competency for EMS clinicians in the U.S. and establish priorities for developing competency assessments. METHODS: A panel of EMS managers, educators, medical directors, and experts in competency assessment, simulation, and certification used a modified Delphi technique to address two questions: "What is the content for continued competency in EMS that should be assessed or verified?" (content) and "How should continued competency of EMS clinicians be demonstrated?" (process). The Delphi process was conducted through electronic conferencing and survey software over a 6-month period. In round one, panelists responded to open-ended prompts and their contributions were analyzed and categorized into themes by independent reviewers. In round two, the panel rated theme importance using five-point Likert-type scales. In round three, the panel ranked their top 10 themes, and in round four, the panel selected the most important themes for each of the two questions through consensus-building discussions. Descriptive statistics and thematic analyses were performed with Excel and STATA 16. RESULTS: Fourteen invited experts participated in all Delphi activities. The panel contributed 70 content and 35 process items from the original prompts. Following thematic analysis, these contributions were reduced to 21 and 14 unique themes, respectively. The final top five prioritized themes for content important for continued competency included (1) airway, respiration, and ventilation, (2) patient assessment, (3) pharmacology, (4) pediatrics, and (5) management of time critical disease progressions. The final top five prioritized themes for the processes for continued competency assessment included (1) assessments of evidence-based practice, (2) performance-based assessments, (3) combined knowledge and skill assessments, (4) performance improvement over time, and (5) frequent, short knowledge assessments. CONCLUSION: This modified Delphi process identified priorities for content and assessment, laying the groundwork for EMS continued competency at a national level. These findings can be leveraged by national task forces to develop transparent and consistent guidelines for systems that verify continued competency related to certification, licensure, and local credentialing.