"We're always an afterthought"- Designing tobacco control campaigns for dissemination with and to LGBTQ +-serving community organizations: a thematic analysis.

PURPOSE: Evidence-based health communication campaigns can support tobacco control and address tobacco-related inequities among lesbian, gay, bisexual, transgender, and queer (LGBTQ +) populations. Community organizations focused on LGBTQ + health (e.g., nonprofits, community centers, and community health centers) can be prime channels for delivering evidence-based health communication campaigns. However, it is unclear how to balance the goals of a) designing campaigns to support broad adoption/uptake and b) adaptation addressing the needs of diverse communities and contexts. As part of an effort to support "designing for dissemination," we explored the key challenges and opportunities staff and leaders of LGBTQ + -serving community organizations encounter when adopting or adapting evidence-based health communication campaigns. METHODS: A team of researchers and advisory committee members conducted this study, many of whom have lived, research, and/or practice experience with LGBTQ + health. We interviewed 22 staff members and leaders of community organizations serving LGBTQ + populations in the US in early 2021. We used a team-based, reflexive thematic analysis approach. RESULTS: The findings highlight the challenges of attempting to use health communication campaigns misaligned with the assets and needs of organizations and community members. The three major themes identified were as follows: (1) available evidence-based health communication campaigns typically do not sufficiently center LGBTQ + communities, (2) negotiation regarding campaign utilization places additional burden on practitioners who have to act as "gatekeepers," and (3) processes of using health communication campaigns often conflict with organizational efforts to engage community members in adoption and adaptation activities. CONCLUSIONS: We offer a set of considerations to support collaborative design and dissemination of health communication campaigns to organizations serving LGBTQ + communities: (1) develop campaigns with and for LGBTQ + populations, (2) attend to the broader structural forces impacting campaign recipients, (3) support in-house testing and adaptations, and (4) increase access to granular data for community organizations.

EMS Program Graduates Who Did Not Retest after Initial Attempt on the National Certification Exam.

Introduction: Becoming an EMS professional in most of the United States requires successful completion of the National Certification process. While multiple attempts are allowed, some candidates who are unsuccessful on their first cognitive examination attempt do not return despite personal investment. Objective: We describe the demographic and testing characteristics of EMT and paramedic candidates that do not return for a second examination attempt after an initial unsuccessful attempt on the National EMS Certification Cognitive Examination. Methods: This was a cross-sectional evaluation of nonmilitary EMT and paramedic graduates, between ages 18 and 85 years, who completed their education program in 2016, attempted the National Certification Examination, and were unsuccessful. Multivariable logistic regression models were used to estimate the odds of retesting for EMT and paramedic graduates for age, sex, initial test length, and elapsed time from course completion to initial examination. Results: Of all EMT graduates eligible to retest (n = 22,088), 33% (n = 7,208) did not retest. Adjusted odds of retesting for EMT graduates decreased with female sex, time from course completion to initial examination, and those with minimal exam length. Adjusted odds of retesting for EMT graduates increased in 20-21 and 22-24 year olds compared to 18-19 year olds. Similarly, of all paramedic graduates eligible to retest (n = 2,755), 14% (n = 390) did not. Adjusted odds of retesting at the paramedic level decreased with time from course completion to initial examination and minimum exam length. Age and sex were not significant contributors to odds of retesting for paramedics. Conclusion: Many EMTs and paramedics who were unsuccessful on the National Certification Exam did not retest. Factors identified that impact the choice varied between EMTs and paramedics but included age, sex, length of initial examination, and time from course completion to that initial examination. These characteristics may present actionable items for EMS educational programs and stakeholders to support EMT and paramedic graduates at risk of not entering the workforce.

Public Health Surveillance of Behavioral Health Emergencies through Emergency Medical Services Data.

Objective: To identify the demographic, clinical and EMS characteristics of events documented as behavioral health emergencies (BHE) by EMS. Methods: This was a cross-sectional study using the 2018 National Emergency Medical Services Information System (NEMSIS) Version 3 dataset. All events that had patient care provided with a documented impression (field diagnosis) of ICD-10 codes F01-F99 (i.e., mental, behavioral, and neurodevelopmental disorders) were labeled a BHE and included. Descriptive statistics were calculated. Results: A total of 1,594,821 (7.3%) EMS calls had a BHE impression. The most common was mental and behavioral disorders due to psychoactive substance use (42.3%). More males than females had BHEs (54.6% vs. 45.4%), and most patients were ages 18-34 (31.5%). Most BHE occurred in urban settings (89.6%). Almost half (47.9%) were dispatched with a complaint unrelated to behavioral health. Conclusion: BHEs were noted in 7.3% of NEMSIS events, and the majority were associated with substance use disorders. EMS professionals need comprehensive training on best practices for BHE. Stakeholders should have information on prevalence of BHEs to ensure proper educational standards, training practices, and resource allocation.

Priorities for Prehospital Evidence-Based Guideline Development: A Modified Delphi Analysis.

Objective: Few areas of prehospital care are supported by evidence-based guidelines (EBGs). We aimed to identify gaps in clinical and operational prehospital EBGs to prioritize future EBG development and research funding. Methods: Using modified Delphi methodology, we sought consensus among experts in prehospital care and EBG development. Five rounds of surveys were administered between October 2019 and February 2020. Round 1 asked participants to list the top three gaps in prehospital clinical guidelines and top three gaps in operational guidelines that should be prioritized for guideline development and research funding. Based on responses, 3 reviewers performed thematic analysis to develop a list of prehospital EBG gaps, with participant feedback in Round 2. In Round 3, participants rated each gap's importance using a 5-point Likert scale, and participants' responses were averaged. In Round 4, participants rank-ordered 10 gaps with the highest mean scores identified in Round 3. In Round 5, participants indicated their agreement with sets of the highest ranked gaps. Results: Of 23 invited participants, 14 completed all 5 rounds. In Rounds 1 and 2, participants submitted 65 clinical and 58 operational gaps, and thematic analysis identified 23 unique clinical gaps and 28 unique operational gaps. The final prioritized list of clinical EBG gaps was: 1) airway management in adult and pediatric patients, 2) care of the pediatric patient, and 3) management of prehospital behavioral health emergencies, with 79% of participants agreeing. The final prioritized list of operational EBG gaps was: 1) define and measure the impact of EMS care on patient outcomes, 2) practitioner wellness, and 3) practitioner safety in the out-of-hospital environment, with 86% of participants agreeing. Conclusions: This modified Delphi study identifies gaps in prehospital EBGs that, if prioritized for development and research funding, would be expected to have the greatest impact on prehospital clinical care and operations.

Paramedic and EMT Program Performance on Certification Examinations Varies by Program Size and Geographic Location.

Introduction: The quality of an Emergency Medical Technician (EMT) or paramedic training program is likely one factor that contributes to a candidate's success on the National Registry Cognitive Examination. However, program pass rates and their associated geographic location have not previously been evaluated. Our objective was to evaluate the performance of EMT and paramedic programs in the United States, pass rates on the National Registry Cognitive Examinations, and relationship to geography.Methods: We conducted a cross-sectional evaluation of EMT and paramedic programs' first and cumulative third attempt pass rates on the National Registry Cognitive Examination in 2015. Included were civilian EMT and paramedic programs with >5 graduates testing for certification. Descriptive statistics were calculated for program pass rates, total graduates testing, and pass rates by National Association of State EMS Officials (NASEMSO) regions.Results: We included 1,939 EMT programs (6-1,892 graduates testing/program) and 602 paramedic programs (6-689 graduates testing/program). We excluded 262 (11.9%) EMT and 51 (7.8%) paramedic programs with ≤5 graduates testing annually due to unstable estimates of program pass rates. EMT programs in the highest quartile for total number of graduates testing outperformed the lowest quartile in both first attempt (65.7% vs. 61.9%, p < 0.001) and cumulative third attempt pass rates (79.1% vs 72.7%, p < 0.001). This difference was also seen for paramedic programs on first attempt (77.3% vs. 62.5%, p < 0.001) and cumulative third attempt (91.9% vs. 76.9%, p < 0.001). EMT program pass rates for first and cumulative third attempts also varied by NASEMSO region (first: 62-68%; third: 74-78%) with the Great Lakes and West regions outperforming the other regions. Paramedic program pass rates differed by NASEMSO regions as well (first: 65-83%; third: 81-95%) with highest pass rates in the West region.Conclusions Program performance for both EMT and paramedic programs varies by total number of graduates testing and geographic location. Graduates from larger EMT and paramedic programs have higher first and cumulative third attempt pass rates compared to graduates from smaller programs. Additionally, there is variability in program pass rates across NASEMSO regions for both certification levels. Further evaluation is necessary to better understand the variability in program performance in the United States.

Methods and Implementation of the 2019 EMS Practice Analysis.

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

Ultrasound Use in the Prehospital Setting for Trauma: A Systematic Review.

BACKGROUND: Trauma is a leading cause of death in the United States. Ultrasound use in the prehospital environment has the potential to change trauma management. Although ultrasound use for prehospital trauma is increasing, the role of this modality is not clearly defined. OBJECTIVES: We examined the use of prehospital ultrasound (PHUS) for trauma patients and the use by different provider types. Specific factors of interest were if prehospital ultrasound has been shown to improve providers' ability to recognize conditions that can be managed in the prehospital setting, treat these conditions, change transport destination, or improve overall mortality rates for trauma patients. METHODS: We searched MEDLINE/PubMed, EBSCOhost, Cochrane Library, and Embase medical literature databases for articles that addressed our outcomes. Abstracts and articles were examined and studies that did not specifically evaluate ultrasound in the prehospital setting for trauma and duplicates were eliminated. Studies included in this comprehensive review were assessed for the use of ultrasound in the prehospital setting to aid in the diagnosis, treatment, and transport of trauma patients. We also conducted an analysis of bias in the included articles. Due to the large heterogeneity in the included studies, no meta-analysis could be performed. RESULTS: Sixteen studies were identified comprising 3,317 patients. One study evaluated Emergency Medical Services (EMS) professionals as the ultrasound operator while five studies involved mixed practitioners and ten studies involved only physicians. Diagnostic accuracy was similar amongst physicians and mixed practitioners with no studies reporting PHUS accuracy for EMS providers alone. Seven studies evaluated treatment and transport impact of PHUS though the variables measured were inconsistent and results varied by protocol and outcomes measured. There were no studies that evaluated PHUS and its impact on patient mortality. CONCLUSION: Ultrasound use in the prehospital setting for trauma is feasible and demonstrates potential. However, the evidence in the medical literature mainly consists of prospective observational studies of physicians utilizing ultrasound for trauma in a HEMS setting. Further scientific research must be undertaken to firmly establish the role of prehospital ultrasound in trauma management by all types of EMS providers.

Demography of the National Emergency Medical Services Workforce: A Description of Those Providing Patient Care in the Prehospital Setting.

BACKGROUND: The emergency medical services (EMS) workforce is a key component of healthcare in the U.S. Characteristics of active EMS professionals who are treating patients in the prehospital setting is unclear. The purpose of this study was to describe the roles and settings in which nationally certified EMS professionals are providing patient care and to evaluate similarities and differences of the demographics and practice settings of the three major certification levels. METHODS: We conducted a cross-sectional evaluation of all nationally certified EMS professionals in the U.S. that recertified between October 1, 2017 and March 31, 2018 and October 1, 2018 and March 31, 2019. Within the recertification application, EMS professionals completed an optional demographic profile. Those who were nationally certified, functioning as a patient care provider for at least one nonmilitary EMS organization, aged 18 to 85 years, and recertified at the EMT level or higher were included. Demographic, agency and job characteristics were assessed and descriptive statistics were calculated. RESULTS: In 2017-2018, 101,363 EMS professionals recertified and 87,471 (86%) completed the profile; in 2018-2019, 106,893 EMS professionals recertified and 92,640 (87%) completed the profile. Of the 142,751 EMS professionals who met inclusion criteria, the population was primarily male (76%) and age increased by certification level. By race/ethnicity, 85% were white, 5% were Hispanic/Latino, 5% were Black/African American, 2% were American Indian/Alaskan Native, 2% were Asian and 1% were Native Hawaiian/Pacific Islander.Paramedics had the highest proportion of associate degrees (EMT:16.0%; AEMT:16.6%; paramedic:28.5%); some college experience was common for all certification levels (EMT:34.7%; AEMT:37.2%; paramedic:31.6%). Most EMS professionals reported 3-7 years of experience, were working full-time (78%) and 28% were working for 2 or more agencies. Most were working for a fire department (48%) or private agency (21%) and providing 9-1-1 service (72%). No substantial differences were observed between the two recertification cycles. CONCLUSION: This is the most comprehensive study evaluating the demographics of the national EMS workforce of active patient care providers. Understanding the characteristics of EMS professionals and the settings they practice in is important for educational and training initiatives, as well as protocols and policies.

Emergency Medical Services Personnel Awareness and Training about Personal Protective Equipment during the COVID-19 Pandemic.

Background: With the emergence of the 2019 novel coronavirus disease (COVID-19), appropriate training for emergency medical services (EMS) personnel on personal protective equipment (PPE) is essential. We aimed: 1) to examine the change in proportions of EMS personnel reporting awareness of and training in PPE during the COVID-19 pandemic; and 2) to determine factors associated with reporting these outcomes.We conducted a cross-sectional analysis of data collected from October 1, 2019 to June 30, 2020 from currently working, nationally certified EMS personnel (n = 15,339), assessing N95 respirator fit testing; training in air purified respirators (APR) or powered APR (PAPR) use; and training on PPE use for chemical, biological, and nuclear (CBN) threats. We used an interrupted time series analysis to determine changes in proportions of EMS personnel reporting training per week, using the date of Centers for Disease Control and Prevention's (CDC) initial EMS guidance (February 6, 2020) as the interruption. We fit multivariable logistic regression models to understand factors associated with each outcome.Results: We found high awareness of N95 respirators (99%) and APR/PAPR (91%), but only 61% reported N95 fit testing and 64% reported training on PPE for CBN threats in the prior 12 months. There was a significant, positive slope change after CDC guidance for N95 respirator fit testing, and significant post-interruption mean increases for fit testing (0.9%, 95% CI 0.6-1.1%), APR/PAPR training (0.3%, 95% CI 0.2-0.5%), and PPE for CBN threats training (0.6%, 95% CI 0.3-0.9%). Factors consistently associated with lower odds of awareness/training included part-time employment, providing 9-1-1 response service, working at a non-fire-based EMS agency, and working in a rural setting.Conclusions: CDC guidance on COVID-19 for EMS may have increased N95 fit testing and training, but there remain substantial gaps in training on PPE use among EMS personnel. As the pandemic continues in our communities, EMS agencies should be supported in efforts to adequately prepare their staff.

Comparison of Volunteer and Paid EMS Professionals in the United States.

BACKGROUND: Emergency medical response is provided by volunteer emergency medical services (EMS) professionals in many parts of the United States. However, little is known about those who serve as volunteer EMS professionals, especially as their main EMS job. Our objective was to compare the characteristics of nationally-certified volunteer versus paid EMS professionals in the U.S. Methods: We conducted a cross-sectional evaluation of EMS professionals who recertified their National EMS Certification between October 1, 2017-March 31, 2018 or October 1, 2018-March 31, 2019. Data were obtained from 2 cycles of the biennial National EMS Certification recertification application. We included currently working, nonmilitary EMS professionals aged 18-85 years at the emergency medical technician (EMT) or higher certification level. Volunteer was defined as receiving nominal or no compensation for the provision of EMS services at an agency as the main EMS job. Comparisons were made, accounting for the large sample size, to determine notable differences between volunteer and paid EMS professionals. Results: Of the 154,229 EMS professionals that met inclusion criteria (response rate = 86%), 13% volunteered at their main EMS job. More volunteer than paid EMS professionals were female (38% vs. 22%). There was also a significant difference in certification level between volunteer and paid (EMT: 82% vs. 46%). Three-quarters (74%) of volunteer EMS professionals reported working in rural communities compared to 30% of paid. The states with the largest proportion of volunteers to any currently working EMS professionals who recertified were Vermont (47%) and North Dakota (45%). Conclusion: Approximately 13% of the EMS workforce held a primary job in EMS as a volunteer, and these volunteer EMS professionals differed from their paid counterparts - e.g., volunteers were more likely to be women, have EMT certification, and work in rural areas. We encourage further research to understand motivations for volunteering in EMS.

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

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

Comprehensive Description of the Advanced Emergency Medical Technician Certification Level.

Background: The nationally-certified advanced emergency medical technician (AEMT) level was created as an intermediate level of care integrating both basic life support and limited advanced life support. Despite adoption of the AEMT certification level nationally, the characteristics of AEMTs have not previously been described. Our objectives were to describe the demographics of nationally-certified AEMTs in the U.S., and to describe the demographic and program characteristics of the AEMT candidates who took the cognitive examination in 2017. Methods: This was a cross-sectional analysis of all currently nationally-certified AEMTs as of July 1st, 2018 and AEMT candidates who took the National AEMT cognitive examination in 2017 and answered a post-test questionnaire. Descriptive statistics were calculated from the 2 data sources for comparison, along with program-level characteristics. Results: Of all nationally-certified AEMTs (n = 14,973), the workforce was primarily male (71.9%), non-Hispanic white (83.0%), with a median (IQR) age of 30 (25-39), from the Southern National Association of State EMS Officials (NASEMSO) region (48.0%). The demographics of the nationally-certified AEMT workforce were similar to those of 2017 AEMT candidates (n = 5,318). Of candidates who completed the post-test questionnaire (n = 5,068, response rate = 95%), the first-attempt pass rate was 54.7%. Almost a third (31.2%) of AEMT candidates had worked for 1-5 years as an EMT before AEMT training. Common program characteristics included requirements for prior EMT certification (86.8%), provision of a textbook (87.3%) and syllabus (85.0%), and completion of a portfolio (86.0%) and course-ending examination (87.9%). Conclusion: AEMTs fill an important gap in prehospital care between the EMT and paramedic levels in the United States. Many AEMT programs required a current EMT certification and completion of a portfolio and course-ending examination. Implementation of the AEMT certification level could be strengthened through further research into high-quality educational practices for AEMT training programs.

The Impact of Working Overtime or Multiple Jobs in Emergency Medical Services.

Background: EMS professionals frequently work more than a standard 40-hour work week. For some EMS professionals, working overtime or multiple jobs may be necessary to make ends meet. Our objective was to evaluate the association between job satisfaction, intention to leave EMS, and financial dependence on overtime or working multiple jobs.Methods: We conducted a cross-sectional analysis of nationally-certified EMS professionals who completed an online questionnaire after submitting their recertification application (22,626/101,363, response rate = 22%) between October 2017 - May 2018. Items included dependence on additional work, satisfaction with job, and intentions of leaving the profession. Multivariable logistic regression models were used to describe the association between dependence on additional work, and job satisfaction and intention to leave EMS within 1 year and 5 years, controlling for age, sex, minority status, agency type, employment status, and urbanicity.Results: A total of 18,285 respondents were included in the analysis. The majority of EMS professionals (75%) worked over 40 hours per week. Most respondents (71%) were dependent on overtime or multiple jobs to make ends meet. Those who were dependent on extra work had higher odds of being dissatisfied with their job (aOR 1.92, 95% CI:1.64-2.44, and higher odds of intentions to leave EMS within 1 year and 5 years respectively (aOR 1.32, 95%CI:1.14-1.54; aOR 1.16, 95%CI:1.07-1.25).Conclusion: Many EMS professionals depend on additional work to make a living. Financial dependence was associated with increased odds of workforce-reducing factors, including job satisfaction and intention of leaving. This can lead to poor individual outcomes such as stress and burnout, as well as to turnover within the workforce, thus reducing the number of individuals available to provide high quality emergency care.

Comparing the Prevalence of Poor Sleep and Stress Metrics in Basic versus Advanced Life Support Emergency Medical Services Personnel.

Background: Emergency medical services (EMS) personnel frequently encounter occupational factors that increase the risk of poor sleep and stress. The national prevalence of poor sleep and stress in EMS personnel is unclear, especially differences between personnel at the basic (BLS) versus advanced (ALS) life support levels. The objectives of this study were to: (1) estimate the prevalence of sleep and stress metrics in EMS personnel; and (2) compare these metrics between BLS and ALS-certified personnel. Methods: This study was a survey of recertifying nationally-certified EMS personnel working in civilian settings. Respondents completed an electronic questionnaire assessing their sleep quality; workday, non-workday, and average sleep duration; sleep debt; perceived stress; and chronic stress. Survey-weighted Poisson regression models were used to estimate adjusted prevalence ratios (PR) comparing BLS (emergency medical technician) to ALS (advanced emergency medical technician and paramedic) for each metric. Models were adjusted for age, sex, minority status, education level, EMS agency type, service type, EMS role, and significant interactions. Results: A total of 17,913 (response rate = 19%) responses were received with 17,522 included in the analysis. Adjusted PRs were significantly higher for ALS-certified personnel compared to BLS-certified for poor sleep quality (PR: 1.23, 95% CI: 1.20-1.27) and short (<7 hours) or long (≥9 hours) workday sleep duration (PR: 1.17, 95% CI: 1.15-1.19). Significant interactions were found between certification level and sex (average sleep duration) or age category (sleep debt, perceived stress, and chronic stress). The highest prevalence of short or long average sleep duration was among ALS men. Sleep debt, perceived stress, and chronic stress differed by age group between certification levels with higher PRs for ALS regardless of age group. Conclusions: There is a high prevalence of poor sleep and stress in EMS personnel, with evidence of the highest prevalence among ALS-certified personnel. Evidence of effect modification by age category and among BLS and ALS personnel suggests that interventions could target certain subgroups, such as older ALS personnel, to be most effective. Continued focus on sleep health and stress reduction is needed to improve the health and well-being of the EMS workforce.

Females and Minority Racial/Ethnic Groups Remain Underrepresented in Emergency Medical Services: A Ten-Year Assessment, 2008-2017.

Background: Workforce diversity can reduce communication barriers and inequalities in healthcare delivery, especially in settings where time pressure and incomplete information may exacerbate the effects of implicit biases. Emergency medical services (EMS) professionals represent a critical entry point into the healthcare system for diverse populations, yet little is known regarding changes in the demographic composition of this workforce. Our primary objective was to describe the gender and racial/ethnic composition of emergency medical technicians (EMTs) and paramedics who earned initial National EMS Certification from 2008 to 2017. Secondarily, we compared demographic characteristics of the 2017 EMT and paramedic cohorts to the U.S. population. Methods: As a proxy for recent graduates likely to enter the workforce, we conducted a serial cross-sectional analysis of all EMTs and paramedics earning initial National EMS Certification from January 1, 2008 to December 31, 2017. Cuzick's non-parametric test of trend was used to assess for changes in the gender and racial/ethnic composition of the EMS cohorts over time. For 2017, we calculated differences the gender and racial/ethnic composition of the EMT and paramedic cohorts to the U.S population, stratifying by Census region. Results: The study population included 588,337 EMTs and 105,356 paramedics. The proportion of females earning initial EMT certification rose from 28% in 2008 to 35% in 2017. Throughout the study period, less than one-fourth of newly certified paramedics were female (range: 20-23%). The proportion of EMS professionals identifying as black remained near 5% among EMTs and 3% among paramedics. The proportion of newly-certified Hispanic EMS professionals rose from 10% to 13% among EMTs and from 6% to 10% among paramedics. Compared to the U.S. population, females and racial/ethnic minorities were underrepresented among EMTs and paramedics earning initial certification and these representation differences varied across geographic regions. Conclusions: The underrepresentation of females and minority racial/ethnic groups observed during this 10-year investigation of EMTs and paramedics earning initial certification suggests that EMS workforce diversity is unlikely to undergo substantial change in the near future. The representation gaps were larger and more stable among paramedics compared to EMTs and suggest an area where concerted efforts are needed to encourage students of diverse backgrounds to pursue EMS.

Workplace Incivility Among Nationally Certified EMS Professionals and Associations with Workforce-Reducing Factors and Organizational Culture.

BACKGROUND: Incivility, defined as negative interpersonal acts that violate workplace and social norms, has been linked to negative outcomes in healthcare settings. A minimal amount is known regarding workplace incivility among emergency medical services (EMS) professionals. Our objectives were to (1) evaluate the prevalence of incivility and factors associated with experiencing workplace incivility; (2) describe the association between incivility and workforce-reducing factors (stress, career satisfaction, turnover intentions, and workplace absences); and (3) quantify the association between incivility and the organizational culture of an EMS agency. METHODS: A random sample of 38,000 nationally-certified EMS professionals received an electronic questionnaire with an EMS-adapted Workplace Incivility Scale, the Competing Values Framework organizational culture scale, and factors that may negatively impact the EMS workforce. All completed surveys from nonmilitary EMS professionals currently providing patient care at the EMT level or higher were included in these analyses. We constructed multivariable logistic regression models (OR, 95% CI) to identify factors associated with experiencing workplace incivility and to examine the associations between experiencing incivility and workforce-reducing factors. We calculated univariable odds ratios to assess the association between organizational culture type and incivility. RESULTS: A total of 3,741 EMS professionals responded to the survey (response rate =10.3%), with 2,815 (75.2%) meeting inclusion criteria. Incivility from supervisors or coworkers was experienced at least once a week by 47.4% of respondents. Factors associated with increased odds of experiencing incivility included female sex, AEMT/paramedic certification level, increasing years of EMS experience, service types other than 9-1-1 response, and higher weekly call volumes. Exposure to regular incivility was associated with increased odds of dissatisfaction with EMS, a main EMS job or a main supervisor; moderate or higher stress levels; intent to leave one's job and EMS in the next 12 months; and 10 or more workplace absences in the past 12 months. The organizational culture type "market" was associated with the greatest odds of incivility. CONCLUSIONS: Nearly half of respondents experienced incivility once a week or more, and incivility was associated with potential workforce-reducing factors. Further research is needed to understand how organizational climate and interpersonal behaviors in the workplace affect the EMS workforce.

Naloxone Administration Frequency During Emergency Medical Service Events - United States, 2012-2016.

As the opioid epidemic in the United States has continued since the early 2000s (1,2), most descriptions have focused on misuse and deaths. Increased cooperation with state and local partners has enabled more rapid and comprehensive surveillance of nonfatal opioid overdoses (3).* Naloxone administrations obtained from emergency medical services (EMS) patient care records have served as a useful proxy for overdose surveillance in individual communities and might be a previously unused data source to describe the opioid epidemic, including fatal and nonfatal events, on a national level (4-6). Using data from the National Emergency Medical Services Information System (NEMSIS),† the trend in rate of EMS naloxone administration events from 2012 to 2016 was compared with opioid overdose mortality rates from National Vital Statistics System multiple cause-of-death mortality files. During 2012-2016, the rate of EMS naloxone administration events increased 75.1%, from 573.6 to 1004.4 administrations per 100,000 EMS events, mirroring the 79.7% increase in opioid overdose mortality from 7.4 deaths per 100,000 persons to 13.3. A bimodal age distribution of patients receiving naloxone from EMS parallels a similar age distribution of deaths, with persons aged 25-34 years and 45-54 years most affected. However, an accurate estimate of the complete injury burden of the opioid epidemic requires assessing nonfatal overdoses in addition to deaths. Evaluating and monitoring nonfatal overdose events via the novel approach of using EMS data might assist in the development of timely interventions to address the evolving opioid crisis.

Similar skills, different frames: a thematic analysis exploring conceptualizations held by community-based organization practitioners and academics regarding skills to use evidence-based interventions to address cancer inequities.

BACKGROUND: Community-based organizations (CBOs) are critical partners in delivering evidence-based interventions (EBIs) to address cancer inequities. However, CBO practitioners do not typically have access to opportunities to build the necessary capacity (skills, knowledge, motivation, and resources) for using EBIs. Although capacity-building interventions can offer a solution, inconsistent definitions and measurements of capacity limit the ability to develop and evaluate such efforts. We explored how and why conceptualizations of core skills for EBI use differ between practitioners and academics addressing cancer and other health inequities. We anchored the inquiry with a commonly used set of target skills for EBI capacity-building efforts. METHODS: The study was conducted by an interdisciplinary team of academic researchers and CBO practitioners. We gathered data through semi-structured, hour-long interviews with practitioners and academics working to address cancer and other health inequities (n = 19). After hearing a brief vignette about a CBO addressing cervical cancer inequities, participants considered a widely accepted list of skills for EBI use that included assessing needs, engaging stakeholders, and selecting, adapting, implementing, evaluating, and sustaining the EBI. We used a team-based, reflexive thematic analysis approach grounded in critical and constructivist perspectives. RESULTS: Overall, the original list resonated with practitioners and academics and they added new skills to the list (cultural humility and systems change). Practitioners' responses described skills from the reference point of addressing broader community needs and context and achieving change over the long term, emphasizing aspects of health promotion in their descriptions. Academics offered a mix of perspectives, with some focused on addressing community needs (and related flexibility regarding EBIs) but more emphasized skills needed to deliver a specific EBI to achieve a focused set of health and equity outcomes. CONCLUSIONS: There is a significant opportunity to leverage complementary expertise and perspectives held by practitioners and academics addressing cancer inequities. However, the different frames utilized suggest proactive efforts will be required to find alignment across groups, particularly in valuing diverse contributions and identifying relevant outcomes of interest for each group. Such alignment is critical to designing effective capacity-building interventions and supporting the routine utilization of EBIs to address cancer inequities.

Priority skills for equity-focused, evidence-based cancer control in community-based organizations: A group concept mapping analysis with academics and practitioners.

Introduction: Community-based organizations (CBOs) are important equity-promoting delivery channels for evidence-based interventions (EBIs). However, CBO practitioners often cannot access needed support to build EBI skills. Additionally, the capacity-building literature is hindered by inconsistent definitions, limited use of validated measures, and an emphasis on the perspectives of EBI developers versus implementers. To address these gaps, we explored commonalities and differences between CBO practitioners and academics in conceptualizing and prioritizing core EBI skills. Methods: We utilized Group Concept Mapping, a mixed-methods approach connecting qualitative data (e.g., regarding the range of critical EBI skills) and quantitative data (e.g., sorting and ranking data regarding unique skills) to create conceptual maps integrating perspectives from diverse participants. A total of 34 practitioners and 30 academics working with cancer inequities participated in the study. Results: Participants nominated 581 core skills for EBI use, and our team (including practitioners and academics) identified 98 unique skills from this list. Participants sorted them into conceptual groups, yielding five clusters: (1) using data and evaluation, (2) selecting and adapting EBIs, (3) connecting with community members, (4) building diverse and equitable partnerships, and (5) managing EBI implementation. The ordering of importance and presence of skill clusters were similar across groups. Overall, importance was rated higher than presence, suggesting capacity gaps. Conclusions: There are helpful commonalities between practitioners' and academics' views of core EBI skills in CBOs and apparent capacity gaps. However, underlying patterns suggest that differences between the groups' perceptions warrant further exploration.

Emergency medical services professional behaviors with violent encounters: A prospective study using standardized simulated scenarios.

Introduction: To evaluate emergency medical services (EMS) professional response to escalating threats of violence during simulated patient encounters and describe differences in behaviors by characteristics. Methods: EMS professionals of a large county-based system participated in 1 of 4 standardized patient care scenarios. Each 8-minute scenario included escalated threats of violence such that EMS personnel should escape the scene for safety. Trained evaluators recorded EMS professionals' performance using standardized data elements. Outcomes included EMS personnel escape and verbal de-escalation attempts. Descriptive statistics and univariable odds ratios (OR) with 95% confidence intervals (95% CI) are reported. Results: There were 270 EMS professionals evaluated as individual members of 2-person crews. Overall, 54% escaped the unsafe scene and 54% made an adequate de-escalation attempt; 20% did not make an adequate de-escalation attempt nor escape the unsafe scene. Paramedics demonstrated lower odds of escaping compared to emergency medical technicians (OR: 0.40; 95% CI: 0.17-0.94), yet greater odds of adequate de-escalation (OR: 3.17, 95% CI: 1.38-7.31). EMS professionals with more than 20 years of experience (OR: 0.32, 95% CI: 0.13-0.79, ref:2 years or less) and those with military experience (OR: 0.37; 95% CI: 0.17-0.81) demonstrated reduced odds of escaping. Crisis intervention team (CIT) training was associated with reduced odds of escape (OR: 0.38; 95% CI: 0.21-0.69), but increased odds of adequate de-escalation (OR: 2.19; 95% CI: 1.19-4.04). Conclusions: Nearly half of EMS professionals did not remove themselves from a simulated patient care scenario with an escalating threat of physical violence. EMS-specific training for de-escalation as a first-line technique, recognizing imminent violence, and leaving a dangerous environment is needed.