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.

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.

Identifying beliefs driving COVID-19 vaccination: Lessons for effective messaging.

Increasing vaccination acceptance has been essential during the COVID-19 pandemic and in preparation for future public health emergencies. This study aimed to identify messaging strategies to encourage vaccine uptake by measuring the drivers of COVID-19 vaccination among the general public. A survey to assess COVID-19 vaccination acceptance and hesitancy was advertised on Facebook in February-April 2022. The survey included items asking about COVID-19 vaccination status and participant demographics, and three scales assessing medical mistrust, perceived COVID-19 risk, and COVID-19 vaccine confidence (adapted from the Oxford COVID-19 vaccine confidence and complacency scale). The main outcome was vaccination, predicted by patient demographics and survey scale scores. Of 1,915 survey responses, 1,450 (75.7%) were included, with 1,048 (72.3%) respondents reporting they had been vaccinated. In a multivariable regression model, the COVID-19 vaccine confidence scale was the strongest predictor of vaccination, along with education level and perceived COVID-19 risk. Among the items on this scale, not all were equally important in predicting COVID-19 vaccination. The items that best predicted vaccination, at a given score on the COVID-19 vaccine confidence scale, included confidence that vaccine side effects are minimal, that the vaccine will work, that the vaccine will help the community, and that the vaccine provides freedom to move on with life. This study improved our understanding of perceptions most strongly associated with vaccine acceptance, allowing us to consider how to develop messages that may be particularly effective in encouraging vaccination among the general public for both the COVID-19 pandemic and future public health emergencies.

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.

Consensus Standard for Evidence Integration into EMS Education and High-Stakes Testing.

BACKGROUND: Incorporating emerging knowledge into Emergency Medical Service (EMS) competency assessments is critical to reflect current evidence-based out-of-hospital care. However, a standardized approach is needed to incorporate new evidence into EMS competency assessments because of the rapid pace of knowledge generation. OBJECTIVE: The objective was to develop a framework to evaluate and integrate new source material into EMS competency assessments. METHODS: The National Registry of Emergency Medical Technicians (National Registry) and the Prehospital Guidelines Consortium (PGC) convened a panel of experts. A Delphi method, consisting of virtual meetings and electronic surveys, was used to develop a Table of Evidence matrix that defines sources of EMS evidence. In Round One, participants listed all potential sources of evidence available to inform EMS education. In Round Two, participants categorized these sources into: (a) levels of evidence quality; and (b) type of source material. In Round Three, the panel revised a proposed Table of Evidence. Finally, in Round Four, participants provided recommendations on how each source should be incorporated into competency assessments depending on type and quality. Descriptive statistics were calculated with qualitative analyses conducted by two independent reviewers and a third arbitrator. RESULTS: In Round One, 24 sources of evidence were identified. In Round Two, these were classified into high- (n = 4), medium- (n = 15), and low-quality (n = 5) of evidence, followed by categorization by purpose into providing recommendations (n = 10), primary research (n = 7), and educational content (n = 7). In Round Three, the Table of Evidence was revised based on participant feedback. In Round Four, the panel developed a tiered system of evidence integration from immediate incorporation of high-quality sources to more stringent requirements for lower-quality sources. CONCLUSION: The Table of Evidence provides a framework for the rapid and standardized incorporation of new source material into EMS competency assessments. Future goals are to evaluate the application of the Table of Evidence framework in initial and continued competency assessments.

Evaluating changes in the emergency medical services workforce: A preliminary multistate study.

Objective: There is growing concern with the strength and stability of the emergency medical services (EMS) workforce with reports of workforce challenges in many communities in the United States. Our objective was to estimate changes in the EMS workforce by evaluating the number of clinicians who enter, stay, and leave. Methods: A 4-year retrospective cohort evaluation of all certified EMS clinicians at the emergency medical technician (EMT) level or higher was conducted for 9 states that require national EMS certification to obtain and maintain EMS licensure. The study spanned 2 recertification cycles (2017-2021) for 2 workforce populations: the certified workforce (all EMS clinicians certified to practice) and the patient care workforce (the subset who reported providing patient care). Descriptive statistics were calculated and classified into 1 of 3 categories: EMS clinicians who entered, stayed in, or left each respective workforce population. Results: There were 62,061 certified EMS clinicians in the 9 included states during the study period, and 52,269 reported providing patient care. For the certified workforce, 80%-82% stayed in and 18%-20% entered the workforce. For the patient care workforce, 74%-77% stayed and 29%-30% entered. State-level rates of leaving each workforce ranged from 16% to 19% (certified) and 19% to 33% (patient care). From 2017 to 2020, there was a net growth of both the certified (8.8%) and patient care workforces (7.6%). Conclusions: This was a comprehensive evaluation of both the certified and patient care EMS workforce dynamics in 9 states. This population-level evaluation serves as the first step for more detailed analyses to better understand workforce dynamics in EMS.

Paramedic educational program attrition accounts for significant loss of potential EMS workforce.

Objective: Recent concerns for the strength and stability of the emergency medical services (EMS) workforce have fueled interest in enhancing the entry of EMS clinicians into the workforce. However, the educational challenges associated with workforce entry remain unclear. Our objective was to evaluate the educational pathway of entry into the EMS workforce and to identify factors that lead to the loss of potential EMS clinicians. Methods: This is a cross-sectional evaluation of all US paramedic educational programs, with enrolled students, in the 2019 Committee on Accreditation of Educational Programs for the EMS Professions annual report survey. This data set includes detailed program characteristics and metrics including program attrition rate (leaving before completion), and certifying exam pass rates. Descriptive statistics were calculated, and multivariable logistic regression analysis was conducted to evaluate the association between high program attrition rates (>30%) and program specific characteristics. Results: In 2019, 640 accredited programs met inclusion with 17,457 students enrolled in paramedic educational programs. Of these, 13,884 students successfully graduated (lost to attrition, 3,573/17,457 [21%]) and 12,002 passed the certifying exam on the third attempt (lost to unable to certify, 1,882/17,457 [11%]). High program attrition rates were associated with longer programs (>12 months), small class sizes (<12 students), and regional locations. Conclusions: Nearly 1 in 3 paramedic students were lost from the potentially available workforce either owing to attrition during the educational program or failure to certify after course completion. Attrition represented the largest loss, providing an avenue for future targeted research and interventions to improve EMS workforce stability.