Acute Effect of Night Shift Work on Endothelial Function with and without Naps: A Scoping Review.

We examined the breadth and depth of the current evidence investigating napping/sleeping during night shift work and its impact on non-invasive measures of endothelial function. We used a scoping review study design and searched five databases: Ovid Medline, EMBASE, Ovid APA PsycInfo, Web of Science Core Collection, and EBSCO CINAHL. We limited our search to English language and publications from January 1980 to September 2022. Our reporting adhered to the PRISMA-ScR guidance for scoping reviews. Our search strategy yielded 1949 records (titles and abstracts) after deduplication, of which 36 were retained for full-text review. Five articles were retained, describing three observational and two experimental research studies with a total sample of 110 individuals, which examined the non-invasive indicators of endothelial function in relation to the exposure to night shift work. While there is some evidence of an effect of night shift work on the non-invasive indicators of endothelial function, this evidence is incomplete, limited to a small samples of shift workers, and is mostly restricted to one measurement technique for assessing endothelial function with diverse protocols. In addition, there is no identifiable research investigating the potential benefits of napping during night shift work on non-invasive measures of endothelial function.

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.

Does the evidence support brief (≤30-mins), moderate (31-60-mins), or long duration naps (61+ mins) on the night shift? A systematic review.

We performed a systematic review of four databases to determine if the evidence supports a short or long duration nap during night shifts to mitigate fatigue, and/or improve health, safety, or performance for emergency services and public safety personnel (PROSPERO CRD42020156780). We focused on experimental research and evaluated the quality of evidence with the grading of recommendations, assessment, development, and evaluation (GRADE) framework. We used the Cochrane Collaboration's risk of bias tool to assess bias and reported findings using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Our search yielded n = 10,345 records and n = 44 were reviewed in full-text. Inter-rater agreement during screening was substantial (Kappa = 0.66). We retained n = 11 publications, reporting on n = 7 experimental studies with a cumulative sample size of n = 140. We identified wide variation in study design, napping interventions (i.e., timing, placement, and duration), and outcomes. We identified mixed findings comparing brief, moderate, and long duration naps on outcomes of interest. All seven studies presented serious risk of bias and the quality of evidence was rated as low. Based on the best available evidence, decisions regarding nap duration during night shift work should be based on time (post-nap) and outcome.

Impact of shift work on blood pressure among emergency medical services clinicians and related shift workers: A systematic review and meta-analysis.

BACKGROUND: Compared to day workers, shift workers face an elevated risk of cardiovascular disease. We reviewed the evidence to address the research question: Does acute exposure to shift work impact (blunt) the natural drop (dip) in Blood Pressure (BP) occurring during sleep and/or nighttime hours? (PROSPERO CRD42018110847). METHODS: We performed a systematic review of five databases. We compared pooled estimates of mean BP stratified by periods of shift work, rest/leisure, and sleep, and evaluated the quality of evidence with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. RESULTS: Our search covered 1/1/1980-10/24/2018 and yielded 1,636 records. Inter-rater agreement during screening was high (Kappa=0.87). We retained 44 studies described in 50 publications. We identified wide variation in shift worker type, shift schedules, and regularity of BP measurements. Most studies examined BP during one shift workday and one rest/leisure day. No study examined the impact of repeated exposure to shift work on the sleep-related dip in BP. Eighteen studies examined night shifts and one reported on BP during sleep post night shift. Compared to BP measured during shift work, BP measured during any sleep period separate from shift work was lower by 17.5 mmHg Systolic BP (95%CI 15.75, 19.27) and 15.4 mmHg lower for Diastolic BP (95%CI 14.38, 16.42) (p < 0.05). CONCLUSIONS: There is limited research exploring the acute and long-term impact of shift work on BP during sleep. The available evidence is heterogenous, low quality, and suggests that the mean dip in BP during sleep separate from shift work is not blunted.

Differences in Paramedic Fatigue before and after Changing from a 24-hour to an 8-hour Shift Schedule: A Case Report.

Emergency medical services (EMS) clinicians often work 24-hour shifts. There is a growing body of literature, with an elevated level of concern among EMS leaders that longer shifts contribute to fatigued workers and negative safety outcomes. However, many questions remain about shift length, fatigue, and outcomes. We describe a case of a 26-year-old male paramedic who switched shift schedules during the midpoint of a randomized trial that addressed fatigue in EMS workers (clinicaltrials.gov identifier: NCT02063737). The participant (case) began the study working full-time with a critical care, advanced life support EMS system that utilized 24-hour shifts. He then transitioned to an EMS system that deploys workers on 8-hour shifts. Per protocol for the randomized trial, the participant completed a battery of sleep health and fatigue surveys at baseline and at the end of 90 days of study. He also reported perceived fatigue, sleepiness, and difficulty with concentration at the beginning, every 4 hours during, and at the end of scheduled shifts, for a total of ten 24-hour shifts and twenty-four 8-hour shifts. We discuss differences in measures taken before and after switching shift schedules, and highlight differences in fatigue, sleepiness, and difficulty with concentration taken at the end of all 34 scheduled shifts stratified by shift duration (24 hours versus 8 hours). Findings from this case report present a unique opportunity to 1) observe and analyze a phenomenon that has not been investigated in great detail in the EMS setting; and 2) address an issue of significance to employers and EMS clinicians alike.

Physician medical direction and clinical performance at an established emergency medical services system.

OBJECTIVE: Few developed emergency medical services (EMS) systems operate without dedicated medical direction. We describe the experience of Hamad Medical Corporation (HMC) EMS, which in 2007 first engaged an EMS medical director to develop and implement medical direction and quality assurance programs. We report subsequent changes to system performance over time. METHODS: Over one year, changes to the service's clinical infrastructure were made: Policies were revised, paramedic scopes of practice were adjusted, evidence-based clinical protocols were developed, and skills maintenance and education programs were implemented. Credentialing, physician chart auditing, clinical remediation, and online medical command/hospital notification systems were introduced. RESULTS: Following these interventions, we report associated improvements to key indicators: Chart reviews revealed significant improvements in clinical quality. A comparison of pre- and post-intervention audited charts reveals a decrease in cases requiring remediation (11% to 5%, odds ratio [OR] 0.43 [95% confidence interval (CI) 0.20-0.85], p = 0.01). The proportion of charts rated as clinically acceptable rose from 48% to 84% (OR 6 [95% CI 3.9-9.1], p < 0.001). The proportion of misplaced endotracheal tubes fell (3.8% baseline to 0.6%, OR 0.16 [95% CI 0.004-1.06], (exact) p = 0.05), corresponding to improved adherence to an airway placement policy mandating use of airway confirmation devices and securing devices (0.7% compliance to 98%, OR 714 [95% CI 64-29,334], (exact) p < 0.001). Intravenous catheter insertion in unstable cases increased from 67% of cases to 92% (OR 1.31 [95% CI 1.09-1.71], p = 0.004). EMS administration of aspirin to patients with suspected ischemic chest pain improved from 2% to 77% (OR 178 [95% CI 35-1,604], p < 0.001). CONCLUSIONS: We suggest that implementation of a physician medical direction is associated with improved clinical indicators and overall quality of care at an established EMS system.

Program accreditation effect on paramedic credentialing examination success rate.

OBJECTIVES: Program accreditation is used to ensure the delivery of quality education and training for allied health providers. However, accreditation is not mandated for paramedic education programs. This study examined if there is a relationship between completion of an accredited paramedic education program and achieving a passing score on the National Registry Paramedic Certification Examination. METHODS: We used data from the National Registry Paramedic Certification Examination for calendar year 2002. Successful completion (passing) of the examination was defined as correctly answering a minimum of 126 out of 180 (70%) of the questions and meeting or exceeding the individual subtest passing scores. Accredited paramedic training programs were certified by the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions (CoAEMSP) on or before January 1, 2002. Candidates reported demographic characteristics including age, gender, self-reported race and ethnicity, education, and employer type. We examined the relationship between passing the examination and attendance at an accredited paramedic training program. RESULTS: A total of 12,773 students completed the examination. Students who attended an accredited program were more likely to pass the examination (OR = 1.65, 95% CI: 1.51-1.81). Attendance at an accredited training program was independently associated with passing the examination (OR = 1.58, 95% CI = 1.43-1.74) even after accounting for confounding demographic factors. CONCLUSION: Students who attended an accredited paramedic program were more likely to achieve a passing score on a national paramedic credentialing examination. Additional studies are needed to identify the aspects of program accreditation that lead to improved examination success.

Quality of BLS decreases with increasing resuscitation complexity.

OBJECTIVE: Multiple procedures performed in parallel may cause each procedure to be performed less effectively than if performed in isolation. BLS performed by prehospital providers potentially includes artificial ventilations, chest compressions, and application of an automated external defibrillator (AED). This study examines the effectiveness of artificial ventilation and chest compressions both with and without an AED. METHODS: Thirty-six prehospital providers participated in a prospective observational study. Tested in pairs (n=18), subjects randomly completed three, 6-min scenarios [apneic patient with a pulse (VENT), a pulseless patient (CPR), and a pulseless patient with an AED available (CPR+AED)]. A full-torso manikin capable of generating a carotid pulse was connected to a computer to record number of ventilations, tidal volume, flow rate, number of compressions, and compression depth. Data were analyzed by t-test, ANOVA, and Mann-Whitney U-test. RESULTS: Artificial ventilation performed in isolation provided more correct ventilations than during CPR or CPR+AED (25.7%, 14.2%, 13.7%, p=0.02). Fewer ventilations were delivered during CPR and CPR+AED (p=0.03). More compressions were delivered with CPR alone vs. CPR+AED (51.9, 35.7 min(-1), p=0.00). More correct compressions were delivered during CPR alone vs. CPR+AED (p=0.05). CONCLUSIONS: Both the quality and quantity of BLS decreases as the number of procedures performed simultaneously increases. Further decrements might occur when ALS skills enter into resuscitation. These results suggest a need to automate and/or prompt the performance of BLS to optimize resuscitation.

The effect of a voice assist manikin (VAM) system on CPR quality among prehospital providers.

UNLABELLED: Numerous studies have documented poor cardiopulmonary resuscitation (CPR) performance among prehospital providers during both simulated and actual resuscitations. Previous studies have shown that a real-time, voice assist manikin (VAM) system may improve CPR performance. OBJECTIVE: To determine whether VAM prompting would improve CPR performance by prehospital providers during simulated resuscitation. METHODS: In this prospective, randomized, crossover design, 114 prehospital providers performed two 3-minute sessions of one-rescuer CPR on a VAM-resuscitation manikin: one round with the VAM feature turned on and one with the feature turned off. The primary outcomes were measured at 15-second intervals and included the fraction of correct compressions, the mean compression depth, the fraction of correct ventilations, and the mean ventilation tidal volume. Generalized estimating equations were used to analyze the repeated measures. RESULTS: The VAM prompting was not directly associated with correct compressions during one-rescuer CPR in a cohort of subjects naïve to the system. However, the general decay in correct compressions seen over 3 minutes was attenuated with VAM prompting. Neither the compression depth nor the decay in compression depth over time was affected by VAM prompting. In contrast, VAM prompting did affect the fraction of correct ventilations and attenuated the time-dependent decline in correct ventilations in tidal volume. CONCLUSIONS: Use of VAM did not directly improve compression or ventilation rate or quality in this cohort of prehospital providers. However, use of VAM did prevent decay of compression and ventilation performance over time.

Evolution of statewide EMS drug formularies and regulations.

OBJECTIVE: To characterize and follow the variability present in statewide emergency medical services (EMS) medication formularies across the United States over a ten-year period. METHODS: Investigators contacted the lead EMS agencies in all 50 states during three years (1992, 1997, and 2002). Using a standardized form, the investigators collected information about each state's prehospital medication policies, including whether a statewide EMS medication formulary existed, the authority of local medical directors to modify it, and what medications it contained. The investigators then sorted states into categories based on the regulatory intent of their EMS medication policies and compared medication listings across years. RESULTS: Responses were obtained from all 50 states (n = 50, 100%) during each of the survey periods. There appeared to be a trend toward stricter state control and toward less variation between statewide formularies. State regulations in seven states stopped allowing local medical directors to retain full control of their systems' formularies, and eight states implemented mandatory statewide formularies. There was a trend toward more consistency between states, with more "most commonly" listed medications (6.9% in 1992 versus 22.1% in 2002) and fewer "least commonly" listed medications (58.3% in 1992 versus 42.3% in 2002). Controversial medications such as neuromuscular blockers and thrombolytics appeared in a small but increasing number of statewide formularies. CONCLUSIONS: Considerable variation was found among statewide EMS medication formularies, both in how they were established and in their contents. Although several states continued to rely solely on local medical direction, there seemed to be a trend toward more uniformity and stricter state control over prehospital medication formularies during the study period.