Emergency Medical Services Policy Research Articles

Building the emergency care workforce in a low resource setting; The Seed Global Health experience in Uganda

Introduction: Low- and middle-income countries (LMICs) face a disproportionate burden of diseases requiring emergency care. In Uganda, road traffic trauma in the context of rapid urbanization, particularly motorcycle accidents, accounts for 48% of medical emergencies. The burden of road traffic accidents, obstetric complications, and non-communicable diseases necessitate robust emergency care, yet Uganda faces systemic challenges in this sector. Following the 60th and 72nd sessions of the World Health Assembly that called for strengthened emergency, critical and operative care to achieve universal health coverage, Uganda committed to strengthening emergency medical services through taking key steps such as developing a national Emergency Medical Services (EMS) Policy. The EMS Policy outlined twelve key focus areas including development of human resources for emergency medical services, key among are emergency physicians. To support these efforts, Seed Global Health, the Ugandan Ministry of Health, Makerere University, and Mbarara University of Science and Technology partnered to strengthen the emergency medicine training between 2019 and 2024. Methods: We conducted a desk review to evaluate the collaborative effort between Seed Global Health, Ministry of Health, Makerere University and Mbarara University of Science and Technology. We reviewed policy documents, health records, and program reports to assess initiatives by Seed Global Health that were focused on developing human resources for emergency medical services, including emergency physicians training, emergency nurses and the contributions of local and international faculty. Results: The partnership between Seed Global Health, Ministry of Health, Mbarara University of Science and Technology and Makerere University successfully trained 21 new emergency physicians, with 43 more residents currently in training. It introduced essential clinical resources, enhancing diagnostic and treatment capacities for improved patient care while improving learning environments through skills laboratory support, simulation support and classroom equipment. Additionally, it supported the coordination of emergency services within emergency departments in hospitals as well as enhanced advocacy efforts to improving emergency care in Uganda. However, despite these tremendous milestones, challenges persist including a shortage of specialists relative to the high demand for services, a need for increased investment for emergency medical services and a need for better integration of emergency services within the healthcare system. Conclusion: This article highlights the value of international collaborations, long term partnership and targeted training in addressing emergency care gaps in LMICs. We recommend expanding emergency medicine programs, increasing government investment in facilities and human resources, and strengthening interdisciplinary emergency response teams. These measures are essential for providing sustainable, quality emergency care to address Uganda's growing needs.

Legal review of state emergency medical services policies and protocols for naloxone administration

BackgroundGiven the continued rise in opioid-related overdoses, many states have expanded access to the opioid antagonist naloxone. We sought to provide comprehensive data on one such strategy: the authority of providers at different emergency medical services (EMS) licensure levels to administer naloxone. MethodsWe conducted a systematic legal review of state laws and protocols governing the authority of different EMS licensure levels to administer naloxone. We used Westlaw, state government websites and scope of practice protocols. We coded relevant policies regarding which, if any, administration routes and dosages of naloxone are permitted for each licensure level: emergency medical responder (EMR), emergency medical technician (EMT), advanced emergency medical technician (AEMT), and paramedic. ResultsAs of July 2020, all states with relevant laws or protocols authorize paramedics, AEMTs, and EMTs to administer naloxone. Thirty-nine states with an EMR licensure level and statewide protocol authorize naloxone administration by EMRs, up from only two in 2013. Permissible routes of administration have increased across all EMS provider levels, providing advanced life support providers (i.e., paramedics and AEMTs) with expanded discretion; however, authorization for intravenous and intramuscular administration remains relatively uncommon for basic life support (BLS) providers. When specified, maximum doses authorized ranged widely, from 2.0 to 12.0 milligrams. ConclusionsNaloxone administration authority is now widely granted to EMS providers. Most states allow all licensed EMS provider levels to administer naloxone, a substantial increase for EMRs and EMTs since 2013. Paramedics and AEMTs have the greatest authority to select the dosage and route of administration.

The Psychological Challenges of Emergency Medical Service Providers During Disasters: A Mini-Review February 2022

The provision of emergency medical services (EMS) is an inherently stressful job. Depression, anxiety, and posttraumatic stress disorder (PTSD) are common psychological challenges affecting EMS providers. As disasters increase worldwide, the need for EMS also increases, as they are an essential part of any disaster management system. Studies have shown that EMS providers experience psychological challenges due to disaster response without receiving the needed psychological support. There is a scarcity of research focusing on EMS providers' psychological challenges in disaster times, especially in the Eastern world. This review highlights the psychological challenges faced by EMS providers in disaster times and discusses the amount of mental health care they receive. By emphasizing the need for mental health support, more research can be conducted to view EMS providers' perspectives on mental health needs before, during, and after disasters, and EMS policy makers can find programs to meet EMS providers' mental health needs, which might reflect positively on EMS and disaster management systems.

Prehospital Airway Management: A Systematic Review

Objective: To assess comparative benefits and harms across three airway management approaches (bag valve mask [BVM], supraglottic airway [SGA], and endotracheal intubation [ETI]) used by prehospital emergency medical services (EMS) to treat patients with trauma, cardiac arrest, or medical emergencies, and how they differ based on techniques and devices, EMS personnel and patient characteristics. Data sources: We searched electronic citation databases (Ovid® MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus®) from 1990 to September 2020. Review methods: We followed Agency for Healthcare Research and Quality Effective Health Care Program Methods guidance. Outcomes included mortality, neurological function, return of spontaneous circulation (ROSC), and successful advanced airway insertion. Meta-analyses using profile-likelihood random effects models were conducted, with analyses stratified by study design, emergency type, and age. Results: We included 99 studies involving 630,397 patients. We found few differences in primary outcomes across airway management approaches. For survival, there was no difference for BVM versus ETI or SGA in adult and pediatric patients with cardiac arrest or trauma. For neurological function, there was no difference for BVM versus ETI and SGA versus ETI in pediatric patients with cardiac arrest. There was no difference in BVM versus ETI in adults with cardiac arrest, but improved neurological function with BVM or ETI versus SGA. There was no difference in ROSC for patients with cardiac arrest for BVM versus ETI or SGA in adults and pediatrics, or SGA versus ETI in pediatrics. There was higher frequency of ROSC in adults with SGA versus ETI. For successful advanced airway insertion, there was higher first-pass success with SGA versus ETI for all patients except adult medical patients (no difference), and no difference in overall success using SGA versus ETI in adults. Conclusions: The currently available evidence does not indicate benefits of more invasive airway approaches based on survival, neurological function, ROSC, or successful airway insertion. Strength of evidence was low or moderate; most included studies were observational. This supports the need for high-quality randomized controlled trials to advance clinical practice and EMS education and policy, and improve patient-centered outcomes.

Validation of the NUE Rule to Predict Futile Resuscitation of Out-of-Hospital Cardiac Arrest

Aim We validated the NUE rule, using three criteria (Non-shockable initial rhythm, Unwitnessed arrest, Eighty years or older) to predict futile resuscitation of patients with out-of-hospital cardiac arrest (OHCA). Methods We performed a retrospective cohort analysis of all recorded OHCA in Marion County, Indiana, from January 1, 2014 to December 31, 2019. We described patient, arrest, and emergency medical services (EMS) response characteristics, and assessed the performance of the NUE rule in identifying patients unlikely to survive to hospital discharge. Results From 2014 to 2019, EMS responded to 4370 patients who sustained OHCA. We excluded 329 (7.5%) patients with incomplete data. Median patient age was 62 years (IQR 49 − 73), 1599 (39.6%) patients were female, and 1728 (42.8%) arrests were witnessed. The NUE rule identified 290 (7.2%) arrests, of whom none survived to hospital discharge. Conclusion In external validation, the NUE rule (Non-shockable initial rhythm, Unwitnessed arrest, Eighty years or older) correctly identified 7.2% of OHCA patients unlikely to survive to hospital discharge. The NUE rule could be used in EMS protocols and policies to identify OHCA patients very unlikely to benefit from aggressive resuscitation.

Emergency medical services targeting opioid user disorder: An exploration of current out-of-hospital post-overdose interventions.

ObjectiveThe opioid epidemic continues to escalate, and out‐of‐hospital emergency medical services (EMS) play a vital role in acute overdose reversal, but could serve a broader role post‐incident for follow‐up, outreach, and referrals. Our objective is to identify the scope and prevalence of community‐based, post‐opioid overdose EMS programs across the United States.MethodsWe used a narrative review of prior studies in PubMed and Scopus for the last 20 years (1999–2020) to identify relevant medical literature and a web search to identify gray literature of EMS interventions involving opioids.ResultsOut of nearly 22,000 EMS agencies across the United States, we found evidence of only 27 programs published in medical or gray literature involving post‐overdose interventions. They were most commonly found in the north and eastern region of the country. Although most of these programs incorporate harm reduction and education, other more innovative aspects such as linkage to outpatient addiction treatment or peer support services, are much less common. The most comprehensive programs involved combinations of innovative outreach, specialized referrals, integration with police and criminal justice, peer support, and even treatment initiation.ConclusionsOut‐of‐hospital emergency care has the potential to provide more comprehensive care after drug overdose, but many programs either do not currently have such an intervention in place, or are not disseminating their practices for other agencies to assimilate. EMS protocols and policies that encourage greater adoption of active community paramedicine practices for opioids should be encouraged.

The state of emergency medical services and acute health facility care in Uganda: findings from a National Cross-Sectional Survey

BackgroundThere is limited information on the state of emergency medical services (EMS) in Uganda. The available evidence is from studies that focused on either assessing EMS capacity and gaps at the national level especially in Kampala or identifying risk factors for specific emergency medical conditions (e.g., injuries). In this study, we sought to provide a snapshot of the state of EMS in Uganda by assessing the pre-hospital and hospital emergency care capacity at both national and sub-national (district) levels.MethodsWe conducted a cross-sectional national survey administering structured questionnaires to EMS providers and policy makers from 38 randomly selected districts across seven of the 14 health regions of Uganda. This resulted in a study sample of 111 health facilities and 52 pre-hospital service providers. We collected data on six pillars of EMS whose frequencies and percentages were calculated and qualitatively compared for different levels of the health care system.ResultsAt the time of this study, Uganda did not have any EMS policy or guidelines. In addition, there was no functional toll-free number for emergency response in the country. However, Ministry of Health reported that a taskforce had been set up to lead development of EMS policy, guidelines, and standards including establishment of a toll-free emergency number.At the sub-national level, ambulances lacked the products and supplies needed to provide pre-hospital care, and mainly functioned as emergency transport vehicles, with no capacity for medical care.Only 16 (30.8%) of the 52 pre-hospital providers assessed had standard ambulances with required equipment, medicines, and personnel. The rest of the service providers had improvised ambulances that were not equipped to provide pre-hospital care.Traffic police and bystanders were the first responders to the majority (> 90%) of the emergency cases.ConclusionOur findings reveal weaknesses at every level of what should be a critical component in the health care system – one that deals with the ability to treat life-threatening conditions in a time sensitive manner. The Ministry of Health needs to speed up efforts to provide policies and guidelines, and to increase investments for the creation of a functional EMS in Uganda.

Meeting science meets public health: Results from the “Stress and Violence in fire-based EMS Responders (SAVER)” Systems Checklist Consensus Conference (SC3)

Introduction: In order to implement a systems-level Emergency Medical Services (EMS) workplace violence intervention, input from end users was critically needed. We convened the two-day Stress and Violence in fire-based EMS Responders (SAVER)” Systems Checklist Consensus Conference (SC3) using methods from meeting science (i.e., ThinkLets) to comprehensively and efficiently gather feedback from stakeholders on the completeness and utility of the draft checklist that would comprise the intervention. Methods: ThinkLets, a codified facilitation technique was used to aid brainstorming, convergence, organization, evaluation, and consensus building activities on the SAVER Systems Checklist among 41 national stakeholders during a two-day conference. A qualitative and quantitative process evaluation was conducted to measure the effectiveness of conference procedures. To verify checklist feasibility results from the conference, a second feasibility assessment was conducted with the four implementation sites. Conclusions: The quantitative conference evaluation results indicated most participants viewed the conference process favorably. Emergent themes reflecting on conference effectiveness and suggestions for improvements are described. The re-evaluation of the checklist’s feasibility completed by the SAVER study sites confirmed prior feasibility findings. SAVER study sites cast 45.5% of votes on checklist items to be most feasible, 34.9% as less feasible, and 19.6% as extremely difficult. Practical Applications: Multidisciplinary collaboration between public health, occupational health psychology, and meeting science led to the development of the SAVER Systems Checklist. The checklist underscores important needs for EMS policy and training development critical to responder safety as identified and supported by over 41 diverse subject matter experts. The incorporation of a widely used meeting science method, ThinkLets, into public health intervention design proved an effective and well-received approach to bring assessment, evaluation, and consensus to the SAVER Systems Checklist. These methods may hold benefit for other industries and disciplines that may not be familiar with such facilitation and consensus-building techniques.

Emergency medical services in Ethiopia: Drivers, challenges and opportunities.

Ethiopia has a well established health care system but lacks significant improvements on emergency medical services and suffers a shortage of equally initiative among all regional states and city administration of Ethiopia. This study aimed to examine the drivers, challenges, and opportunities of Emergency Medical Services (EMS) and to identify new evidence for future policy making in Ethiopia. A narrative review of the literature related to EMS was undertaken to describe the drivers, challenges, and opportunities for EMS in Ethiopia from July, 2000 to September, 2018. The search was done from four relevant electronic databases: MEDLINE, Science Directs, Scopus and PubMed by using Google Scholar and Google with key search words used mainly as "Emergency Medical services in Ethiopia". The inclusion criteria were an original study or review studies involving Emergency Medical Services in Ethiopia. Among the available papers, the relevant articles were selected while the irrelevant ones were excluded. There was lack of trained emergency medical providers and misdistribution of trained professionals, immaturity of the program, lack of partnership and stakeholders and lack of motivation towards Emergency medical services. Emergency medical services hamper significant problems similar to other African countries that required being addressed in Ethiopia context for achieving the program and in order to obtain intended outcomes for the country. A long-term discussion is needed to further improve the services system in various health care facilities. An Emergency Medical services policy making and analysis framework is needed to make quality emergency medical care at Emergency department in hospitals and outside the hospitals.

Perceptions of leadership, motivation, structure, and assurance for implementation of emergency medical services in Ethiopia: Perspectives of emergency medical services case teams based on focus group discussions

The research was assessed the Ethiopian Emergency Medical Services Case teams' and officers views on Emergency Medical services in Ethiopia. The aim of study was to present the point of views, prospect and priorities of Emergency medical services case teams and its coordinator along some main dimensions of emergency medical services, such as Leadership, Motivation, Structure, and Assurance for implementation. Six focus group discussion were facilitated with EMS case teams, focal persons and FMoH emergency medical services case teams from December to August, 2017 in all regions chosen of the study. The focus group techniques were used in the study as qualitative research method for examination of viewpoints of case team members towards to the emergency medical care system and overall pre-hospital and at hospital emergency care services. The discussion was addressing the topics of: general aspects of emergency Medical Services (EMS) and which occupations included in EMS; possibilities to importance review EMS issues based on Leadership, Motivation, Structure, and Assurance for implementation of EMS in the country. Finally, thematic analysis was used to evaluate data sets which collected during the focus group discussion. There were 6 focus groups in total: an Emergency medical services case teams, officers, Directorates, and integrated disease prevention and control program coordinators groups in each of the regional, city Administration Health Bureau and Federal Ministry of Health in Ethiopia. Findings of the thematic analysis were summarized along the following dimensions: Leadership, Motivation, Structure, and Assurance for implementation. The result shown that lack of resources, shortage of training, lack of professionals and community awareness on EMS, immaturity of EMS strategic plan and lack of revision, workload as a result of limited skilled manpower, lack of partnerships and collaboration on EMS and lack of research and community services evidence are among factors affecting the quality EMS and continuity of the program at various health care facilities at the regional and national levels. The study shows views of the Ethiopian Emergency Medical Services Case teams' and officers in Emergency Medical services in Ethiopia. The participants were considered determining factors of the EMS were rather similar among the participated regional, city Administration Health Bureau and Federal Ministry of health. Nonetheless, there was some degree of difference among those participated institutes. Especially, as a national level, Ethiopian Ministry of Health is exists only one emergency medical service directorate that leading the whole national activities. Therefore, EMS program need to respond to the challenges by respondents to articulate emergency medical services policies appropriate to Ethiopia, including the pre-hospital, at hospital care system and Ambulance services with more reformed professional skills and case team work at country level including all regions, Zone, Woreda (Districts) and other related sectors.

Determining Potentially Avoidable Emergency Medical Services (EMS) Transports: A Population Level Study Using Linked Administrative Data in Alberta Health Services (AHS)

IntroductionTraditionally Emergency Medical Services (EMS) transports patients to Emergency Departments (EDs). However, some patients might be appropriately managed in alternative settings outside the ED. A number of non-traditional EMS programs have evolved in Alberta, in an attempt to provide quality care through a community-based care model.
 Objectives and ApproachThe project aimed to identify and quantify potentially avoidable EMS transports to EDs in Alberta.
 We identified 911 responses by ground ambulance in Alberta between September 1, 2017 and December 31, 2017. Patients 18 years and over transported to EDs were linked to Alberta Provincial Registry for more accurate demographic Information, and linked to Long Term Care (LTC) and ED data to capture patient characteristics and frequency of potentially avoidable EMS transports to EDs, defined as the Canadian Triage and Acuity Scale (CTAS) Level IV and Level V in EDs not requiring inpatient admission.
 ResultsWe identified 72,182 transports to EDs, of which 1 in 4 patients were rural residents. After excluding individuals<18 years and non-Alberta residents, we were able to match 58,137 of the 60,020 EMS transports to EDs (96.8%). Overall, 7,697 (13%) were triaged as less urgent with no hospital admission. Patients 65 years and over accounted for almost half (49%) of the transports in this cohort, 6% of which were for LTC clients. Percentage of potentially avoidable transports in LTC clients were similar to seniors living in the community (12%). Geographic visualization at the provincial level indicated variation across the province. In general, rural residents were more likely than urban residents to be transported to EDs with less urgent conditions (18% vs 12%).
 Conclusion/ImplicationsThis is the first analysis exploring potentially avoidable EMS transports to EDs in Alberta, Canada, where a comprehensive, single source of EMS system data is currently available. The project suggests opportunities for future EMS research and policies focusing on enhancing community–based care.

Abstract WP229: The Impact of EMS Directly Transporting Patients With Suspected Acute Ischemic Stroke to Comprehensive Stroke Centers in South Florida

Background: After endovascular therapy (EVT) became standard of care for acute ischemic stroke (AIS) in 2015, emergency medical services (EMS) in 3 urban southeast Florida counties modified their transport protocols for suspected AIS. In 2015, Broward (BC) and Palm Beach counties (PBC) phased in EMS transport of all stroke alerts to state-attested comprehensive stroke centers (CSC). Miami-Dade (MDC) adopted a severity-based protocol. Methods: The impact of EMS policy changes was assessed using the AHA Get with the Guidelines-Stroke data prospectively collected for the Florida-Puerto Rico Stroke Registry involving 35,794 AIS cases in the 3 counties with 27 CSC between 2010 and 2016. Results: The percent of patients transported directly by EMS from scene to CSCs in BC and PBC rose from 34% and 13% during 2010, to 97% and 86%, respectively, in 2016 (p=0.002). In MDC, it increased from 62% to 77%. In 2016, the percentage of AIS patients that presented to CSC as transfers from primary stroke centers (PSC) was 5% in BC, 8% in PBC, and 12% in MDC. Of all patients receiving IV tPA in 2016, 81% were transported by EMS and 87 % of IV tPA treatment was administered in a CSC. From 2010 to 2016, IV tPA treatment increased from 8% to 18% in CSC vs. 8% to 12% in PSC (p=0.41). By 2016 the mean door to needle time was 13 min shorter in CSCs (p<0.001). Mean interval from symptom onset to IV tPA (OTT) decreased to 112 min in CSC vs. 125 min in PSC (p=0.047) and 19% of patients at CSCs had an OTT in the “golden hour” compared to 11% at PSCs. In 2016 the mean onset to arrival in patients transferred from PSC to CSC for EVT was 109 min longer than in those directly transported to CSC. The percentage of patients receiving EVT increased overall to 6%, with 9 CSC reporting greater than 10% EVT, 5 CSC greater than 15%, and 2 greater than 20% EVT for all AIS cases. Conclusion: Modifying EMS policies to transport most suspected AIS patients directly to CSCs was associated with higher rates of IV tPA treatment, shorter intervals to IV tPA after symptom onset, faster arrival times for EVT evaluation and higher rates of EVT compared to patients triaged to PSCs. Based on these findings, directly transporting suspected AIS patients to CSC may be a successful strategy to expedite stroke care interventions in urban centers with high CSC density.

The Impact of Using Emergency Lights and Sirens During Noncritical Patient Transport

Introduction: Unnecessary use of lights and sirens during transport of noncritical patients is a major cause of vehicle crashes contributing to injury and death among emergency medical technicians (EMTs), patients and bystanders. This study examines whether EMT stress levels and ambulance transport times differ as a function of using lights and sirens, and whether EMTs support policies for their use. Methods: Data for this quasi-experimental quantitative study was collected from 80 New Jersey EMTs using the Depression Anxiety Stress Scale. Results were assessed for ambulance transport times for noncritical patients and EMT stress levels, both with and without the use of lights and sirens. Data were analyzed using the t test and regression procedures. Results: Analysis shows no statistically significant difference in transport times with lights and sirens in use compared to when they were not used. Findings are statistically significant in the undue and increased stress level of the EMTs when lights and sirens are used. Participants demonstrated support for a policy for their use. Conclusion: Findings suggest that the use of lights and sirens in transporting noncritical patients is unnecessary. Practical applications: Recommendations include the development of a state Emergency Medical Services policy to provide guidelines on the use of lights and sirens, or a system that allows for the objective evaluation of whether the situation warrants the use of lights and sirens. The implications for positive social change include savings of money, property and, most importantly, human lives.

Emergency Response Community Effectiveness: A simulation modeler for comparing Emergency Medical Services with smartphone-based Samaritan response

Mobile emergency response applications involving location-based alerts and physical response of networked members increasingly appear on smartphones to address a variety of emergencies. EMS (Emergency Medical Services) administrators, policy makers, and other decision makers need to determine when such systems present an effective addition to traditional Emergency Medical Services. We developed a software tool, the Emergency Response Community Effectiveness Modeler (ERCEM) that accepts parameters and compares the potential smartphone-initiated Samaritan/member response to traditional EMS response for a specific medical condition in a given geographic area. This study uses EMS data from the National EMS Information System (NEMSIS) and analyses geographies based on Rural-Urban Commuting Area (RUCA) and Economic Research Service (ERS) urbanicity codes. To demonstrate ERCEM's capabilities, we input a full year of NEMSIS data documenting EMS response incidents across the USA. We conducted three experiments to explore anaphylaxis, hypoglycemia and opioid overdose events across different population density characteristics, with further permutations to consider a series of potential app adoption levels, Samaritan response behaviors, notification radii, etc. Our model emphasizes how medical condition, prescription adherence levels, community network membership, and population density are key factors in determining the effectiveness of Samaritan-based Emergency Response Communities (ERC). We show how the efficacy of deploying mHealth apps for emergency response by volunteers can be modelled and studied in comparison to EMS. A decision maker can utilize ERCEM to generate a detailed simulation of different emergency response scenarios to assess the efficacy of smartphone-based Samaritan response applications in varying geographic regions for a series of different conditions and treatments.

Policies for managing emergency medical services in mass casualty incidents

IntroductionDiverse decision-making is needed in managing mass casualty incidents (MCIs), by emergency medical services (EMS). The aim of the study was to review consensus among international experts concerning policies of EMS management during MCIs. MethodsApplicability of 21 EMS policies was tested through a 2-cycle modified e-Delphi process, in which 38 multi-disciplinary experts from 10 countries participated. Threshold for approving proposed solutions was defined as consensus of >80%. Policies that did not achieve the targeted consensus were reviewed to detect variability according to respondents' origin country. Results16 policies were endorsed in the first cycle including collaboration between ambulance service providers; implementing a unified mode of operation; preparing criteria for ground versus aerial evacuation; and, developing support systems for caregivers exposed to violence. An additional policy which proposed that senior EMS officers should not necessarily act as on-site MCI commanders was endorsed in the second cycle.Demographic breakdown of views concerning non-consensual policies revealed differences according to countries of origin. Assigning ambulances to off-duty team members was highly endorsed by experts from Israel and South Africa and strongly rejected by European respondents. Avoiding entry to risk areas until declared safe was endorsed by European, Asian and Oceanic experts, but rejected by Israeli, South African and North American experts. ConclusionsDespite uniqueness of countries and EMS agencies, solutions to most dilemmas were applicable to all organizations, regardless of location or affiliation. Cultural diversity was found concerning readiness to implement military-civilian collaboration in MCIs and a rigid separation between work-leisure responsibilities.

Recruitment and Retention of New Emergency Medical Technician (EMT)-Basics and Paramedics.

The purpose of this paper is to describe factors important for the recruitment and retention of Emergency Medical Technician (EMT)-Basics and EMT-Paramedics new to the Emergency Medical Services (EMS) field (defined as two years or less of EMS employment) through an analysis of 10 years of Longitudinal EMT Attributes and Demographic Study (LEADS) data. Data were obtained from 10 years of LEADS surveys (1999-2008). Individuals new to the profession were identified through responses to a survey item. Their responses were analyzed using weights reflecting each individual's probability of selection. Means, proportions, and 95% confidence intervals (CIs) were determined and used to identify statistically significant differences. There were few changes in the demographic characteristics of new EMT-Basics and Paramedics across survey years. New EMT-Basics tended to be older and less likely to have a college degree than new EMT-Paramedics. More new EMT-Basics than EMT-Paramedics worked in rural areas and small towns and reported that they were working as a volunteer. There were differences between new EMT-Basics and EMT-Paramedics in several of the reasons for entering the profession and in facets of job satisfaction. The findings provide guidance for recruiters, educators, employers, and governmental EMS policy organizations and will provide better insight into how to attract and retain new entrants to the field. Chapman SA , Crowe RP , Bentley MA . Recruitment and retention of new Emergency Medical Technician (EMT)-Basics and Paramedics. Prehosp Disaster Med. 2016;31(Suppl. 1):s70-s86.

A Descriptive Analysis of US Prehospital Care Response to Law Enforcement Tactical Incidents.

Law enforcement tactical incidents involve high-risk operations that exceed the capabilities of regular, uniformed police. Despite the existence of tactical teams for 50 years, little is known about the frequency or nature of emergency medical services (EMS) response to tactical events in the United States. The purpose of this study was to perform a descriptive analysis of tactical events reported to a national EMS database. Descriptive analysis of the 2012 National Emergency Medical Services Information System (NEMSIS) Public Release research data set, containing EMS emergency response data from 41 states. A total of 17,479,328 EMS events were reported, of which 3,953 events were coded as "Activation-Tactical or SWAT Specialty Service/Response Team." The most common level of prehospital care present on scene was basic life support (55.2%). The majority (72.3%) of tactical incident activations involved a single patient; mass casualty incidents occurred in 0.5% of events. The most common EMS response locations were homes (48.4%), streets or highways (37.0%), and public buildings (6.3%). The mean age of treated patients was 44.1 years ± 22.0 years; 3.5% of tactical incident activation patients were aged 8 years or less. Injuries were coded as firearm assault in 14.8% and as chemical exposure in 8.9% of events. Cardiac arrest occurred in 5.1% of patients, with the majority (92.2%) occurring prior to EMS arrival. The primary symptoms reported by EMS personnel were pain (37.4%), change in responsiveness (13.1%), and bleeding (8.1%). Advanced airway procedures occurred in 30 patients. No patients were documented as receiving tourniquets or needle thoracostomy. Approximately 11 EMS responses in support of law enforcement tactical operations occur daily in the United States. The majority occur in homes and involve a single patient. Advanced airway procedures are required in a minority of patients. Cardiac arrest is rare and occurs prior to EMS response in the majority of cases. Better understanding of the nature and location of EMS responses to tactical incidents is required to develop consistent EMS policies in support of law enforcement tactical operations.

Creating an infrastructure for comparative effectiveness research in emergency medical services.

Emergency medical services (EMS) providers deliver the initial care for millions of people in the United States each year. The Institute of Medicine noted a deficit in research necessary to improve prehospital care, created by the existence of data silos, absence of long-term outcomes, and limited stakeholder engagement in research. This article describes a regional effort to create a high-performing infrastructure in southwestern Pennsylvania addressing these fundamental barriers. Regional EMS records from 33 agencies in January 2011 were linked to hospital-based electronic health records (EHRs) in a single nine-hospital system, with manual review of matches for accuracy. The use of community stakeholder engagement was included to guide scientific inquiry, as well as 2-year follow up for patient-centered outcomes. Local EMS medicine stakeholders emphasized the limits of single-agency EMS research and suggested that studies focus on improving cross-cutting, long-term outcomes. Guided by this input, more than 95% of EMS records (2,675 of 2,800) were linked to hospital-based EHRs. More than 80% of records were linked to 2-year mortality, with more deaths among EMS patients with prehospital hypotension (30.5%) or respiratory distress (19.5%) than chest pain (5.4%) or nonspecific complaints (9.4%). A prehospital comparative effectiveness research infrastructure composed of patient-level EMS data, EHRs at multiple hospitals, long-term outcomes, and community stakeholder perspectives is feasible and may be scalable to larger regions and networks. The lessons learned and barriers identified offer a roadmap to answering community and policy-relevant research questions in prehospital care.

PCDRecognizes Outstanding Student Research: Patel et al on Emergency Medical Services Capacity for Prehospital Stroke Care in North Carolina

This week, Preventing Chronic Disease (PCD) publishes the winning submission in the journal’s third annual Student Research Paper Contest, “Emergency Medical Services Capacity for Prehospital Stroke Care in North Carolina,” by Mehul D. Patel and colleagues (1). The contest is part of PCD’s effort to support and encourage the development of the next generation of public health professionals. Mr Patel is an epidemiology student in the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill, and Dr Wayne Rosamond is his academic and dissertation advisor. As in previous years, submissions in the 2013 contest examined a range of topics and used a variety of analytic methods. Since the first contest in 2011, the quality of the submissions has improved, making the final decision that much more difficult for the panel of judges. As Patel and colleagues note, stroke morbidity and mortality is high in the United States and in North Carolina. It is well known that early treatment of stroke can make a difference in event outcomes. During the past decade, efforts have been made to raise public awareness of stroke signs and symptoms and the importance of acting early and to increase the knowledge and capacity of emergency medical services (EMS) to improve health outcomes. Patel and colleagues examined improvements in EMS capacity to identify and treat stroke in North Carolina from 2001 through 2012. A statewide survey in 2001 found deficiencies in EMS education and the use of protocols. The authors’ survey in 2012 documented major improvements since 2001, especially in prehospital stroke screening, and highlighted other areas that remain in need of improvement, including the use of destination plans. This article nicely demonstrates the relationship among data, health, health care, and policy. The 2001 survey documented the need to improve the stroke care capacity of EMS systems in North Carolina, and surveillance data documented the burden of stroke (2,3). Together, this information supported the development and passage of state legislation in 2006 to address the availability of stroke-related resources among hospitals and EMS systems and the implementation of standardized EMS stroke care practices and policies. Results from the 2012 survey indicated that EMS had made progress in its capacity to provide services. The decline in stroke mortality in North Carolina documented by external data sources provides some ecological support to changes in health outcomes. The study had one limitation that highlights an opportunity for collaboration between clinical and public health systems: the study had no direct measures of services provided, patient outcomes, or population-level indicators. This limitation points to a challenge faced by many public health researchers: access to health outcome data in addition to process and proxy outcome measures. Direct measurement of health outcomes is ultimately needed to determine intervention effectiveness and to make a convincing argument for public health programs and policies. In North Carolina, the decline in stroke mortality documented by external data sources parallels changes in policy and service protocols. However, Patel’s study did not include data on health outcomes or services provided, both of which could offer evidence that changes in health outcomes resulted from changes in policies and service protocols. Data from other sources can sometimes be used to triangulate findings; however, this approach has limitations. This gap in data highlights an opportunity for clinical and public health systems to work together to collect data that will provide the strongest evidence to evaluate policy changes. Congratulations to Mr Patel and his colleagues on their outstanding work. We invite you to read the winning article (www.cdc.gov/pcd/issues/2013/13_0035.htm) and to listen to the accompanying podcast, an interview with the author. The study represents exceptional work, selected from a pool of several outstanding manuscripts, performed by members of the next generation of public health researchers. Although there can be only one contest winner, we were pleased to find that several manuscripts were of sufficient merit to warrant future publication in PCD. The review process for these student submissions was conducted by a panel of PCD editorial board members as well as Ellen Kersten, winner of the 2012 PCD Student Research Paper Contest. We look forward to the next round of student papers for the 2014 contest. The deadline for submission of student papers is January 31, 2014.

Out-of-Hospital Resuscitation: Have We Gone Too Far?

Americans are living longer and are more likely to be chronically or terminally ill at the time of death. Although surveys indicate that most people prefer to die at home, the majority of people in the United States die in acute care hospitals. Each year, approximately 400,000 persons suffer sudden cardiac arrest in the US, the majority occurring in the out-of-hospital setting. Mortality rates are high and reach almost 100% when prehospital care has failed to restore spontaneous circulation. Nonetheless, patients who receive little benefit or may wish to forgo life-sustaining treatment often are resuscitated. Risk versus harm of resuscitation efforts can be differentiated by various factors, including cardiac rhythm. Emergency medical services policy regarding resuscitation should consider its utility in various clinical scenarios. Patients, family members, emergency medical providers, and physicians all are important stakeholders to consider in decisions about out-of-hospital cardiac arrest. Ideally, future policy will place greater emphasis on patient preferences and quality of life by including all of these viewpoints.