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Rob Lawrence
EMS1.com Columnists
Takeaways from the 90-plus posters on display at this year’s National Association of EMS Physicians annual meeting
TAMPA, Fla. — This year’s NAEMSP annual meeting included a bumper crop of poster presentations. In this Quick Take, I will review my top five takeaways from the posters presented with a bonus two entries selected by my Medical Director, Dr. Maia Dorsett.
1. Use of emergency warning devices during EMS transport to hospital
The NAEMSP quality improvement and safety course 2020 cohort, under Bryan Wilson, MD, presented a poster with the aim to reduce the frequency of red lights and sirens (RLS) transports to less than 2% of transports by the end of 2020. They employed several changes, including updating their policy to enable crew discretion in the use of RLS and changed EMS charts rules so charts can only be closed with the declaration of “lights and sirens” or “no lights and sirens” options.
Their key takeaways included that a large amount of misinformation exists surrounding lights and sirens use, but crews were very willing to limit RLS use once any risks became clear and no harm to patients was seen. The study also noted by focusing on lights and sirens in transport, their use during response also decreased. A similar study and poster by the medical college of Wisconsin offered similar conclusions and mirrored the findings, particularly by identifying that ensuring provider comfort with any guideline is vital to crew wellness.
Rob’s takeaway: It is exciting to see many papers and studies continuing to come forward on this subject as we require this level of evidence to convince systems, elected officials and the general public that turning off the lights is the safe and responsible thing to do when the patient’s condition does not warrant their use.
2. Factors associated with paramedics leaving EMS – a pandemic evaluation
This poster, presented by the National Registry of Emergency Medical Technicians, identified something we already knew, but it is worth presenting in an academic setting, that the EMS workforce turnover is a challenge faced by many communities in the United States. The study examined the period during the pandemic with the objective of understanding the factors associated with paramedics’ likelihood of leaving the EMS profession.
Using national registry data, the investigators conducted a cross-sectional analysis of nationally registered, civilian paramedics, ages 18-85, from October 2021 to April 2022. On recertifying, respondents were invited to complete a survey regarding their primary role, additional jobs, and their likelihood of leaving EMS in the next 12 months.
The poster and study concluded that increased stress factors related to the pandemic now lead to the reasons for leaving EMS. The most impactful factor on the likelihood of leaving was job satisfaction, and therefore a better understanding of the factors that drive job satisfaction need to be evaluated to develop strategies to enhance retention.
Rob’s takeaway: This is an issue that requires sharp focus. While we are continually seeking greater reimbursement and income to provide a competitive wage and compete with other employers, creating and sustaining a job that engages and satisfies is a leadership task that must remain at the top of the fix-it list.
3. Transition interest and rules assessment for EMS personnel in the U.S. military
NREMT also presented this paper, in which they identified that over 10,000 medically trained military service members with national EMS certification transition into civilian careers each year. Many members of the military’s EMS-related medical occupation specialties who are nationally certified and have completed all the required accredited courses have let their certifications lapse as they depart the military and take up other occupations.
Rob’s takeaway: We are in the middle of the most severe staffing crisis we have known, and we most probably have a job for every qualified/certified medic emerging from the military. Further liaison and work needs to happen to ensure we open our doors and educate those with existing certifications on the job opportunities in the civilian EMS world. Additionally (as some of our national associations are already working on) we must create a smooth pathway for those emerging from the military who wish to train as an EMT or provide a bridge between their existing military medical qualifications and their civilian equivalent.
4. Association of body mass index and waist circumference with cardiovascular risk factors among emergency medical services professionals and firefighters
Michael W. Supples, MD, MPH, NRP, et al, from the Wake Forest University School of Medicine hypothesized that obesity – defined by waist circumference and body mass index – is associated with specific cardiovascular risk factors (hypertension, dyslipidemia and insulin resistance) among EMS professionals and firefighters. The group conducted a one-year cross-sectional study in 2021 across three mid-West fire departments with separate EMS divisions. Those departments conducted compulsory, yearly, physical examinations, measuring height, weight, waist circumference, blood pressure, cholesterol panel and HbA 1c. The study identified that obese BMI, but not waist circumference, was associated with higher odds of having abnormal blood pressure, non-HDL-c or HbA1c in this sample. Overall, most EMS professionals and firefighters had at least one cardiovascular risk factor.
Rob’s takeaway: We must look after ourselves so that we can look after the patient on duty and our families when off duty. Staying in shape, through diet and activity, must be a priority. The stressed and fast-paced lifestyle of the first responder sometimes drives us to fast food and poor nourishment choices, which is never a good thing. We are still early enough into 2023 to make a self-health/help resolution!
5. A preview of pediatric, cardiac arrest and termination of resuscitation protocols across California
This San Diego-based study identified that pediatric out-of-hospital cardiac arrests (OHCA) are low-frequency, high-severity events, often associated with poor outcomes. Multiple previous studies have identified the “stay-and-play” approach as likely beneficial for pediatrics.
EMS protocols vary significantly across jurisdictions in the United States and this study examines California’s collections of pediatric OHCA protocols, termination of resuscitation protocols and current best practice guidelines. EMS in California is regulated by the State EMS Agency via 33 regional Local EMS Agencies (LEMSAs), each with its own – frequently different – EMS protocols. The study therefore set out to compare existing pediatric cardiac arrest and field termination of resuscitation protocols in each LEMSA in the state against best practice guidelines.
Specific protocol elements analyzed included rapid transport versus “stay and play” resuscitation, allowance or parameters for termination of resuscitation protocols, airway and breathing interventions.
The results identified key differences: namely that 15.2% of the protocols had rapid transport while 30.3% called for some version of “stay and play.” (54.5% did not explicitly address the question of prioritizing rapid transport or on-scene resuscitation measures). Overall, protocols regarding airway interventions varied widely and termination of resuscitation was allowed with base contact 48.5% and allowed independently in 6 (18.2%) LEMSAs
The investigators concluded that California’s LEMSAs demonstrated a wide range of protocols with guidance for on-scene resuscitation varying significantly, specifically surrounding time on scene, and necessity of advanced airways. They note further work needs to be conducted.
Rob Writes: I selected this poster as one of note to highlight the variance in practice and protocol across just one state in the U.S., with such a variance of practice and protocol it could certainly cause confusion amongst providers that may work in different jurisdictions.
A BONUS TWO POSTERS
In trying to make my picks in which papers to highlight, I was consciously aware that I had leaned into research on management, operations, protocol and policy. To offer a little balance, I reached out to my own Prodigy EMS Medical Director, Dr. Maia Dorsett, for her top picks. She identified that her selection was based on those posters that made her question, “What are the greatest opportunities to improve care in my system?”
6. Factors associated with unrecognized, acute ischemic stroke among EMS transported patients
The study from Alyssa M. Green, et al, uses the 2019 ESO data, collaborative public use research data sets. The data identified that stroke was unrecognized in the prehospital setting for more than one in three patients diagnosed with ischemic stroke. It further went on to discuss that stroke recognition was lower when an injury was present, suggesting a possible target for performance improvement initiatives. Disparate, prehospital stroke recognition was observed for female, Hispanic and Black patients, which certainly warrants further investigation.
Dr. Dorsett’s takeaway: To that end, a research poster by Alyssa Green using the ESO data set identified that stroke was not recognized by EMS for 39% of patients with ischemic stroke. This highlights the potential harms of diagnostic error – and further advocates for the availability of patient outcomes to EMS so that we can measure and improve in this critical aspect of patient care.
7. Minimization of unrecognized failed supraglottic airways using a structured quality improvement program
A Medstar, Fort Worth, and UT Southwestern study from Dr. Veer Vithalani, et al, identified that prehospital intubation success rates remain highly variable despite a large variety of approaches to mitigate this challenge. Supraglottic airways (SGAs) have been used as an alternative in many EMS Systems. The goal of the study was to demonstrate that a multifaceted quality management program generates significant improvement in clinical performance, specifically, minimization of unrecognized failed supraglottic airway placement.
The program included three interventions – protocol/policy, education and quality improvement. Protocol and policy changes were implemented requiring EtCO2 measurement as the standard objective means of airway success, mandatory uploads of cardiac monitor data, and operational cooperation in educational initiatives. The educational aspects include implementation of new-hire and continuing education. Lastly, a continuous quality improvement process was developed, including a retrospective review of airway cases with individualized feedback, and the creation of targeted clinical improvement plans to remediate clinician skills. This program was implemented over a 12-month period, with subsequent effects analyzed over the following 5 years.
This study confirmed that a rigorous, multifaceted quality improvement program can significantly increase the safety of airway management. The interventions were able to produce a significant and persistent decrease in unrecognized failed airways and increase clinicians’ abilities to safely utilize SGAs.
Dr. Dorsett’s takeaway: The Medstar team led by Veer Vithalani had a quality improvement poster on the reduction of unrecognized failed supraglottic airways using a structured quality improvement program, during which they were able to reduce unrecognized failed supraglottic airways (by capnography) from 1 in 5 to 1 in 100. If you are not evaluating failed supraglottic airways in your system, you might be missing a lot.
In the final analysis, this article only represents less than 10% of the posters presented. The number and spectrum of posters, presenters and topics were encouraging and bodes well for EMS research in the future.
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