Ten Steps to Take Today Toward Safer Systems Tomorrow

Policy: Our profession is hazardous to its workers in many ways; EMTs and paramedics have an injury rate three times the national average.¹ 

Strategy: Embrace of sound, scientific advances across a variety of areas can demonstrably reduce risk to EMS providers. 

Vision: By 2020, EMS providers will operate more safely in vehicles and at scenes, providing quality, appropriate care to all patients. 

Six years ago, who could have foreseen the state of EMS at the dawn of 2014? Already more than 200 U.S. systems have developed community paramedic/mobile integrated healthcare programs, and more begin every day. Fitfully but resolutely, we strive toward operations that are smarter and safer for our providers and their patients. Knowledge grows, approaches evolve, technology advances, and you try to keep up. 

Another six years promises greater changes yet. Over the last year in our EMS 2020 project, sponsored by Ferno, we’ve looked at what some of those might be, examining best current efforts and envisioning ultimate answers. That work will continue in 2014 as EMS 2020 hones in on further solutions to the challenges facing EMS leaders—which, let’s face it, aren’t getting any simpler. 

Find all of this material, past and future, at www.emsworld.com/2020. And as a year-end summary, enjoy this, 10 steps you can start taking today to increase the safety of your systems.

1. Pursue and implement evidence-based safety standards

This call is part of the National EMS Culture of Safety Strategy Project, which includes among its elements the creation of an EMS Safety Resource Center to promulgate evidence-based standards to improve responder and patient safety. But even without an organizing entity to lead national efforts, EMS systems should work to develop and implement objective, evidence-based standards for their own safe operations. Areas suitable for standards, according to Culture of Safety experts, may include physical fitness; shifts/fatigue; categorizing and reporting violence; medical and patient-moving equipment; ambulance design; dispatch; driving; and PPE. For more: www.emsworld.com/2020/culture-of-safety. 

2. Embrace Just Culture

Stop blaming and shaming: Just Culture encourages the reporting of mistakes under the notion that most mistakes are system-based. Reporting errors without fear of individual retribution or punishment lets organizations fix the systemic flaws that lead to errors by individuals. For instance, keeping two similarly packaged medications next to each other in a drug box could lead to the wrong one being given. Rather than punish a provider who’s tripped up by that trap (which will discourage future reporting), systems can solve the root cause by reconfiguring how they keep their drugs. For more: www.emsworld.com/2020/culture-of-safety.

3. Know your risks

Our injury and death rates are high, but we know why: vehicle crashes and injuries related to patient movement. 

Risks in ambulances relate to things like restraint use, seating position and how we travel. Restrained occupants do better in crashes. Smart organizations also select the right drivers, checking personal driving records and weeding out those with unsafe histories. 

For ensuring safe operation, driver-feedback systems are proven to help. In the patient compartment, seats should keep providers forward- and rear-facing and allow them to stay restrained. 

Tools that reduce lifting burdens can help avert musculoskeletal injuries, as can efforts to help providers stay strong and fit (gym memberships, physical training, etc.). Physical abilities testing can identify candidates not up to the rigors of EMS. 

Newer literature also recognizes assault as a major hazard.¹ Know what’s behind your own injuries and LODDs. With all such events, organizations must collect reliable data, scrutinize it and intervene against identified risks in sound, scientific ways. For more: www.emsworld.com/2020/risk-management.

4. Improve ambulance safety

Proven measures can enhance safety in our rigs and reduce the risks described above. Help providers stay seated and restrained by designing patient compartments around range-of-reach calculations and operational task analysis. Eliminate the squad bench. Portable equipment go-bags can reduce the need for cabinetry and thus head-impact hazards. Secure equipment against crashes. A patient-loading height of 27 inches is optimal to minimize the risk of back strain. Keep heavy equipment low in exterior compartments. For more: www.emsworld.com/2020/ambulance-design.

5. Ergonomic solutions for patient movement and scene management

The physical forces experienced by providers as they move and treat patients and operate at emergency scenes can often be reduced through ergonomic design. When moving patients, rolling and sliding are better than lifting and carrying, as chronicled by ergonomists who have measured forces during common EMS maneuvers. Invest in tools and designs that can reduce the effort required of exerted and contorted providers. For more: www.emsworld.com/2020/scene-management. 

6. Take advantage of technology

Embrace the advances enabled by smartphones, iPads and other modern technological marvels. Apps proliferate for everything from drug calculations to finding defibrillators and people who can do CPR. As well, the public safety broadband network is coming, potentially enabling wider use of things like streaming data and video. 

Thinking ahead, start trying to figure out what kinds of broadband applications might improve your service and benefit your patients. What kinds of information on what kinds of patients should be sent ahead to hospitals? Who might benefit from a remotely connected doc in the back of an ambulance? How could you use patients’ complete medical histories if you had them in hand? Get involved with your state efforts and start readying your agency to take advantage of this unprecedented resource. For more: www.emsworld.com/2020/technology. 

7. Forge community connections

The safest run is one you never make, and in the spirit of mobile integrated healthcare, a little proactive effort to solve patients’ problems, even nonmedical ones, can go a long way toward stopping future 9-1-1 calls. 

Establish alliances or make contacts with social and senior services, transportation providers, food sources, charitable organizations and others who might help address the underlying problems of those in need. Think outside the box; maybe a builder can install a grab rail or fix a step, preventing a senior’s fall. 
We in EMS are among the few professionals invited into people’s homes at their moments of vulnerability. That uniquely suits us to help identify threats and intercede. For more: www.emsworld.com/2020/integrated-services. 

8. Look abroad

European services have some advantages when it comes to safety and some different ideas in general. Their vehicles feature fluorescent yellows, oranges and greens for visibility. Retroreflective patterns further stand out. The colors also recur in uniforms. 

Their ambulances also run smaller, with electronic stability control and other safety features. Interiors are minimal: flush cabinets, few protrusions, no sharp edges or exposed metal. Mounted equipment is secured with crash-tested brackets. Side-facing and bench seats aren’t used. We don’t necessarily need physicians on ambulances, but don’t be proud about stealing other good ideas. For more: www.emsworld.com/2020/rett-mobil. 

9. Groom qualified leaders

EMS services deserve a solid selection process and formalized training to cultivate leaders to guide us into the future. Tomorrow’s leaders need broad skills; they must be team players, diplomats, strategizers, technophiles, marketers and orators. Seek out those with such special qualities and place individuals into positions where they can excel. For more: www.emsworld.com/2020/professional-development. 

10. Stay EMS-fit

EMS has specific physical requirements with unique fitness needs. We require soft-tissue flexibility for safe movement of muscle groups and mobility in joints. Exercises should be specific to individual needs and carry over to job performance. Begin with a validated job-specific prehire physical abilities test to ensure capable employees. Test incumbent employees annually. Have a policy to deal with those who can no longer pass; help them work with trainers and therapists. For more: [URL TK]. 

Reference

1. Maguire BJ, Smith S. Injuries and fatalities among emergency medical technicians and paramedics in the United States. Prehosp Disaster Med, 2013 Aug; 28(4): 376-82. 

Sidebar: Expert Opinions: Safety Advances

EMS World surveyed the members of its editorial advisory board about the most important prehospital EMS safety advances of the last few years. Here are some of their responses. 

Ambulances are notoriously easy to flip, and there are still too many ways for patients and attendants to be injured during an accident. The changes in attendant seats and implementation of hydraulic stretchers and loading platforms are huge improvements, but more must be done for stability. 

—Gene Gandy, JD, LP, EMS educator/consultant

Automatic driving recording cameras really change providers’ behavior and make them drive more slowly and safely. 

—Sean Kivlehan, MD, NREMT-P, emergency medicine resident, UCSF

Research into the need for use of lights and siren, thus priority dispatching and reduced emphasis on fast responses for all calls. 

—Vince Robbins, president/CEO, MONOC (NJ)

Wider utilization and/or implimentation of termination-of-resuscitation protocols that prevent the unnecessary lights-and-sirens transport of futile patients. 

—David Wampler, PhD, LP, assistant professor, emergency health sciences, University of Texas Health Science Center at San Antonio

The NFPA 1710 ambulance design specs are goofy in many ways; however, the interior design process had a great start, involving automotive and ergonomic engineers who actually solicited and listened to the few field providers who responded. They analyzed the seating positions in the ambulance as “work stations” (what a concept!) and concluded an ambulance needs to be designed so it’s physically possible for a field provider to remain restrained in a forward-facing seat and take care of a single patient, and systems need to be designed so that happens routinely. 

—Thom Dick, quality care coordinator, Platte Valley Ambulance (Colo.)

The most important safety issue is related to transport. First, the number of emergent transports should significantly decrease as we identify patients who can and cannot benefit from saving a few minutes. Decrease in the number of air medical transports may correspond as states start to look at the issue from a safety and cost standpoint. Second, the configuration of the standard ambulance should change to a more European model with appropriate seating and recognition that treatment en route should be the exception and not the rule. 

—Ken Lavelle, MD, NREMT-P, attending physician, Thomas Jefferson University Hospital (Penn.)

The holistic advance is the acknowledgement and embrace of the requirement to develop a ‘just’ culture and an EMS culture of safety. The fact that a medic a week seems to perish or suffer injuries in a vehicle-related incident is attracting attention. That there are now devices in the market to aid safe lifting and handling of patients that make patients safer and also protect our most expensive assets—our staff—is a great step in the right direction. 

—Rob Lawrence, MCMI, COO, Richmond Ambulance Authority (Va.)

There is a growing (and hopefully sustainable) interest in preventing violence against EMTs and paramedics. The recent attention of NEMSMA on this issue is critical. When EMS managers cooperate with local law enforcement and prosecutors to ensure that violence against EMTs is taken just as seriously as violence against police, we will have made significant progress. 

—Greg Friese, NREMT-P, director of education, CentreLearn

I think the most important EMS safety changes are coming out of the “Hartford Consensus” (see www.naemt.org/education/TCCC/tccc.aspx) and tactical training for EMS providers. Training and education in tactical emergencies are essential in our new reality, and we can prioritize providers’ safety in these events and do more to save more lives in active-shooter situations. 

—Will Chapleau, RN, EMT-P, manager, ATLS program, American College of Surgeons

Sidebar: Expert Opinions: Current Priorities

EMS World surveyed the members of its editorial advisory board about the most important priorities for EMS systems moving forward toward 2020. Here are some of their responses. 

Developing a more efficient business model. Public funds are drying up, and those incapable of being efficient and running EMS like a business will suffer. Use of data and metrics at both the organizational and national levels is key to efficiency and success. 

—Rob Lawrence, MCMI, COO, Richmond Ambulance Authority (Va.)

Systems will need to look at redundancy from a cost standpoint. Some send an EMS engine, BLS ambulance and ALS squad to patients with simple issues who hardly need eight-plus personnel to respond. Systems should look at consolidation to avoid redundancy in officers and boards and improve support such as training. 

—Ken Lavelle, MD, NREMT-P, attending physician, Thomas Jefferson University Hospital (Penn.)

Dealing with diverse workers (new, senior, etc.) and how to work with them and help them work together. Measuring what matters—developing clinical and experiential measures and benchmarks that prove what we do makes a difference. Detoxing us and our communities off response-time metrics that don’t matter. 

—Matt Zavadsky, MS, EMT, director of public affairs, MedStar Mobile Healthcare (Tex.)

Reducing the level of fatigue of the workforce. This includes a continuing move from 24-hour and longer shifts to shorter shifts. It also requires a significant cultural shift for both organizations that create situations where employees must work multiple jobs and employees seeking a work/life balance. 

—Greg Friese, NREMT-P, director of education, CentreLearn

Closing the data gap. There is still no effective and universal way EMS data is collected. There is no way to measure what EMS is doing now, let alone how changes affect what’s being done. Universally EMS is guessing and not making decisions based on objective data. EMS needs to know what it is doing now if it is going to measure any change in the future. 

—Bill Toon, EdD, NREMT-P, battalion chief, training, Johnson County Med-Act (Kan.)

Emergency medical records with communication capability with receiving hospitals is huge, as well as system interoperability. This includes the ability to transmit ECGs. Although we are seeing more of this, there is still a long way to go. An ability to better mine data for research (just more complete contributing to NEMSIS and state databases). Telemedicine—the ability to do stroke assessments is one great example. I think Skyping into the the ambulance to do assessments and guide treatments is definitely in the future. GPS and integrated dispatch systems can really help with operations streamlining. 

—Sean Kivlehan, MD, NREMT-P, emergency medicine resident, UCSF

The overhaul and revamping of the existing reimbursement structure, which pays for and thus encourages transport of all patients to hospitals. Modifying reimbursement mechanisms to allow payment for appropriate treat-and-release and transportation to alternative healthcare facilities will not only save money, it will likely improve patient outcomes and reduce excessive use of the most costly part of our healthcare system, EDs and inpatient care. 

—Vince Robbins, president/CEO, MONOC (NJ)

We need to look hard at protocols and training based on prehospital science. The literature increasingly shows in most cases basic care is adequate if not preferred. We still have advanced technical solutions in search of problems to fix. 

—Will Chapleau, RN, EMT-P, manager, ATLS program, American College of Surgeons

Enhancing health and wellness programs for field providers. Providers suffer from the effects of poor health and wellness lifestyles and modifiable risk factors. The most important resource for any public safety provider is its people—let’s take better care of them. 

—Todd Leduc, CFO, CEM, assistant fire chief, Broward Sheriff Fire Rescue (Fla.)