EMS World Expo 2016 Sessions Shine Spotlight on Safety

EMS World Expo gave pointed recognition to the expanding priority of safety in EMS by providing a special, half-day program full of sessions focusing on some of the most critical, safety-centric issues within EMS.

The topics ranged from sleep health to OSHA standards to “Just Culture,” but each presentation was interconnected in a way that allowed attendees to leave with a well-rounded summary of the most important safety topics facing EMS crews today and a number of resources from across the globe with which they could address these issues.

Sleep Matters

Dr. Heather Davis, a researcher from UCLA, started things off with a presentation on the role sleep plays in a provider’s ability to function, the value an extra hour of sleep can have and the physiological response that occurs when someone isn’t getting enough shut eye.

Sleep deprivation occurs when a person sleeps for less than six hours in a 24-hour cycle or when they are awake for more than 17 hours straight. Extended sleep deprivation occurs when this daily limit on sleep happens for more than two weeks straight, at which point permanent cognitive decline can occur.

Davis argued the rather realistic idea that providers don’t always go home and go straight to sleep. Real life happens, and often it is one’s sleep cycle that suffers.

Data on the dangers of sleep deprivation is well published. The most commonly cited study compares the coordination and decision making capacity of someone that has been awake for 24 hours straight to a person with 0.10 blood alcohol content. This means that a first responder working towards the end of a 24-hour shift will have a slower reaction time, potentially impacting their safety. They will also have a decreased capacity to hold information in their working memory, meaning instead of remembering the patient’s name, age, medications and chief complaint, that provider will be lucky to remember two of those details without prompting.

Davis addressed the idea that we self-medicate head on with caffeine to keep awake during a shift and alcohol to help with sleep. Both substances, at the simplest level, interrupt sleep by resulting in an increase in urine production.

She finished her presentation by explaining the link between lack of sleep and some of the more prevalent chronic conditions affecting first responders. Mainly, the first step to losing weight is typically to get more sleep because the hormone gherlin spikes when tired, which is the hormone that drives us to eat calorie-heavy or fatty foods to stay awake.

From a long-term perspective, prolonged sleep deprivation results in a spike in norepinephrine levels, which cause glucose levels in the blood vessels to stay elevated. The blood glucose molecules then get stuck, potentially clot, and result in any number of clot-related acute illnesses. Even if someone is lucky enough to avoid a clot, they are likely to develop glucose intolerance should these elevated levels continue in the longer term.

Just Culture

Lee Varner from the Center for Patient Safety (CPS) started his talk on “Just Culture” by asking everyone in the audience to write down their own definition, knowing the answers would be diverse because no two organizations, shifts or even units within the same organization typically share the same culture.

Varner focused on the role leaders and mangers play in the development and perpetuation of an organization’s culture. If there is a punitive environment that discourages open lines of communication, or one in which leadership doesn’t prioritize safety, no one will be willing to speak up, which puts everyone at risk.

Shifting the paradigm to a just culture, one focused on safety, requires a concerted effort by everyone within the organization, which traditionally requires buy-in from those at the top before line-level providers are willing to trust the feasibility of the idea. Varner recommended walk-arounds and messaging safety to ensure leaders and managers get the exposure necessary to impact change.

In walk-arounds, senior leaders interact with employees on a daily basis. During these sessions, they spend more time listening than talking, but when they are discussing something with an employee, they do it in a way that ties in values at all levels within the organization.  

The concept of messaging safety relies on every communication tying back to the larger vision of prioritizing safety. This means any conversation, no matter how casual or serious, is somehow brought back to safety. Usually this can be done by using stories on either end of the spectrum to make a point: how something went wrong or how an employee made a great catch.

Varner observed that while many in EMS may be starting to understand the significance of safety, the concept has yet to become make it to our, missions, visions, values or anywhere else on organizational websites.

Starting from scratch can be difficult, and Varner recommended an organization interested in making an impact on safety start by measuring the culture via an anonymous survey. CPS has the only survey specifically tailored to safety culture in EMS. He finished by reminding the audience that changing the culture of an organization is a long process, it starts small, but can balloon into something of significance as leadership comes on board and is able to create buy-in across employees.

Self-Reporting

Rob Lawrence from Richmond Ambulance Authority (RAA) gave a brief overview of their self-reporting process for errors, in which providers are encouraged to speak up when mistakes are made without the fear of punitive retribution.

Employees are trained to self-report such that management can evaluate issues at all levels of the system. If necessary, this allows for a more effective solution to be developed that considers all potential causal factors.  

RAA has been using some variation of a self-reporting system for over five years. Their success suggests self-reporting of safety errors can be implemented in a way that respects the needs of the organization while also respecting the autonomy of the providers.

EMS CrossChecks

David Page, of UCLA, discussed the benefits of including checklists and cross checks in organizations. While most in healthcare are familiar with checklists since they were popularized by Atul Gawande’s Checklist Manifesto, at a generic level, cross checks are simply instances in which one person verifies the completeness and accuracy of a task performed by another person.

Using the plot line of the recent blockbuster, Sully, Mr. Page explained that even as Captain Sully was flying the airplane towards the Hudson River, his copilot was pulling out a checklist. Although the major steps Captain Sully needed to follow were relatively basic, there was no guarantee he would remember them in a time of high stress.

Checklists, when properly culled of unnecessary details, remove the onus of remembering critical details from the user. Page used the chest pain checklist by Shaugh Maxwell as an example of a well-developed application within EMS, since it has only three steps, and all have been validated by scientific evidence.

Cross checks often act in conjunction with a checklist. In EMS, a service in Australia has started asking patients to cross check their medication doses. They do this by placing an easy-to-read dosage chart in the back of the ambulance, and having the patient confirm the dose. All told, the medication cross check script takes about 26 seconds.

Page closed by providing the audience with an EMS Reference link to a number of cross checks they could download and use for free.

Creating a Behavioral Health Program

Jeff Dill of the Firefighter Behavioral Health Alliance gave an engaging presentation that resonated with every member of the audience on the importance of a strong behavioral health program. Inspired by the stories he heard post-Katrina, but frustrated by the lack of resources available specifically for first responders, Dill started advocating for mental health programs within public safety.

During his talk, Dill outlined the key components of developing a successful behavioral health program: a knowledgeable counselor, a robust peer support team, the necessary infrastructure for an employee assistance program and integration with the community at large.

Dill explained that while most counselors mean well, only a select subset have the capacity to hear and empathize with the experiences of first responders. This means they must be vetted and educated prior to working with anyone. Dill has a list of about a dozen questions he always asks a potential counselor, something he is happy to share with anyone starting one of these programs.

The peer support team is a group of trained individuals that have the maturity, communication skills and confidence to know how to interact with fellow first responders in their time of need. Although all members of the peer support team are volunteers, Dill admitted that buy-in for a behavioral health program may require hiring one employee to support the recruitment and development of the team.

Although almost all organizations have employee assistance programs they must be more than a “number on the wall” to be effective. This means ensuring guidelines and policies respect the confidentiality of the employees who access these programs while allowing them flexibility to seek help outside of the formal system, such as through faith leaders or other community organizations. This means the stronger the ties are within the community, the better it is for everyone involved.

Putting it all together

Lee Varner, who had previously discussed Just Culture, closed the session out by showing a few of the powerful videos, including Alone by Sally McCabe, that were developed at the Digital Safety Story Workshop where participants learned to use digital mediums to tell a story.  

Catherine R. Counts is a doctoral candidate in the department of Global Health Management and Policy at Tulane University School of Public Health and Tropical Medicine where she also previously earned her Master of Health Administration. Counts has research interests in domestic health care policy, quality and patient safety, organizational culture and prehospital emergency medicine. Follow her on Twitter at @CatherineCounts.