Exceptionally high rates of occupational fatality and injury rates among paramedicine clinicians indicates EMS-specific risk reduction research — including PPE-related research and system funding — are desperately needed.
Personal protective equipment (PPE) is used to minimize exposure to hazards and to reduce occupational risks. Despite the use of PPE by paramedicine clinicians in emergency medical services (EMS) systems, exposures and risks remain high. Targeted research is needed to determine where PPE use and access is failing, but this research will not by itself be sufficient. Fundamental EMS system reforms are also needed to support research efforts and to ultimately reduce risks based on research findings.
In recognition of the urgent need for new efforts to address PPE needs, the National Academies of Sciences (NAS) convened a virtual meeting of the Standing Committee on Personal Protective Equipment for Workplace Safety and Health to discuss plans and needs for a NIOSH Public Safety Sector PPE Action Plan.1 The August 9, 2021, meeting focused on identifying the PPE needs of first responders, including police, firefighters and emergency medical services (EMS) personnel.
In this article we: expand on some of the EMS-related PPE issues that were raised during that meeting; describe reasons why targeted research is needed to identify and evaluate the EMS profession’s unique PPE requirements; and describe PPE needs within the context of EMS system needs, including the influence of federal policies.
The approximately one million EMS professionals in the United States (U.S.), referred to in this article as paramedicine clinicians, include emergency medical technicians (EMT) and paramedics. These clinicians respond to 40 million calls for assistance each year.2,3 They are a vital workforce and, as seen in Figure 1, their responsibilities contribute significantly to the healthcare, public health, disaster operations and public safety sectors in the U.S.4
Despite these contributions, EMS in the U.S. is severely underfunded with some EMS agencies “holding their ambulances together with duct tape”5 or “relying on bake sales.”6 Rural ambulance services are struggling to stay open.7 One of the outcomes of underfunding is the salaries that are paid to paramedicine clinicians. Relative to other professionals who provide vital services to the citizens of the U.S., paramedicine clinicians are not adequately compensated for their services. They are often paid half of what a firefighter, police officer or nurse is paid annually.4 This poor compensation is based in large part on federal policies that result in insurance reimbursement that is far below the cost of providing professional EMS services. This problem is exacerbated by a belief, by many state and local jurisdictions, that per-transport insurance reimbursement should be the sole means of funding for EMS. Largely as a result of this insufficient funding, and the resulting poor wages, the turnover rate for paramedicine professionals in the U.S. is 24% per year.8,9
More from the Authors
- Occupational Fatalities Among EMS Clinicians and Firefighters in the New York City Fire Department; January to August 2020
- Paramedicine Strategic Planning
- The Ethics of PPE and EMS in the COVID-19 Era
- COVID-19: Urgent EMS Issues
This state of the EMS profession is not universal. In other developed countries such as Australia, paramedics are highly respected,10 and are paid more than nurses, police and firefighters.4,11-14 In the United Kingdom (UK), paramedics are also paid more than nurses.4 Compared to the 24% annual attrition rate of paramedics in the U.S.,9 the annual attrition rate for paramedics is 9% in the UK,15 and 2.7% in Australia.16
Furthermore, this inadequate system of funding also impacts EMS agencies’ ability to provide adequate PPE. This lack of funding was most apparent during COVID when agencies with no budget reserves struggled to provide the proper PPE precautions required to protect themselves and their patients from harm.6
EMS is a dangerous occupation. In Australia, no occupational group has a higher injury or fatality rate than paramedics.17 In the U.S., paramedicine clinicians have very high rates of both occupational injuries and fatalities. Figure 2 shows that for non-fatal occupational injuries, the paramedicine clinicians’ risks is about six times higher than the U.S. national average for all workers, and far above the rates for police and firefighters.18
About 75% of the occupational fatalities among paramedicine clinicians each year in the U.S. are transportation related, and almost 10% are homicides.19 Figure 3 illustrates that paramedicine clinicians have an occupational fatality rate that is far above the national average for all workers, with rates comparable to police and firefighters.19
Paramedicine clinicians face a host of risks in variable and changing arenas of practice. Many of these risks could potentially be mitigated by providing appropriate evidence-based PPE equipment and training. Paramedicine clinicians need:
- PPE to reduce the risks of transportation-related injuries and fatalities for both ambulance occupants and for clinicians caring for patients on the side of highways. Transportation-related incidents cause the most occupational fatalities,19 and result in very severe occupational injuries for these clinicians.20
- PPE that is temperature tolerant and sun protective, decreasing the wearer’s risk of heat or cold related injury; thus, improving the clinician’s personal safety and ability to perform necessary tasks when exposed to extreme temperatures.
- PPE that will offer protection from exposure to commonplace, novel and weaponized biological and non-biological contaminants.
- PPE that will offer protection around bodies of water, including personal flotation and anchoring devices.
- PPE that will offer protection in industrial areas and confined spaces, including hearing protection and head, eye, hand, knee and foot protection.
- PPE to mitigate the risks of back injuries. Although a quarter of paramedicine non-fatal injuries are back injuries,18 and PPE is available (e.g., slide boards, ergonomic lifting devises, back braces) evaluation of the effectiveness of back injury prevention efforts is limited. Common EMS tasks have never had the “Revised NIOSH Lifting Equation” analysis applied to determine the safe values and work practices.21
- Proper PPE fitting, as well as training on proper donning, doffing, PPE storage and care, including refresher training.
- Access to single-use NIOSH approved respirators.22
- Systems to maintain and clean (or replace) the PPE as well as systems (and resources) to provide initial and on-going training for the clinicians to be proficient in the use of the PPE.
PPE in the EMS Environment
The environment where the PPE is used also requires consideration. Very little is known about how currently used PPE performs in the EMS environment as it relates to reducing risks for the clinicians and their patients. As an example, urgent attention needs to be given to paramedicine clinicians’ exposure risks to airborne etiological agents in the enclosed space of an ambulance patient-treatment compartment. Protocols for testing ambulance ventilation systems are needed to assess air exchange and filtration of those airborne agents in an enclosed space (especially when the crew is administering aerosol generating treatment or procedures). PPE needs, including face masks, face shields and respirators need to be clarified for use under those conditions. Furthermore, consistent and thorough ambulance decontamination is needed. Emergency vehicles have been shown to be disease vectors.23,24 Dedicated infection control teams should perform ambulance decontamination.25,26 Paramedicine clinicians should not be mopping and decontaminating ambulances for the same reasons that nurses should not be mopping and decontaminating patient hospital rooms; specially trained teams should be cleaning, stocking and maintaining ambulances. Decontamination-specific research is needed because some research indicates that the current standards for decontamination of ambulances may not be sufficient to reduce the levels of contamination.27-29
Furthermore, a lack of adequate PPE for paramedicine clinicians, and contaminated ambulances, could be putting their patients (and the patients’ family members) at increased risk of exposure and possible infection.30 EMS personnel transporting patients in and out of nursing homes, and to and from any department in a hospital, could contribute to increasing the spread of disease between locations, and to subsequent EMS patients. Emergency medical vehicles have been shown to be potential disease vectors.23,24 Research is needed to document the number of family members of paramedicine clinicians who became ill or died as a result of being infected by a paramedicine clinician who was likely infected at work.
PPE and COVID-19
Paramedicine clinicians are at risk when they enter homes or premises where the risk of contagious disease is unknown. The COVID-19 pandemic provided a glimpse into the paramedicine clinicians’ risks of contracting illnesses while working. Paramedicine clinicians had a high rate of contracting COVID-19 and, as seen in Figure 4, had a COVID-related fatality rate far above the rates for other emergency services and health care personnel.31 Compounding the risks during much of the pandemic was the large increases in call volume,32 and shortages of PPE that resulted in many EMS agencies and paramedicine clinicians having insufficient supplies of N95 masks and other critical PPE supplies.33
During the COVID-19 pandemic, the PPE supplied to EMS services was the same PPE used in hospitals. Polypropylene/cellulose N95 masks were designed to be single use, single-patient, indoor devices. Instead, paramedicine clinicians had to wear the N95s in every type of weather condition, for the entirety of 12-, 16-, or 24-hour shifts, and for multiple patient encounters. Many clinicians had to reuse the N95s for days at a time.34 These conditions may have led to spreading the infection to other paramedicine clinicians and patients.
PPE and Violence-Related Injuries
Figure 5 shows that the violence-related injury rate for paramedicine clinicians is about 30 times higher than the national average;18 it is also about 30 times higher than the rate for firefighters.35 Although little is known about how PPE might mitigate this risk, body armor (ballistic protection), stab-proof vests or body-cams could conceivably reduce the risks of violence-related injury. Some EMS agencies in the U.S., England and Australia are using body-cams as a way to try to reduce the risks of assault injuries among paramedicine clinicians.36-38
It is also important to determine if PPE needs differ between male and female paramedicine clinicians. Research has shown that female paramedics may have a much higher rate of injuries compared to male paramedics.39 At present, any reasons for these differences are unknown. The differences in risks may mean that gender-specific PPE is necessary among paramedicine clinicians.
Studies of current PPE practices and protocols are also needed to ensure evidence-based practices are being utilized. For example, anecdotal evidence suggests that some EMS agencies engage in the practice of placing a few shared sets of PPE on board ambulances, instead of providing individually-fitted PPE to each member of the service. This practice may be dangerous in that ill-fitting PPE may not function properly; in addition, the shared apparel may serve as a vector for passing hazardous contaminants (e.g., organisms) between the shared users. Consistent availability of PPE is required, as is quality assurance programs to ensure appropriate PPE is used when required.
Training and Compliance
There has been a paucity of research about the factors that may influence compliance with the use of PPE by paramedicine clinicians. However, it seems likely that lack of funding to support ongoing education and training is a factor. EMS agencies are “holding their ambulances together with duct tape”5 and do not have the resources to conduct and support necessary PPE training. Training needs include both initial training for new hires and for new equipment, as well as continuing or periodic training aimed at developing and maintaining competencies.
For example, during the Ebola outbreak health care workers were exposed to the virus when doffing their PPE.40 This resulted in the implementation of teams to assist with doffing of PPE to reduce exposures. EMS providers need the resources (including training), to comply with the proper procedures to doff PPE, in order to reduce contamination. Table 1 lists several urgent questions that must be addressed:
|1||Does current PPE reduce risks for paramedicine clinicians and their patients?|
|2||Does some current PPE put paramedicine clinicians at increased risk? For example, does body armor that was developed for other professions increase risks, or provide adequate safety, for paramedicine clinicians; and does infectious disease PPE provide adequate protection or increase risks for both paramedicine clinicians and their patients?|
|3||What can be done to assure adequate PPE (i.e., individually issued, properly fitted, and hazard-appropriate), is available for paramedicine clinicians at all times? For example, during the COVID pandemic, there was a lack of appropriate PPE, no dedicated supply chain for PPE, and OSHA respirator regulations were largely unachievable.|
|4||Is the PPE that is currently used by EMS services adequate for the EMS environment?|
|5||Although OSHA has training requirements for emergency medical services,41 are they adequate and are EMS agencies capable of implementing them?42|
|6||Are current Association for Professionals in Infection Control (APIC) recommendations for prehospital decontamination adequate? Does wiping down an ambulance adequately disinfect the ambulance or is higher level disinfection, for example, using UVC light or hydrogen peroxide mist required?|
|7||Can we continue to ask paramedicine clinicians to protect themselves with PPE when our system will not protect them if they are injured on the job when they wear it? This question is vitally important because today, in typical communities across the U.S., if a police officer, firefighter and paramedic suit up with the same PPE, and enter the same incident zone, and all three receive career-ending injuries, the police officer and firefighter will receive three-quarters pay and health insurance for life. The paramedic will be terminated and will not receive those benefits.|
Federal Policies Contribute to the Infectious Disease Risks for Paramedicine Clinicians and Their Patients
The EMS system in the U.S. is heavily reliant on federal funding and is also impacted by the downstream effects of federal policies. Current federal policies have contributed to the risks for paramedicine clinicians and their patients in significant ways.
Medicare reimbursement, by itself, is too low to support a professional EMS system.43 Medicare is structured to pay the isolated per-transport cost of the paramedicine system without providing for true system costs that include training, research disaster preparedness and other overhead costs; local and county governments have often refused to cover those costs, leaving the system significantly underfunded.43 Compounding the problem is that both Medicare and Medicaid cover only a third of EMS costs7 and have generally not kept pace with the cost of providing EMS care in many states, forcing paramedicine systems to lose hundreds of dollars for each transported patient. Other insurance issues, such as bans on balance billing for emergency medical care,44 further reduces funding to support paramedicine systems.
The federal policy that, until the pandemic, limited reimbursement to those instances where an ambulance transported a patient to a hospital, created a condition where paramedicine clinicians were uncompensated for treating a patient at home and not transporting to the hospital. This policy effectively prohibited paramedicine clinicians from participating in injury-prevention initiatives, advancing their capabilities to treat patients at home and refer them for follow-up care, and from preparing for the pandemic. There is growing recognition of the value of having paramedicine clinicians provide at home care instead of bringing every frail older patient to a busy emergency department.45,46
The Occupational Health & Safety Administration (OSHA) has a well-recognized standard that respirators need to be used when there is a chance of a respiratory threat. However, during COVID, OSHA allowed the re-use of respirators.47 Further, anecdotal evidence suggests that many EMS agencies may be incapable of following OSHA standards due to insufficient funding.
The CDC Guidance for First Responders, including paramedicine clinicians, did not comport with the existing body of research regarding either personal protection or vehicle decontamination. CDC recommendations have historically focused on the optional performance of PPE rather than incorporating additional protection factors like OSHA does. This was also seen during the Ebola Virus Disease (EVD) outbreak where a nurse caring for an EVD patient was infected due to inadequate PPE recommendations.48
The federal government has programs to track risks for police officers,49 and firefighters.50 The federal program for police officers states it is to help “keep law enforcement officers safe;” its goal is to “provide relevant, high quality, potentially lifesaving information.” Paramedicine clinicians have occupational fatality rates comparable to police and firefighters19 and occupational injury rates far above the rates for police officers and firefighters,18 yet there are no federal programs to track fatalities or injuries for EMS. In order to improve EMS safety, a national system is needed to track EMS injuries, fatalities and extraordinary events such as ambulance crashes, assaults on clinicians and events such as pandemic-related adverse health outcomes. Some police departments and some fire departments provide EMS services. In order to determine true EMS risks, any system of tracking risks should track risks by the duty performed and not by the agency type.
In a 2007 report by the Institute of Medicine, the Institute president noted: “The more secure and stable our emergency care system is, the better prepared we will be to handle any possible outbreak.”51 Almost fifteen years later, our EMS system was unprepared for the COVID outbreak in large part because federal policies have prevented the EMS system from becoming secure and stable.
Although beyond the scope of this paper, it is likely that the “ideal” EMS system funding model will be a combination of per-call (as opposed to per-transport) reimbursement funds from Medicare and other health insurers, coupled with stable annual funding from state/local sources. The stable funding component might look much like the typical models used to fund police, fire services, and other public-health services. The stable funding would help cover costs including PPE and other training, professional salaries and developing and maintaining EMS surge capacity.
The policies described above are evidence of how current federal policies directly contribute to the infectious disease risks for paramedicine clinicians and their patients.
EMS Targeted Research Is Needed
One of the reasons that paramedicine clinicians have such high risks is due to the paucity of research that has been done to examine and document those risks, including research on how PPE might reduce the paramedic’s risk of contracting infectious diseases from their patients. A completely inadequate amount of research funding8,52 has meant that few paramedicine clinicians in the U.S. have pursued research degrees. When research funding is made available for paramedicine research but goes to non-paramedicine research groups, the money does not support the development of a sustainable EMS research infrastructure. As a result, Australia now has 30 times more the per-capita number of paramedic PhDs than the United States. Paramedic PhDs are a critical ingredient for the development of the profession. Therefore, any funds that are made available for this research should be earmarked to go to paramedicine researchers.
There have been previous funding mechanisms that were earmarked for fire departments and EMS. For example, the FEMA “Assistance to Firefighters Grants Program” “funds critically needed resources to equip and train emergency personnel, enhance efficiencies and support community resilience.”53 Money goes to both fire and EMS. Regrettably, those funds went largely to benefit fire services with “no more than two percent” going to stand-alone EMS agencies.54 Further, although firefighters deserve great respect, the research has clearly shown that firefighters and paramedicine clinicians have very different skills and jobs, and very different risks. Funding is desperately needed to focus on EMS risks, and risk prevention for paramedicine clinicians.
Although research on the PPE needs of EMS is necessary, it must be recognized that PPE is the least effective mechanism to reduce occupational risks.55 Beyond PPE, research is needed to determine other ways to reduce risks for paramedicine clinicians. For example, research to reduce EMS transportation risks should include investigations of turnout and reflective apparel, as well as vehicle design, driver warning devices, and speed mitigation devices. Investigators should look at how changes in dispatch or driving policies might reduce risks. Researchers might also evaluate the effect of legislation that addresses approaching stopped emergency vehicles.
In addition to funding for research, the pandemic has demonstrated the urgent need for fundamental EMS funding reform. There is little point in announcing new safety initiatives if EMS agencies do not have the funding to buy, maintain and replace equipment, or to train clinicians, or ensure proper practices in the field. The same new EMS funding mechanisms to ensure safety could also fund system improvement that expands the role of paramedicine clinicians to include prevention and community health. An early example of this expanded role is a paramedic-driven pilot program that reduced the pediatric drowning rate in a county by 50%.56 When the paramedicine clinicians recognized that they were responding to a high number of drownings, they took it upon themselves to focus on preventative measures. Today, the EMS system in the U.S. must move beyond being a reactive resource and begin to develop more proactive capabilities including injury prevention, community care and preparedness for events such as the next pandemic. Federal, state and local financing must be fundamentally restructured in order to both reduce risks and to create a 21st century paramedicine system in the U.S.
The approximately one million paramedicine clinicians in the U.S. have very high rates of occupational injury and fatality. These risks have been largely unstudied with little research on interventions to reduce these risks. The pandemic exacerbated these risks as paramedicine clinicians became exposed to, were sickened by, and died of COVID-19 at alarmingly high rates. A large part of the reason for these high rates was inadequate PPE resources, training and research.
EMS-specific risk reduction research, including PPE-related research, is desperately needed to reduce these exceptionally high rates of paramedicine occupational fatality and injury rates. Paramedicine clinicians are an underserved population in critical need of support.
Likely as a result of high injury rates, and very low pay, about a quarter of paramedicine clinicians leave the profession every year.9 This is loss of highly skilled professionals impacts EMS operations, safety and patient care.
Federal policies that resulted in inadequate system funding contributed to the higher risks for paramedicine clinicians. A fundamental restructuring of EMS system financing at the federal, state and local levels is necessary to allow for needed research to reduce provider risks, maintain paramedicine clinicians and support EMS operations.
The same funding that will support comprehensive efforts of risk reduction, will also support a fundamental restructuring of the EMS system. In order for the U.S. to have 21st century health care, public health, disaster management and public safety systems, paramedicine must be recognized and supported to not only transport critically injured and ill patients to hospitals, but also to bring high-quality health care to citizens in their homes and offices, where they work, play and travel, in our cities and in small towns across America.
Acknowledgements: The authors wish to express our thanks to NAS for convening the PPE hearing, to NIOSH for their work on the Public Safety PPE Action Plan, and to both for their continued efforts to address these urgent needs.
Funding: There was no funding for this project.
Disclaimer: The views expressed in this journal article reflect the results of research conducted by the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.
Conflict of interest: The authors report no conflicts of interest.
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