Even in the same department, EMS providers can face a higher risk of assault than firefighters. A 2016 study found paramedics in one big city 14-fold more likely to experience a patient-initiated violent injury than their fire-side colleagues1—a figure startling by its degree, if not its existence.
Now the investigators behind that discovery—from Drexel University’s Center for Firefighter Injury Research & Safety Trends (FIRST)—are leading a pair of additional projects aimed at 1) reducing and analyzing violence against fire-based EMS responders and 2) evaluating and improving organizations’ safety cultures.
In the first project, SAVER (for Stress and Violence in Fire-Based EMS Responders), four major urban fire departments (Chicago, Dallas, Philadelphia, and San Diego) will implement a systems-level checklist aimed at reducing violence. As they use it investigators will track and analyze violence against their EMS providers, looking for characteristics and correlates.
Both projects are funded through FEMA’s Assistance to Firefighters Grant program, but the SAVER program is the first AFG research award directed specifically to EMS.
“The EMS side of fire has never been considered, at least from the FEMA R&D side, even though it’s 60%–90% of what every fire department does,” says Jennifer Taylor, PhD, MPH, director of the FIRST Center and an associate professor at Drexel’s Dornsife School of Public Health. “We’re stoked about the project because we know the emotional demands of the EMS job are totally underrecognized. Such stress, combined with patient and bystander-initiated violence, makes EMS very dangerous work.”
Learning More, Allowing Less
Any look at EMS safety leads inevitably to the issue of violence, which is the core of the SAVER project. SAVER has four main parts:
Development of a checklist to address violence against fire-based EMS responders throughout each phase of emergency response;
Implementation of the checklist in the four participating departments;
Measurement and reporting of physical violence and verbal attacks; and
Analysis of dispatch data, patient care reports, and calls resulting in injury to describe community needs and identify clusters and correlations.
There isn’t good data nationally about how often EMS responders are assaulted by patients, and such attacks are often dismissed as part of the job. The idea of a checklist is to formalize organizational recognition of the problem and an intent to address it through specific training, policy, and environmental changes.
“The checklist identifies actionable things departments and unions can do to say to their EMS workers, ‘We care, we value you, and we’re going to express it in policy,’” says Taylor.
It has about 170 items, drawn initially from a review of the relevant academic and industrial literature, then vetted last summer at a two-day conference that involved more than 40 experts from fire and EMS, government, academia, and labor, including the departments that will implement it. Representatives came from the NAEMT, NAEMSP, National EMS Management Association, AMR, NHTSA’s Office of EMS, FEMA, the International Association of Fire Fighters, International Association of Fire Chiefs, and more.
While the checklist was developed for fire-based departments under grant terms, Taylor emphasizes, it will be useful for any EMS entity. It is currently in peer review for journal publication, then will be shared to EMS audiences.
The four departments will use the checklist for a year and a half, and FIRST Center researchers will assess burnout, engagement, job satisfaction, mental health outcomes (depression, PTSD, etc.), and injuries pre- and post-intervention. They’ll also look at where assaults are happening, how they relate to overall injury rates, and what we can tell about high EMS demand communities—are there correlations with certain health needs or conditions?
Information like that can help inform risk-reduction efforts and decisions about solutions like community paramedicine/mobile integrated healthcare.
“If a department is interested in models like that,” says Taylor, “then they can provide their membership the public health and social work skills to serve those community needs. That leaves providers more satisfied, because they can solve this patient’s problem and not just put them back in bed, and now they don’t have to go back there. That improves community satisfaction and reduces burnout.”
The second program the FIRST Center developed is a new safety assessment tool. FOCUS—the Fire Service Organizational Culture of Safety survey—is a validated instrument for evaluating departmental safety culture and its effect on injury, morale, engagement, and burnout. It’s already been administered in more than 400 fire departments, and FIRST Center researchers want to give it to 1,000 more.
The FOCUS survey provides objective data for participating departments to better understand their safety climate.
In development since 2012, it began with the collection of qualitative data. Investigators visited fire departments around the nation to talk about safety culture and what providers saw as important. That yielded an initial list of some 400 items to inform the survey, and these were beta-tested across 132 randomly selected departments and more than 10,000 providers. With the results, Taylor says, “two factors emerged that were emblematic of fire and rescue service safety climate.”
The resulting survey provides departments an overall score consisting of two components: management commitment and supervisor support. The first evaluates top leadership: How do they support and reward safety? How do frontline providers perceive their efforts? The second zooms down to the station level: How do the officers and direct supervisors who give daily orders practice safety?
A surprising early finding is a difference in the perceptions of those groups’ support for safety.
“Supervisor support across the nation has been rated 10 points higher on average than management commitment to safety,” says Taylor. “What the fire service is telling us—more than 35,000 firefighters at this point—is that supervisors are doing a good job, but leadership has some opportunity for improvement.”
Such results have already informed concrete policy changes. In one example, members of a department in Georgia had been seeking clean cabs that protected them from exposure to combustion products following fire scenes. Converting to those can be difficult, requiring changes to equipment storage processes and capabilities. But when the department’s FOCUS assessment revealed a lower score for management commitment than supervisor support, leaders responded by providing the clean cabs.
“That’s where we want to move the needle,” says Taylor. “We want to get management committed to becoming more engaged and more communicative with the rank and file about what they’re doing for their safety.”
EMS and Burnout
Another insight from the 400 departments that have utilized FOCUS so far: Running EMS calls contributes more to burnout than running fire calls.
In the FIRST Center’s home base of Philadelphia, the fire department’s 50 ALS ambulances run around 1,000 calls a day. “We run the system on the backs of the workers here,” Taylor says, “so you can imagine what their burnout looks like. You can imagine their perceptions of management’s commitment to safety if they’re running that hard. Who’s concerned for their safety if they’re doing 30 runs a day?”
Engagement is also lower on the EMS side of the job. That may relate to EMS’ traditional “stepchild” status in some combined departments, as manifested in things like hiring and promotion practices, equipment investments, and overall prioritization of mission.
“That [fire-first] paradigm hasn’t totally changed, and we don’t always put the resources where they need to be,” Taylor says. “There are no national standards for, say, how many EMTs we should have per 100,000 population or per 10,000 runs, because those standards don’t exist. And so we don’t staff appropriately. There are standards for things like firehouse and fireplug locations, but there’s nothing for paramedics or EMTs. We need to change that, and that’s an area where we think these data will be helpful.”
Participating departments will receive a customized analysis describing their safety culture at the departmental and station levels; a comparative analysis of their safety culture to similar departments’; evidence to inform safety-related policy decisions; and a trip for two members to FOCUS Culture Camp, a two-day training event covering safety culture, the FOCUS survey, and how to interpret its results.
“That will let them get really down and dirty with their data,” says Taylor. “They’ll learn about theory and meet with scientists and the team from the FIRST Center, and we’ll help them get really competent at talking about the data in their report so they can go back and take it to others. Our goal is to get the data to the fire service first, before making decisions, before anyone says to a city council, ‘This is what we need.’ Where’s the data to back that up? We’re creating that data so departments can have objective information before asking for resources or making policy.”
FIRST Center researchers have done a lot more work in this area; find that on the center’s publications page. Meanwhile, EMS providers in both fire-based systems and others can take heart in what they’ve discovered about violence, safety, injury, and stress in EMS and how they’ll target future research.
Says Taylor: “EMS providers should know we hear them and we’re coming. We think FEMA understands now too, as do all the organizations on our advisory board and people who participated in our conference. People will say, ‘That’s what you signed up for—you knew it was a violent job.’ No, no, no! No one signed up for this job because they thought they’d have to be Jean-Claude Van Damme. They didn’t know, and we haven’t helped them.
“When you go through the academy, when you go to paramedic school, you get about 10 seconds of, ‘People are crazy, be careful.’ That is not a prevention strategy that gives people the proper protection they need for the job. That protection actually comes in the form of policy and training: de-escalation training, cultural competency training, evasive self-defense. We don’t have that, and so these are the kinds of things we developed in this checklist.”
1. Taylor JA, Barnes B, Davis AL, Wright J, Widman S, LeVasseur M. Expecting the unexpected: A mixed methods study of violence to EMS responders in an urban fire department. Am J Ind Med, 2016 Jan 4; https://onlinelibrary.wiley.com/doi/full/10.1002/ajim.22550.
John Erich is senior editor of EMS World. Reach him at email@example.com.