The purpose of this study is to show the challenges emergency medical services (EMS) face while maintaining the safety of themselves and their patients. The study attempts to answer the research question, What factors are influencing their current level of service? This literature review will examine the various impacts, including staffing, budget constraints, response time, and fatigue have on EMS personnel.
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Emergency Medical Services (EMS) has been an integral part of our society by being the first ones to respond to emergent calls. They are a vital part of the communities as a vital link between life and death. They are a multi-faceted company with the same issues plaguing them year after year: staffing, budget constraints, response times, and being fatigued. These issues are complex because they are unable to be solved even many years later and it is a strain on the employees leading to high turnover rates. No single agency is able to solve this ongoing issue since it involves multiple disciplines to look at the broader picture and find the root cause of the same problems and once that is found then they can begin to fix it.
This literature review will discuss the factors affecting EMS as stated above and will further show that more research is required in order to effectively change the way they operate for the better instead of remaining in the same vicious cycle especially since technology and advancements are being made in the medical world.
Review of Literature
Emergency Medical Service (EMS) departments encounter various obstacles that are both challenging and complex. For instance, retaining employees has always been a struggle for EMS leading them to have a high turnover rate and becoming short staffed due to low wages, forceable overtime, lack of advancement, and low morale. Often times, administrators will overlook the problems and simply fix it with temporary solutions which end up having a negative effect on their level of service. Patterson, et al. (2010) conducted a study of the annual turnover rate to reflect the multiple staff categories: paid, volunteer, and a combination of both and found that the volunteers led the turnovers with 12.4%, followed by the paid/volunteer at 12.3%, and the paid medics/emts had a rate of 10.2% overall. However, the cost of these turnovers across the board came to $86,452.05 due to conditions from being understaffed. These statistics are staggering considering that EMS plays such a vital role in the community by saving lives on a daily basis. Blau, et al. (2016) found that even though retention was a problem in EMS, that EMT’s and Paramedics were less likely to leave the profession due to their overall satisfaction with the job. This differs from the previous study since the reasons for leaving were not due to lack of pay, etc. but because individuals were choosing to get a higher education along with moving to various locations in order to advance their career.
According to the Bureau of Labor Statistics (BLS; Washington, DC USA) projection, paramedics and emergency medical technicians are expected to rise by 15% from 2016-2026, which is high considering the rate of turnovers. In another study, Dover spike surveyed over several hundred organizations in various parts of the country and found that there is currently a 25% turnover rate for full time EMT’s and a 24% turnover rate for full time paramedics. This raises the question as to why EMS continues to have such high turnover rates in which Lawton has theorized that, “We (in EMS) don’t do a wonderful job at communicating and providing fairness in the organization. We can do a better job at performance management, which can have an impact on reducing turnover.” (Friese, 2018). Therefore, the research shows that additional studies are needed to explain the reasons for high turnovers and how researchers could learn from them.
Financial issues have often been the root cause that EMS agencies face on a daily basis since it directly impacts everything from labor costs to operations which is due to the lack of federal funding at the local level. This is evident in Pinellas County where officials wanted to shed $2.3 million from funding over a three-year period. The implications of reducing the budget would lead to less medics on the road and increase response times which ultimately puts citizens at a higher risk. However, Moeller who is the executive director of safety and emergency services insists that such budget cuts can be made without impacting the time it takes to respond to a call. (O’Donnell, 2014)
Unfortunately, they do not have a reliable source of funding since revenue for these organizations are usually generated through grants, insurance billing, and tax subsidies. In addition, they use these funds for fuel, dispatch, supplies, maintenance of the ambulances, and infrastructure. Often when an ambulance transports, they get reimbursed from the insurance company based on the criteria met: “type of response (emergency or nonemergency), level of service provided (ALS or BLS), distance patient is transported, and the location of the patient (rural vs. urban). (Washko, 2015) This is important because often times they are not properly reimbursed, and this leads to failures in the system.
In public safety, EMS ambulances are expected to respond to calls within eight minutes or less from the time they are dispatched until they arrive on scene. Pons (2002) found that patients who were not in cardiac arrest due to an injury had a better chance at survival if CPR was begun within the first four minutes and defibrillation provided in eight minutes. However, if an ambulance was to exceed the allocated response time then it would diminish the patient’s overall survival especially if they suffered traumatic injuries. In addition, the Denver Health Medical Center conducted their own study and found that paramedics in the < 8 mins group spent more time on scene and had shorter turnaround times but found no differences in the percentage of patients who were transported using lights and sirens. In the ISS group, ambulances who had a response time of > 8 minutes patients had to undergo endotracheal intubation; whereas; the ISS group III, ambulances who had a response time of over eight minutes patients had a better survival rate. Overall, this study showed that there was no effect on trauma patients and their survival based on ambulance <8 minute response times and that other factors can affect what happens to the patient.
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Some tenets in EMS believe that by responding to a call faster it would lead to better outcomes for the patient and that is why they implemented the ALS system of eight minutes or less to respond to a call. Blanchard, et al. (2013) studied whether longer response times increased patient mortality in an ALS EMS system in a large city. They found that there were no key differences between the patients who had response times less than eight minutes compared to those who had a higher response time. The mortality rate for patients who had a longer response rate was 7.1% compared to the 6.4% of those who had an ambulance respond in less than eight minutes. While further research is needed to highlight the response system in order to define who benefits from an emergency response, there are certain expectations to be upheld by paramedics to provide the fastest service to the citizens of the community.
A typical work day consists of an 8-hour shift, five days a week for regular people. In EMS, they work 24 hour shifts with 48 hours off but that is not always the case. There are times when employees are drafted or on overtime and end up working 48 hours with only 24 hours off. Research has shown that employees who work extended hours are at an increased risk for fatigue, potential medical errors, and injuries by 60% (Weaver, et al. 2015) In addition, Weaver, et al. suggests that those who are most at risk for being severely fatigued are employees who work 24-hour shifts, and they are at a 9% risk for vehicle crashes driving to and from work than those who work 12-hour shifts or less. Paramedics and emergency medical technicians who are sleep deprived during their shift would have a tough time processing information needed to take care of a patient since there is a correlation between intoxication and being awake for an extended amount of time. This study concludes that interventions are needed to reduce the risk of fatigue amongst the employees.
To many, napping on the job is frowned upon because one should not be sleeping while conducting their work. However, in EMS it can be beneficial if paramedics and emergency medical technicians could catch a quick nap so that they are alert and ready to tackle the next batch of calls. According to Martin-Gill, et al. 2018, the benefits of allowing naps while on the job could increase the safety and performance of the employees and the public in which they serve. Unfortunately, in the EMS environment trying to schedule a nap would be difficult since they never know when the tones will go off for them to head to an emergency. Further research is needed to improve the overall health and safety of paramedics and emergency medical technicians and the benefits napping might have to correct the issue of being fatigued.
In conclusion, the sources that I found that would be the most helpful for my project were “The Longitudinal Study of Turnover and the Cost of Turnover in EMS,” “Why do Emergency Medical Services (EMS) professionals leave EMS?” and “Understanding Why EMS Systems Fail” since they were the most informative and reflected the overall issues affecting EMS. The information I gathered from reviewing the literature is that nothing has changed over the years with regards to budget problems, staffing, the fatigue, and response times but rather put on the back burner. The gap in the research is that there is not enough research in the field of EMS to make the necessary improvements and that by applying an interdisciplinary approach with multiple disciplines then EMS might have a chance at becoming a well known entity and not just viewed as a “glorified” taxi service since they do save lives and are the lifeline between you and the hospital.
- Patterson, P. Daniel et al. “The Longitudinal Study of Turnover and the Cost of Turnover in EMS.” Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors 14.2 (2010): 209–221. PMC. Web. 12 Oct. 2018.
- Friese, Greg. “AAA Study Sets a Benchmark for Turnover in the EMS Industry.” EMS1, Praetorian Digital, 18 July 2018, https://www.ems1.com/ems-management/articles/387159048-AAA-study-sets-a-benchmark-for-turnover-in-the-EMS-industry/
- Blau G, Chapman SA. Why do Emergency Medical Services (EMS) professionals leave EMS? Prehosp Disaster Med. 2016;31(Suppl. 1):s105-s111.
- Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, EMTs and Paramedics,
- on the Internet at https://www.bls.gov/ooh/healthcare/emts-and-paramedics.htm
- O’Donnell, Christopher. “Florida County Considers Cutting EMS Funding,” JEMS, Pennwell Corporation, 31 January 2014, https://www.jems.com/articles/2014/01/florida-county-considers-cutting-ems-fun.html
- Washko, Jonathan. “Understanding Why EMS Systems Fail,” JEMS, Pennwell Corporation, 26 January 2015, https://www.jems.com/articles/print/volume-40/issue-2/administration-and-leadership/understanding-why-ems-systems-fail.html
- Pons, Peter. Journal of Emergency Medicine Volume: 23 Issue 1 (2002)
- Ian E. Blanchard, Christopher J. Doig, Brent E. Hagel, Andrew R. Anton, David A. Zygun, John B. Kortbeek, D. Gregory Powell, Tyler S. Williamson, Gordon H. Fick & Grant D. Innes (2012) Emergency Medical Services Response Time and Mortality in an Urban Setting, Prehospital Emergency Care, 16:1, 142-151, DOI: 10.3109/10903127.2011.614046
- Weaver, Matthew D.; Patterson, P. Daniel; Fabio, Anthony; Moore, Charity G.; Freiberg, Matthew S.; Songer, Thomas J.. American Journal of Industrial Medicine, December 2015, Vol. 58 Issue: Number 12 p1270-1277, 8p
- Christian Martin-Gill, Laura K. Barger, Charity G. Moore, J. Stephen Higgins, Ellen M. Teasley, Patricia M. Weiss, Joseph P. Condle, Katharyn L. Flickinger, Patrick J. Coppler, Denisse J. Sequeira, Ayushi A. Divecha, Margaret E. Matthews, Eddy S. Lang & P. Daniel Patterson (2018) Effects of Napping During Shift Work on Sleepiness and Performance in Emergency Medical Services Personnel and Similar Shift Workers: A Systematic Review and Meta-Analysis, Prehospital Emergency Care, 22:sup1, 47-57, DOI: 10.1080/10903127.2017.1376136
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