National Registry of Emergency Medical Technicians

During out-of-hospital cardiac arrest (OHCA), initial airway device choice as well as final device choice in the event of failure may both influence overall procedural success and patient outcomes. Understanding national practice patterns in airway device placement may inform resuscitation strategies and system-level quality improvement. To assess patterns in the order of advanced airway device use for adults in the United States receiving OHCA treatment during emergency medical service (EMS) activations. This retrospective cross-sectional study used data from the National EMS Information System (NEMSIS) database from January 2018 to December 2023. During this period, NEMSIS included more than 256 million EMS activations from nearly 14 000 agencies across 54 states and territories. Activations for 911 responses during adult OHCA with advanced airway device attempts after EMS arrival, with documented success (yes or no) and number of attempts, were included. Advanced airway devices documented by EMS clinicians. Order of advanced airway device use, measured by EMS clinician documentation. From 2018 to 2023, EMS reported 2 365 224 activations involving adults having an OHCA, with 650 440 patients (0.3%) receiving either endotracheal intubation (ETI) and/or supraglottic airway (SGA). Most patients received a successful initial airway device attempt (503 774 [77.4%]). Although ETI was the most common initial airway device (458 546 [70.5%]), SGA had a higher first-pass success rate (93.0% vs 71.0%). Among patients whose first ETI attempt failed (133 177 of 458 546 [29.0%]), the final documented device remained ETI in 72 167 cases (72.3%) and changed to SGA in 27 651 (27.7%). Among patients whose first SGA attempt failed, 13 480 (61.9%) remained with SGA and 3388 (38.1%) were switched to ETI. In this cross-sectional study, most patients with OHCA received ETI as the first advanced airway procedure, despite higher SGA first-pass success. Among patients whose initial attempt failed, most continued with the same device. However, switching from ETI to SGA had a higher final success rates. These findings highlight the importance of airway device sequence in prehospital care and may inform training and protocols for airway management.

Background: Exhaled end-tidal (EtCO 2 ) is widely measured and may indicate the quality of ventilation in out-of-hospital cardiac arrest (OHCA). While EtCO 2 is reliably used after advanced airway placement, it is unknown if bag-valve-mask (BVM) EtCO 2 is similarly measurable and reliable. We sought to determine EtCO 2 differences between BVM and advanced airways during resuscitation from OHCA. Methods: We performed a secondary analysis of data from the Pragmatic Airway Resuscitation Trial (PART), which tested endotracheal intubation or laryngeal tube strategies in OHCA resuscitation. Using previously validated automated signal processing, we identified maximal EtCO 2 values for each ventilation then summarized them into in one-minute(min) epochs. We included all cases with ≥1min EtCO 2 during BVM ventilation. We described BVM EtCO 2 values through medians with interquartile ranges (IQR). We performed a sub-analysis of cases with up to 4min EtCO 2 around advanced airway placement time (2 minutes before and 2 minutes after advanced airway. Using fixed effects models, we compared EtCO 2 during BVM ventilation with values immediately after advanced airway placement. Results: Of the 3004 enrolled in PART, 450 had EtCO 2 recorded during BVM ventilations. A total of 27351 EtCO 2 minutes were captured through PART (advanced airway: 24309min; BVM: 2422min). On average each case had 3 min (IQR: 1-6 min) BVM EtCO 2 recording. EtCO 2 values were variable with median 25 mmHg (IQR:15.4-38.8). In the sub-analysis (Figure 1), EtCO 2 values before and after advanced airway placement were similar with a mean difference 0.48 mmHg (95% CI -2.0 to 1.0, p=0.536, n=235 cases with 774 min EtCO 2 ). Conclusions: Capnography values are detectable during BVM ventilation. BVM EtCO 2 values before and after AA EtCO 2 values appear similar.

Limited recent national data exist measuring burnout levels among emergency medical services (EMS) clinicians and the potential impact of burnout on workforce strength and stability. We aimed to measure current EMS burnout and its association with workforce-reducing factors. In April 2022, a random sample of nationally certified EMS clinicians was sent a survey that included the Copenhagen Burnout Inventory (CBI) to assess for burnout in 3 dimensions: personal, work-related, and patient-related. Descriptive statistics (count and percentage) and multivariable logistic regression (odds ratio [OR] and 95% CI) were used to identify and measure each domain of burnout and the relationship between these domains and workforce-reducing factors. From 1838 survey responses (9% response rate), prevalence of EMS burnout was high in the personal (52%), work-related (49%), and patient-related (23%) domains. Burnout was higher for paramedics than for emergency medical technicians across all domains. Higher odds of reporting 10 or more sick days was observed for those with personal (OR, 2.66; 95% CI, 1.70-4.15), work-related (OR, 1.99; 95% CI, 1.31-3.01), or patient-related burnout (OR, 1.85; 95% CI, 1.20-2.86). Higher odds of reporting likelihood to leave the EMS profession was observed for those with personal (OR, 3.06; 95% CI, 2.16-4.33), work-related (OR, 3.34; 95% CI, 2.35-4.74), or patient-related burnout (OR, 3.42; 95% CI, 2.39-4.90). Nationally certified EMS clinicians demonstrated high burnout in 2022. Combined with increased absenteeism and intent to leave the profession associated with these high levels of burnout, these findings suggest that a renewed and deliberate focus on EMS clinician well-being is needed to ensure job satisfaction and workforce stability.

BackgroundFor emergency medical services (EMS) clinicians, clinical judgment is a higher-order construct that encompasses the initial thought process (clinical reasoning) that assists clinicians in reaching conclusions (clinical decision making). Current theoretical frameworks of clinical judgment contain other higher order constructs (e.g., leadership, communication) which may play a significant role in delivery of care. It is unknown whether this definition of clinical judgment includes additional higher order constructs of leadership and communication. The goal of this evaluation was to determine whether leadership and communication overlap and are subsumed under the larger construct of clinical judgment.MethodsFocus groups of experts in prehospital paramedic and advanced emergency medical technician levels of certification were recruited to generate tasks and their associated knowledge, skills, and abilities (KSAs) in for the domains of clinical judgment, communication, and leadership. These tasks and KSAs were then evaluated for commonality between the domains to evaluate whether communication and leadership are incorporated within clinical judgment.ResultsTask-KSA matrices were generated by focus groups for each domain and evaluated by certification level. There were no differences by certification level in the tasks-KSA matrices for the domains. A total of 77 tasks were identified, comprised of 392 KSAs across three domains (9 sub-domains). An analysis of commonality of tasks between the domains of communication and leadership with clinical judgment demonstrated that 61% of communication tasks were similar to the identified clinical judgment tasks. Similarly, in leadership, clinical judgment had a total of 79% commonality overall.ConclusionClinical judgment was found to be a higher order construct that overlaps with and incorporates the domains of leadership and communication in the theoretical framework of EMS clinical judgment. This study provides validity evidence for the proposed clinical judgment theoretical framework. Future work should focus on pilot evaluations in simulated settings for building additional construct validity.

Background: Emergency medical service (EMS) clinicians provide time-sensitive care for patients with suspected stroke. While model evidence-based guidelines (EBG) exist, there is limited research on national adoption. Our objectives were to describe nationwide care delivery for suspected stroke patients and measure associations between guideline-compliant stroke care (GCSC) and patient characteristics. Methods: This retrospective analysis of the 2022 national ImageTrend Collaborate dataset evaluated 9-1-1 transported EMS incidents with primary impression of stroke. Included are advanced life support agencies with >6 annual strokes. Key components of GCSC from the National Model EMS Clinical Guidelines include documented stroke screen, 12-lead electrocardiogram, blood glucose (BG), onset time/last known well (LKW/Onset), pre-alert hospital notification, and scene time <15 minutes. Provision of GCSC was defined as providing at least five of the six components above. Multivariable logistic regression(OR,95%CI) used to describe the odds of GCSC adjusted for race/ethnicity, gender, and urbanicity. Results: In 2022, 43,555 events met inclusion criteria. Patients were commonly White (70.5%), female (52.3%), and with a median age 73 (IQR:62, 82). Most were in urban areas (88.2%) and had a dispatch complaint of stroke (56.1%). Key components of GCSC had varying degrees of compliance: stroke assessment (83.9%), LKW/Onset (93.7%), BG (85.1%), 12-lead (42.3%), pre-alert (58.7%) and on-scene time <15 minutes (58.9%). At least five components were completed in 43.0% of patients, and only 10.0% had all six. Adjusted odds of GCSC were higher for males (1.12,1.08-1.17), lower for Black/African American patients (0.71,0.67-0.76; referent: White), and lower for suburban and rural areas (0.52,0.48-0.56; 0.39,0.32-0.47; referent: urban). Conclusion: Prehospital GCSC delivery in the United States varies widely even with EBG’s providing a standardized approach. Variations in care are associated with gender, race, and urbanicity. Our results may be limited by reporting bias in the medical record. Future efforts may focus on agency-level implementation and documentation of these criteria to improve patient-based outcomes.

Background:The occurrence of behavioral health emergencies (BHEs) in children is increasing in the United States, with patient presentations to Emergency Medical Services (EMS) behaving similarly. However, detailed evaluations of EMS encounters for pediatric BHEs at the national level have not been reported.Methods:This was a secondary analysis of a national convenience sample of EMS electronic patient care records (ePCRs) collected from January 1, 2018 through December 31, 2021. Inclusion criteria were all EMS activations documented as 9-1-1 responses involving patients < 18 years of age with a primary or secondary provider impression of a BHE. Patient demographics, incident characteristics, and clinical variables including administration of sedation medications, use of physical restraint, and transport status were examined overall and by calendar year.Results:A total of 1,079,406 pediatric EMS encounters were present in the dataset, of which 102,014 (9.5%) had behavioral health provider impressions. Just over one-half of BHEs occurred in females (56.2%), and 68.1% occurred in patients aged 14-17 years. Telecommunicators managing the 9-1-1 calls for these events reported non-BHE patient complaints in 34.7%. Patients were transported by EMS 68.9% of the time, while treatment and/or transport by EMS was refused in 12.5%. Prehospital clinicians administered sedation medications in 1.9% of encounters and applied physical restraints in 1.7%. Naloxone was administered for overdose rescue in 1.5% of encounters.Conclusion:Approximately one in ten pediatric EMS encounters occurring in the United States involve a BHE, and the majority of pediatric BHEs attended by EMS result in transport of the child. Use of sedation medications and physical restraints by prehospital clinicians in these events is rare. National EMS data from a variety of sources should continue to be examined to monitor trends in EMS encounters for BHEs in children.

ObjectiveEmergency medical services (EMS) clinicians operate in environments that predispose them to occupational hazards. Our objective was to evaluate the frequency of occupational hazards and associations with mitigation strategies in a national dataset.MethodsWe performed a cross-sectional analysis of currently working, nationally certified civilian EMS clinicians aged 18–85 in the USA. After recertifying their National EMS Certification, respondents were invited to complete a survey with questions regarding demographics, work experience and occupational hazards. Three multivariable logistic regression models (OR, 95% CI) were used to describe associations between these hazards and demographics, work characteristics and mitigation strategies. Models were adjusted for age, sex, minority status, years of experience, EMS agency type, service type and EMS role.ResultsA total of 13 218 respondents met inclusion criteria (response rate=12%). A high percentage of EMS clinicians reported occupational injuries (27%), exposures (38%) and violence (64%) in the past 12 months. Odds of injury were lower with the presence of a lifting policy (0.73, 0.67–0.80), lift training (0.74, 0.67–0.81) and always using a powered stretcher (0.87, 0.78–0.97). Odds of exposure decreased with chemical, biological and nuclear exposure protection training (0.75, 0.69–0.80). Training in de-escalation techniques was associated with lower odds of experiencing violence (0.87, 0.79–0.96).ConclusionsOccupational hazards are commonly experienced among EMS clinicians. Common mitigation efforts are associated with lower odds of reporting these hazards. Mitigation strategies were not widespread and associated with lower odds of occupational hazards. These findings may present actionable items to reduce occupational hazards for EMS clinicians.

ObjectiveThere is growing concern with the strength and stability of the emergency medical services (EMS) workforce with reports of workforce challenges in many communities in the United States. Our objective was to estimate changes in the EMS workforce by evaluating the number of clinicians who enter, stay, and leave.MethodsA 4‐year retrospective cohort evaluation of all certified EMS clinicians at the emergency medical technician (EMT) level or higher was conducted for 9 states that require national EMS certification to obtain and maintain EMS licensure. The study spanned 2 recertification cycles (2017–2021) for 2 workforce populations: the certified workforce (all EMS clinicians certified to practice) and the patient care workforce (the subset who reported providing patient care). Descriptive statistics were calculated and classified into 1 of 3 categories: EMS clinicians who entered, stayed in, or left each respective workforce population.ResultsThere were 62,061 certified EMS clinicians in the 9 included states during the study period, and 52,269 reported providing patient care. For the certified workforce, 80%–82% stayed in and 18%–20% entered the workforce. For the patient care workforce, 74%–77% stayed and 29%–30% entered. State‐level rates of leaving each workforce ranged from 16% to 19% (certified) and 19% to 33% (patient care). From 2017 to 2020, there was a net growth of both the certified (8.8%) and patient care workforces (7.6%).ConclusionsThis was a comprehensive evaluation of both the certified and patient care EMS workforce dynamics in 9 states. This population‐level evaluation serves as the first step for more detailed analyses to better understand workforce dynamics in EMS.

Objective Mobile integrated health care (MIH) leverages emergency medical services (EMS) clinicians to perform local health care functions. Little is known about the individual EMS clinicians working in this role. We sought to describe the prevalence, demographics, and training of EMS clinicians providing MIH in the United States (US). Methods This is a cross-sectional study of US-based, nationally certified civilian EMS clinicians who completed the National Registry of Emergency Medical Technicians (NREMT) recertification application during the 2021–2022 cycle and completed the voluntary workforce survey. Workforce survey respondents self-identified their job roles within EMS, including MIH. If an MIH role was selected, additional questions clarified the primary role in EMS, type of MIH provided, and hours of MIH training received. We merged the workforce survey responses with the individual’s NREMT recertification demographic profile. The prevalence of EMS clinicians with MIH roles and data on demographics, clinical care provided, and MIH training were calculated using descriptive statistics, including proportions with associated binomial 95% confidence intervals (CI). Results Of 38,960 survey responses, 33,335 met inclusion criteria and 490 (1.5%; 95%CI 1.3–1.6%) EMS clinicians indicated MIH roles. Of these, 62.0% (95%CI 57.7–66.3%) provided MIH as their primary EMS role. EMS clinicians with MIH roles were present in all 50 states and certification levels included emergency medical technician (EMT) (42.8%; 95%CI 38.5–47.2%), advanced emergency medical technician (AEMT) (3.5%; 95%CI 1.9–5.1%), and paramedic (53.7%; 95%CI 49.3–58.1%). Over one-third (38.6%; 95%CI 34.3–42.9%) of EMS clinicians with MIH roles received bachelor’s degrees or above, and 48.4% (95%CI 43.9%-52.8%) had been in their MIH roles for less than 3 years. Nearly half (45.6%; 95%CI 39.8–51.6%) of all EMS clinicians with primary MIH roles received less than 50 hours (h) of MIH training; only one-third (30.0%; 95%CI 24.7–35.6%) received more than 100 h of training. Conclusion Few nationally certified US EMS clinicians perform MIH roles. Only half of MIH roles were performed by paramedics; EMT and AEMT clinicians performed a substantial proportion of MIH roles. The observed variability in certification and training suggest heterogeneity in preparation and performance of MIH roles among US EMS clinicians.