Conflict in the EMS Workforce: An Analysis of an Open-Ended Survey Question Reveals a Complex Assemblage of Stress, Burnout, and Pandemic-Related Factors Influencing Well-Being.

Emergency Medical Services (EMS) clinicians provide patient care within a high-stakes, unpredictable, and complex work environment in which conflict is inevitable. Our objective was to explore the extent to which added stressors of the pandemic exacerbated EMS workplace conflict. We administered our survey to a sample of U.S. nationally certified EMS clinicians during the COVID-19 pandemic in April 2022. Out of 1881 respondents, 46% (n = 857) experienced conflict and 79% (n = 674) provided free-text descriptions of their experience. The responses were analyzed for themes using qualitative content analysis, and they were then sorted into codes using word unit sets. Code counts, frequencies, and rankings were tabulated, enabling quantitative comparisons of the codes. Of the fifteen codes to emerge, stress (a precursor of burnout) and burnout-related fatigue were the key factors contributing to EMS workplace conflict. We mapped our codes to a conceptual model guided by the National Academies of Sciences, Engineering, and Medicine (NASEM) report on using a systems approach to address clinician burnout and professional well-being to explore implications for addressing conflict within that framework. Factors attributed to conflict mapped to all levels of the NASEM model, lending empirical legitimacy to a broad systems approach to fostering worker well-being. Our findings lead us to propose that active surveillance (enhanced management information and feedback systems) of frontline clinicians' experiences during public health emergencies could increase the effectiveness of regulations and policies across the healthcare system. Ideally, the contributions of the occupational health discipline would become a mainstay of a sustained response to promote ongoing worker well-being. The maintenance of a robust EMS workforce, and by extension the health professionals in its operational sphere, is unquestionably essential to our preparedness for the likelihood that pandemic threats may become more commonplace.

Enhanced evasion of neutralizing antibody response by Omicron XBB.1.5, CH.1.1, and CA.3.1 variants.

Omicron subvariants continuingly challenge current vaccination strategies. Here, we demonstrate nearly complete escape of the XBB.1.5, CH.1.1, and CA.3.1 variants from neutralizing antibodies stimulated by three doses of mRNA vaccine or by BA.4/5 wave infection, but neutralization is rescued by a BA.5-containing bivalent booster. CH.1.1 and CA.3.1 show strong immune escape from monoclonal antibody S309. Additionally, XBB.1.5, CH.1.1, and CA.3.1 spike proteins exhibit increased fusogenicity and enhanced processing compared with BA.2. Homology modeling reveals the key roles of G252V and F486P in the neutralization resistance of XBB.1.5, with F486P also enhancing receptor binding. Further, K444T/M and L452R in CH.1.1 and CA.3.1 likely drive escape from class II neutralizing antibodies, whereas R346T and G339H mutations could confer the strong neutralization resistance of these two subvariants to S309-like antibodies. Overall, our results support the need for administration of the bivalent mRNA vaccine and continued surveillance of Omicron subvariants.

Perspectives of Volunteer Firefighters during the COVID-19 Pandemic: Stumbling Blocks and Silver Linings.

The COVID-19 pandemic has profoundly affected the lives of almost every individual in every nation, with numbers of infections continuing to grow. Across these nations, first responders are essential in their roles addressing emergencies, despite their risk of exposure to COVID-19 in the course of their work. We sought to understand the impacts of the COVID-19 pandemic on the lives of volunteer firefighters in the United States, an understudied group of these first responders. Interviews were conducted with volunteer firefighters between September and November 2021. Interviews were analyzed using deductive dominant thematic analysis. Thirty-three firefighters were interviewed who had an average of 22 years of service and a mean age of 52 years. Interviewees described pandemic-related challenges including the fear of COVID exposure and frustrations with work and personal relationships. They also identified unexpected work-related benefits including a deepened commitment to serve and improvements to training and safety. Further, some volunteers noted personal benefits such as developing stronger connections with others, having a new outlook on life, and observing goodwill. Our findings provide insight into the multifaceted and complex impact of the COVID-19 pandemic on volunteer firefighters.

Impact of COVID-19 on initial emergency medical services certification in the United States.

Objective: As the COVID-19 pandemic began, there were significant concerns for the strength and stability of the emergency medical services (EMS) workforce. These concerns were heightened with the closure of examination centers and the cessation of certification examinations. The impact of this interruption on the EMS workforce is unclear. Our objective was to evaluate the impact of COVID-19 on initial EMS certification in the United States. In addition, we evaluated mitigation measures taken to address these interruptions. Methods: This study was a cross-sectional evaluation of the National Certification Cognitive Examination administration and results for emergency medical technician (EMT) and paramedic candidates. We compared the number of examinations administered and first-attempt pass rates in 2020 (pandemic) to 2019 (control). Descriptive statistics and 2 one-sided tests of equivalence were used to assess if there was a relevant difference of ±5 percentage points. Results: Total number of examinations administered decreased by 15% (EMT, 14%; paramedic, 7%). Without the addition of EMT remote proctoring, the EMT reduction would have been 35%. First-time pass rates were similar in both EMT (-0.9%) and paramedic (-1.9%) candidates, which did not meet our threshold of a relevant difference. Conclusion: COVID-19 has had a measurable impact on examination administration for both levels of certification. First-time pass rates remained unaffected. EMT remote proctoring mitigated some of the impact of COVID-19 on examination administration, although a comparison with mitigation was not assessed. These reductions indicate a potential decrease in the newly certified workforce, but future evaluations will be necessary to assess the presence and magnitude of this impact.

Trends in demographic and employment characteristics of US emergency medical technicians and paramedics, 2011-2019.

Background: Describing the US emergency medical services workforce is important to understand gaps in recruitment and retention and inform efforts to improve diversity. Our objective was to describe the characteristics and temporal trends of emergency medical technicians (EMTs) and paramedics in the United States. Methods: We performed a repeated cross-sectional evaluation of US Census Bureau's American Community Survey 1-year Public Use Microdata Sample data sets from 2011-2019. We included respondents working as an EMT or paramedic. Survey-weighted descriptive statistics of demographic and employment characteristics were calculated. Trend analysis was conducted using joinpoint regression to estimate slope and annual percent change (APC). Results: The total estimated number of EMTs and paramedics in the United States increased from 216,310 (95%CI 204,957-227,663) in 2011 to 289,830 (95%CI 276,918-302,743) in 2019 (APC 3.0%; 95%CI 1.4%, 4.7%). There was a slight increase in the proportion of females (2011, 31%; 2019, 35%). There was a significant decrease in proportion of non-Hispanic whites (2011, 80%; 2019, 72%; APC -1.5%; 95%CI -2.0%, -0.9%) with concurrent increases in other racial/ethnic groups (e.g., Hispanics, 2011, 10%; 2019, 13%). About half worked >40 hours per week, with little change over time. Between 15% and 18% lived and worked in different states, and about 40% traveled ≥30 minutes to their workplace. Conclusions: The number of EMTs and paramedics actively working in EMS as their primary paid occupation has increased over time. However, there have been only modest changes in their demographic diversity.

COVID-19 Booster Uptake among First Responders and Their Household Members May Be Lower than Anticipated.

(1) Background: COVID-19 vaccination status varies widely among law enforcement and emergency medical services professionals. Though at high risk of exposure, these first responders have demonstrated significant vaccine hesitancy, with only 70% reportedly vaccinated. We sought to understand whether similar vaccine hesitancy exists for first responders and their household contacts around COVID-19 boosters. (2) Methods: In a prospective longitudinal cohort of first responders and their household contacts, survey data was collected, including demographics, medical history, COVID-19 exposure risks, and vaccination and/or booster status. The statistical analysis focused on primary vaccination and booster rates of both the first responders and their household contacts. (3) Results: Across 119 study participants, 73% reported having received some combination of vaccine and/or booster, and 26% were unvaccinated. Vaccinated individuals were older, reported less prior exposure to COVID-19 and had more comorbidities. Only 23% reported having received a COVID-19 booster. Pairing of the data for household contacts demonstrated a 60% agreement to receive primary vaccination but only a 20% agreement for boosters within households. (4) Conclusions: This study provides insight into the vaccination and booster rates of first responders and household contacts. Focused efforts to enhance vaccinations is essential for the protection and maintenance of this critical workforce.

Pandemic Experience of First Responders: Fear, Frustration, and Stress.

Police officers, firefighters, and paramedics are on the front lines of crises and emergencies, placing them at high risk of COVID-19 infection. A deeper understanding of the challenges facing first responders during the COVID-19 pandemic is necessary to better support this important workforce. We conducted semi-structured interviews with 21 first responders during the COVID-19 pandemic, asking about the impact of COVID-19. Data collected from our study interviews revealed that, despite large numbers of COVID-19 infections among the staff of police and fire departments, some-but not all-first responders were concerned about COVID-19. A similar divide existed within this group regarding whether or not to receive a COVID-19 vaccination. Many first responders reported frustration over COVID-19 information because of inconsistencies across sources, misinformation on social media, and the impact of politics. In addition, first responders described increased stress due to the COVID-19 pandemic caused by factors such as the fear of COVID exposure during emergency responses, concerns about infecting family members, and frustration surrounding new work policies. Our findings provide insight into the impact of COVID-19 on first responders and highlight the importance of providing resources for education about COVID-19 risks and vaccination, as well as for addressing first responders' mental health and well-being.

The COVID-19 vaccine concerns scale: Development and validation of a new measure.

Reasons for COVID-19 hesitancy are multi-faceted and tend to differ from those for general vaccine hesitancy. We developed the COVID-19 Vaccine Concerns Scale (CVCS), a self-report measure intended to better understand individuals' concerns about COVID-19 vaccines. We validated the scale using data from a convenience sample of 2,281 emergency medical services providers, a group of professionals with high occupational COVID-19 risk. Measures included the CVCS items, an adapted Oxford COVID-19 vaccine hesitancy scale, a general vaccine hesitancy scale, demographics, and self-reported COVID-19 vaccination status. The CVCS had high internal consistency reliability (α = .89). A one-factor structure was determined by exploratory and confirmatory factor analyses (EFA and CFA), resulting in a seven-item scale. The model had good fit (X2[14] = 189.26, p < .001; CFI = .95, RMSEA = .11 [.09, .12], NNFI = .93, SRMR = .03). Moderate Pearson correlations with validated scales of general vaccine hesitancy (r = .71 , p < .001; n = 2144) and COVID-19 vaccine hesitancy (r = .82; p < .001; n = 2279) indicated construct validity. The CVCS predicted COVID-19 vaccination status (B = -2.21, Exp(B) = .11 [95% CI = .09, .13], Nagelkerke R2 = .55), indicating criterion-related validity. In sum, the 7-item CVCS is a reliable and valid self-report measure to examine fears and concerns about COVID-19 vaccines. The scale predicts COVID-19 vaccination status and can be used to inform efforts to reduce COVID-19 vaccine hesitancy.

An Opportunity to Understand Concerns about COVID-19 Vaccination: Perspectives from EMS Professionals.

Some healthcare professionals, including emergency medical service (EMS) professionals, remain hesitant about receiving COVID-19 vaccines. This study sought to understand EMS professionals' perspectives regarding COVID-19 vaccination. Using open-ended comments from a national survey deployed electronically to over 19,000 EMS professionals in April of 2021, we examined perspectives about acceptance of and hesitancy toward COVID-19 vaccines. Survey comments revealed differences in perspectives between vaccinated and unvaccinated EMS professionals regarding their personal role in improving public health through COVID-19 vaccination as well as vaccine benefits and the protection conferred by vaccination. Unvaccinated individuals also expressed concerns over the research and development of the COVID-19 vaccines that led to their decision not to get vaccinated. Individuals who were vaccinated suggested ways to increase uptake of the vaccine including having healthcare professionals serve as leaders for vaccination and educating individuals about COVID-19 vaccination through credible resources. Vaccine hesitancy remains a challenge to achieving herd immunity to COVID-19 through vaccination, even among healthcare professionals. Understanding the perspectives of those who have chosen not to be vaccinated can help direct strategies to reduce confusion and concerns. The perspectives of vaccinated individuals may also be valuable in identifying opportunities to promote vaccination in the professional setting.

Closing the Gap on COVID-19 Vaccinations in First Responders and Beyond: Increasing Trust.

Although COVID-19 vaccines are widely available in the U.S. and much of the world, many have chosen to forgo this vaccination. Emergency medical services (EMS) professionals, despite their role on the frontlines and interactions with COVID-positive patients, are not immune to vaccine hesitancy. Via a survey conducted in April 2021, we investigated the extent to which first responders in the U.S. trusted various information sources to provide reliable information about COVID-19 vaccines. Those vaccinated generally trusted healthcare providers as a source of information, but unvaccinated first responders had fairly low trust in this information source-a group to which they, themselves, belong. Additionally, regardless of vaccination status, trust in all levels of government, employers, and their community as sources of information was low. Free-response explanations provided some context to these findings, such as preference for other COVID-19 management options, including drugs proven ineffective. A trusted source of COVID-19 vaccination information is not readily apparent. Individuals expressed a strong desire for the autonomy to make vaccination decisions for themselves, as opposed to mandates. Potential reasons for low trust, possible solutions to address them, generalizability to the broader public, and implications of low trust in official institutions are discussed.

COVID-19 Vaccinations in EMS Professionals: Prevalence and Predictors.

Background: Immunizations for emergency medical services (EMS) professionals during pandemics are an important tool to increase the safety of the workforce as well as their patients. The purpose of this study was to better understand EMS professionals' decisions to receive or decline a COVID-19 vaccine.Methods: We conducted a cross-sectional analysis of nationally certified EMS professionals (18-85 years) in April 2021. Participants received an electronic survey asking whether they received a vaccine, why or why not, and their associated beliefs using three validated scales: perceived risk of COVID-19, medical mistrust, and confidence in the COVID-19 vaccine. Data were merged with National Registry dataset demographics. Analyses included descriptive analysis and multivariable logistic regression (OR, 95% CI). Multivariate imputation by chained equations was used for missingness.Results: A total of 2,584 respondents satisfied inclusion criteria (response rate = 14%). Overall, 70% of EMS professionals were vaccinated. Common reasons for vaccination among vaccinated respondents were to protect oneself (76%) and others (73%). Common reasons for non-vaccination among non-vaccinated respondents included concerns about vaccine safety (53%) and beliefs that vaccination was not necessary (39%). Most who had not received the vaccine did not plan to get it in the future (84%). Hesitation was most frequently related to wanting to see how the vaccine was working for others (55%). Odds of COVID-19 vaccination were associated with demographics including age (referent <28 years; 39-50 years: 1.56, 1.17-2.08; >51 years: 2.22, 1.64-3.01), male sex (1.26, 1.01-1.58), residing in an urban/suburban area (referent rural; 1.36, 1.08-1.70), advanced education (referent GED/high school and below; bachelor's and above: 1.72, 1.19-2.47), and working at a hospital (referent fire-based agency; 1.53, 1.04-2.24). Additionally, vaccination odds were significantly higher with greater perceived risk of COVID-19 (2.05, 1.68-2.50), and higher vaccine confidence (2.84, 2.40-3.36). Odds of vaccination were significantly lower with higher medical mistrust (0.54, 0.46-0.63).Conclusion: Despite vaccine availability, not all EMS professionals had been vaccinated. The decision to receive a COVID-19 vaccine was associated with demographics, beliefs regarding COVID-19 and the vaccine, and medical mistrust. Efforts to increase COVID-19 vaccination rates should emphasize the safety and efficacy of vaccines.

Emergency medical services education research priorities during COVID-19: A modified Delphi study.

OBJECTIVE: Our objective was to identify research priorities to understand the impact of COVID-19 on initial emergency medical services (EMS) education. METHODS: We used a modified Delphi method with an expert panel (n = 15) of EMS stakeholders to develop consensus on the research priorities that are most important and feasible to understand the impact of the COVID-19 pandemic on initial EMS education. Data were collected from August 2020 to February 2021 over 5 rounds (3 electronic surveys and 2 live virtual meetings). In Round 1, participants submitted research priorities over 9 specific areas. Responses were thematically analyzed to develop a list of research priorities reviewed in Round 2. In Round 3, participants rated the priorities by importance and feasibility, with a weighted score (2/3*importance+1/3*feasibility) used for preliminary prioritization. In Round 4, participants ranked the priorities. In Round 5, participants provided their agreement or disagreement with the group's consensus of the top 8 research priorities. RESULTS: During Rounds 1 and 2, 135 ideas were submitted by the panel, leading to a preliminary list of 27 research priorities after thematic analysis. The top 4 research priorities identified by the expert panel were prehospital internship access, impact of lack of field and clinical experience, student health and safety, and EMS education program availability and accessibility. Consensus was reached with 10/11 (91%) participants in Round 5 agreeing. CONCLUSIONS: The identified research priorities are an important first step to begin evaluating the EMS educational infrastructure, processes, and outcomes that were affected or threatened through the pandemic.

Emergency Medical Services Personnel Awareness and Training about Personal Protective Equipment during the COVID-19 Pandemic.

Background: With the emergence of the 2019 novel coronavirus disease (COVID-19), appropriate training for emergency medical services (EMS) personnel on personal protective equipment (PPE) is essential. We aimed: 1) to examine the change in proportions of EMS personnel reporting awareness of and training in PPE during the COVID-19 pandemic; and 2) to determine factors associated with reporting these outcomes.We conducted a cross-sectional analysis of data collected from October 1, 2019 to June 30, 2020 from currently working, nationally certified EMS personnel (n = 15,339), assessing N95 respirator fit testing; training in air purified respirators (APR) or powered APR (PAPR) use; and training on PPE use for chemical, biological, and nuclear (CBN) threats. We used an interrupted time series analysis to determine changes in proportions of EMS personnel reporting training per week, using the date of Centers for Disease Control and Prevention's (CDC) initial EMS guidance (February 6, 2020) as the interruption. We fit multivariable logistic regression models to understand factors associated with each outcome.Results: We found high awareness of N95 respirators (99%) and APR/PAPR (91%), but only 61% reported N95 fit testing and 64% reported training on PPE for CBN threats in the prior 12 months. There was a significant, positive slope change after CDC guidance for N95 respirator fit testing, and significant post-interruption mean increases for fit testing (0.9%, 95% CI 0.6-1.1%), APR/PAPR training (0.3%, 95% CI 0.2-0.5%), and PPE for CBN threats training (0.6%, 95% CI 0.3-0.9%). Factors consistently associated with lower odds of awareness/training included part-time employment, providing 9-1-1 response service, working at a non-fire-based EMS agency, and working in a rural setting.Conclusions: CDC guidance on COVID-19 for EMS may have increased N95 fit testing and training, but there remain substantial gaps in training on PPE use among EMS personnel. As the pandemic continues in our communities, EMS agencies should be supported in efforts to adequately prepare their staff.