LIMITATIONS 54% response rate

 Accuracy of recall of CI not examined

 Terms “threatened” or “assaulted” not defined

Exposure to critical incidents in a cohort of US emergency medical services providers:career frequency, perceived difficulty with coping, and association with burnout and stress

Lori L. Boland, MPH; Russell N. Myers, BCC; Pamela J. Mink, PhD; Karl M. Fernstrom, MPH; Kai G. Hanson, MS; William M. Spinelli, MD

Allina Health Emergency Medical Services, St. Paul, Minnesota, USA

BACKGROUND Studies of exposure to critical incidents (CI) in emergencymedical services (EMS) responders have largely focused onpolice officers and firefighters

 Exposure to CI has not been well-studied in US ambulanceworkers

OBJECTIVES Assess CI exposure in a cohort of US ambulance personnel

Measure coping difficulty associated with specific types of CI

 Explore the association of CI exposure with burnout and stress

METHODSSetting & Design

 Large ambulance service in Minnesota

 Cross-sectional, 165-item electronic survey

 Distributed to all employees (n=400) in September 2012

Measures

 Critical Incident History Questionnaire (CIHQ)  

– Developed in law enforcement, modified for this use in EMS

  – Asks about frequency and coping difficulty (“severity”) of29 CI (Figure 1)

 Maslach Burnout Inventory (MBI) – used to assessprofessional burnout

 Cohen’s Perceived Stress Scale (PSS) – score range 0-14,higher values indicate more stress

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CONCLUSIONSPediatric CI are particularly distressing for EMS respondersand the experience of being assaulted by a patient orthreatened with a gun or other weapon is disturbinglycommon. Cumulative frequency of exposure to CI was notstrongly associated with burnout or stress in this cohort, butstudies should continue to explore how CI influence thepsychoemotional wellbeing of ambulance workers in the US.

 Years in EMS Median # (IQR) of CIs recalled

Overall (0.5-30) 154 (59, 267)

Quartile I (≤6) 58 (20, 155)

Quartile II (7-12) 146 (66, 226)

Quartile III (12-24) 154 (80, 236)

Quartile IV (25-30) 287 (194, 419)

Total # CI Recalled Burnout Perceived Stress

  Quartile I (0-59) 11% (5) 3.8 (2.7)

  Quartile II (60-154) 24% (11) 5.1 (3.3)

  Quartile III (155-266) 15% (7) 5.3 (3.2)

  Quartile IV (267-658) 22% (10) 5.2 (3.3)

RESULTS N = 217 survey responses (54%; Table 1)

 CI involving children received 7 of the top 10 mean severityscores (Table 2)

 Mean frequency of exposure to CI was negatively correlatedwith mean severity rating (Table 2)

 43% of respondents report having been threatened with agun/weapon while on duty (Table 3)

 Median CI recalled increased with years as EMS provider(Table 4)

 Burnout and perceived stress were not strongly associatedwith cumulative exposure to CI (Table 5)

 Variable N=217

Age categories

18-2930-3940-4950+

27% (58)20% (43)25% (54)27% (57)

Gender MaleFemale

60% (131)40% (84)

 Years as EMS provider

≤= 1 year2-5 years

6-10 years11-20 years>20 years

3% (6)18% (40)23% (50)24% (51)32% (70)

Primary response setting MetroNon-Metro or Rural

70% (152)30% (64)

Table 4: Median number of CIs recalled in EMS career, byquartiles of years in EMS

Table 1: Demographic characteristics of survey respondents

Table 5: Prevalence of burnout and mean perceived stressscore by quartiles of total # of CI recalled

Results are expressed as mean (SD) or percent (n)

Figure 1: Format of the 29-item CIHQ

Table 2: Critical incident types (n=29), ranked by meanseverity score and mean reported career frequency

Table 3: Proportion of respondents who report having beenthreatened with a gun/weapon, or assaulted by a patientwhile on duty

OverallBy Provider Gender

Male Female

Threatened with gun or other weapon? 43% 50% 33%

Assaulted by a patient? 68% 73% 60%

Pearson correlation between mean severity and mean frequency = -0.72 (p< 0.001)

Never 1 2 3 4 5 6 7 8 9 10-20 21-50 5 1+

Been seriously injured

Been present when afellow paramedic/EMTwas seriously injured

Been threatened with agun or other weapon

N ot at all A little bit Mod era tely Q uite a bit Extremely

Been seriously injured

Been present when afellow paramedic/EMTwas seriously injured

Been threatened with agun or other weapon

During your career as a paramedic/EMT/dispatcher, howmany times have you….

In your opinion, how difficult would it be for paramedics/ EMTs/dispatchers to cope with this type of incident? 

  Score = 0 1 2 3 4

Mean Severity Score* Mean Reported Career Frequency

Encountered murdered child  3 .46 Encountered recent ly dead body 28.5Encountered child badly beaten 3.25 Seen someone dying 26.5Made mistake that lead to injury/death ofpatient

3.20 Made a death notification 18.0

Encountered child accidentally k il led 3.15 Encountered a suicide victim 14.8Encountered child sev erel y ne gl ect ed 3 .12 E nco un tere d adul t ba dl y bea ten 14 .0

Encountered child sexually assaulted 2.99Encountered mutilated body or humanremains

9.3

Encountered a SIDS death 2.93 Encountered child severely injured 8.9Encountered child severely injured 2.75 Encountered adult sexually assaulted 7.1Present when paramedic seriously injured 2.74 Exposed to AIDS/life-threatening diseases 6.6Threatened with a gun or other weapon 2.71 Elderly person severely abused/neglected 5.9Trapped in life-threatening situation 2.66 Encountered a SIDS death 4.8

Response involving persons known to crew 2.63Response involving persons known tocrew

4.8

Been seriously injured 2.62 Responded to MCI 4.4Been in a serious motor vehicle accident 2.58 Encountered child accidentally killed 4.2Elderly person severely abused/neglected 2.52 Encountered patient severely burned 3.9

Had life endangered in a large-scale disaster 2.50Exposed to life-threatening toxicsubstance

3.8

Exposed to li fe -threa tening toxi c substance 2 .33 Been assau lted by a pa tien t 3 .6Exposed to AIDS/life-threatening diseases 2.30 Encountered child severely neglected 2.7Encountered adult sexually assaulted 2.24 Encountered child sexually assaulted 2.5Encountered patient severely burned 2.23 Responded to large-scale disaster 2.4Responded to large-scale disaster 2.17 Encountered child badly beaten 1.7Encountered mutilated body or humanremains

2.16 Threatened with a gun or other weapon 1.7

Encountered adu lt bad ly bea ten 2 .09 Trapped in l if e- th reaten ing s itua tion 1 .4Responded to MCI 2.04 Been seriously injured 1.1Made a dea th not ifica tion 1 .99 Present when paramed ic ser ious ly i njured 0 .8B ee n a ss aul te d by a pa ti en t 1 .99 E nco un tere d mu rde re d ch il d 0 .6Encountered a suicide victim 1.96 Been in a serious motor vehicle accident 0.4

Seen someone dying 1.64Had life endangered in a large-scaledisaster

0.3

Encountered body of someone recently dead 1.45Made mistake that lead to injury/death ofpatient

0.2