OSHA-2016-0014 4.6.17 RMM - Drexel University

Taylor & Murray Executive Summary: Violence Against EMS Responders OSHA-2016-0014 April 6th, 2017

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OccupationalSafetyandHealthAdministration(OSHA),DOLDocketNumber:(OSHA-2016-0014)RE:RequestforInformation(RFI)PreventionofWorkplaceViolenceinHealthcareandSocialAssistance

ExecutiveSummary:ViolenceAgainstEmergencyMedicalServices(EMS)responders

Preparedby:JenniferA.Taylor,PhD,MPH,CPPS&ReganMurray,EMT,MPHcDrexelUniversityDornsifeSchoolofPublicHealth

DepartmentofEnvironmentalandOccupationalHealthPhiladelphia,PA

Submissiondate:April6th,2017

IntroductionPreventionofworkplaceviolenceagainstEmergencyMedicalServices(EMS)respondersisanissuethatwarrantstheattentionofagenciescapableofenforcingregulatoryactionstobetterprotectthehealth,safety,andoverallwell-beingofEMSrespondersintheUnitedStates.EMSresponders(e.g.,firstresponders,EMTs,paramedics,andfirefighters)areanunderstudiedandunderservedpopulationofhealthcareservicesexperiencingincreasingratesofviolencedirectedatthemfrompatients,familymembers,andbystanders.ObjectiveWesupportthedevelopmentofstandards,policies,andinterventionstoreduceandpreventviolencefromoccurringintheworkplace;ThissubmissionservesasanappealtoOSHAandsupportingagenciestoincludedirectguidelinesandrecommendationstoprovidecounseltoEmergencyMedicalServicesrespondersinanefforttoreducetheexposuretoandimpactofviolenceoccurringintheworkplace.BackgroundWiththisExecutiveSummary,weseektoeducateabouttheimportanceofincludingEMSresponderswithinthescopethatthisOSHAactionconsiders.Unlikethehospitalsetting,workplaceviolenceinthepre-hospitalsettingpresentsaparticularlyuniquechallengeduetothemobileandunpredictablenatureofthework.EMSrespondersareexpectedtoprovidepatientcareinhigh-stress,high-risk,andhighlyvariableenvironments.TheEMSsystemservesasacriticalcommunity-basedinterfaceforthepopulationenteringthehealthcaresystem.IntheUnitedStates,approximately22millionpatientsayearreceivecarethroughEMSservicesprovidedbyanestimated900,000EMSresponders(Maguire,2013).EMSplaysanexpandingroleinthehealthofcommunitiesandisacrucialpublichealthsafetynet.Asaresultofthisrelationshipwithcommunities,theEMSsysteminheritsandinterceptssocietiesissuesbeforetheyarrivetothehospital,therebyplacingrespondersatincreasedriskforexperiencingviolenceatthehandsoftheverypatientstheyarecalledtoserve.ContextIn2014,approximately2,600EMSrespondersweretreatedintheEmergencyDepartment(ED)forinjuriesresultingfromworkplaceviolence(CenterforDiseaseControlandPrevention,EmergencyMedicalServicesWorkers,2014).MaguireandSmithdemonstratedthatwork-relatedinjuriesamongEMSresponderswerethreetimeshigherthanthenationalaverageforallotheroccupations(B.J.Maguire&Smith,2013).Inregardstooccupationalfatalities,therateamongparamedicsismorethantwicethenationalaverageforalloccupationsandiscomparabletothoseofpoliceandfirefightersat12.7per100,000workersperyear(BrianJ.Maguire,Hunting,Smith,&Levick,2002).Therateofnon-fatalinjuriesamongUSparamedicswas34.6per100fulltimeworkersperyear,aratemorethanfivetimeshigherthanthenationalaverageforallworkers(B.J.Maguire,Hunting,Guidotti,&Smith,2005).Inregardstofatalinjuries,aretrospectivecohortstudyofnationallyregisteredEMTsintheU.S.foundthat8%offatalitieswereduetoassaults(B.J.Maguire&Smith,2013).TragedymostrecentlystrucktheEMScommunityinMarch2017whenYadiraArroyo,a14yearveteranofFDNY,hadherambulancecommandeeredbyacareercriminalwhothenstruckandkilledherwithherownambulance.Situationssuchasthesemayberareoccurrences,yettheydemandtheattentionofEMSadministratorsandgoverningofficialstoenactsafetymeasuresthatmaypreventandreducethenumberofnon-fatalandfatalinjuriessufferedinEMS.TypesofViolenceInJanuary2016,DrexelUniversitywassubcontractedbytheInternationalAssociationofFireFighters(IAFF)undertheircontractwiththeDepartmentofHomelandSecurity/FederalEmergencyManagementAgency(FEMA)contractnumber:HSFE20-15-Q-0053fortheResearch/StudyofMitigationofIncidenceofViolencetoFireFightersandEMSResponders.ThisfundingallowedforthecompletionofasystematicliteraturereviewonworkplaceviolencemitigationofviolencetofirefightersandEMSresponders.Fromthisliteraturereview,wefoundthatinstudiesmeasuringcareerprevalence,between57and93%ofEMSrespondersreportedhavingexperiencedanactofverbaland/orphysicalviolenceatleastonceduringtheircareer(Bighametal.,2014;Boyleetal.,2007;

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Corbett,1998;Koritsasetal.,2007;Petzalletal.,2011;Pozzi,1998;Suserudetal.,2002;Thomsenetal.,2000;Tintinalli,1993).ArecentsurveyconductedusingdatafromtheLongitudinalEMTAttributesandDemographicsStudy(LEADS)collectedbytheNationalRegistryofEmergencyMedicalTechnicians(NREMT),foundthatamongthe1,789respondents,69.0%experiencedatleastoneformofphysicaland/orverbalviolenceinthepast12months(Gormleyetal.,2016).Furthermore,43.6%experiencedoneormoreformsofphysicalviolenceoverthesamestudyperiod(Gormleyetal.,2016).InEMSviolence-relatedresearchinthepre-hospitalsetting,workplaceviolenceismostoftencategorizedasverbalandphysicalabuse,propertydamageortheft,sexualharassment,sexualassault,andintimidation(Bighametal.,2014;Boyle,Koritsas,Coles,&Stanley,2007;Corbett,1998;Koritsas,Coles,Boyle,&Stanley,2007;Mock,Wrenn,Wright,Eustis,&Slovis,1998;Pozzi,1998).ActsofviolenceagainstEMSrespondershavebeenreportedas“struckbypatient,”“punchedinthefacebyadrunkard,”“tackledbyalargeman,”and“assaultedbyacombativepatient”(Tayloretal.,2016).ItisimportanttonotethatviolenceagainstEMSproviderstakesontwoforms:UnintentionalviolenceandIntentionalviolence.Unintentionalviolencearisesfromcompromisedpatientswhomaybeundertheinfluence,havementalhealthissues,orexistinghealthconditionsthatresultinaggressivebehaviorsandactions.Intentionalviolenceispatient-causedviolencethatispre-meditatedandwasintendedtocauseharm,injury,ordeathtootherindividuals.ViolencerelatedEMSliteratureidentifiesmanysourceswhereintentionalviolenceoccurs,includingovertsituationssuchasbombings,activeshooters,domesticviolence,gangs,workplaceviolence,andterrorism,aswellasmoreinconspicuoussituationssuchas‘normal’responsestoresidencesforcardiacevents.Eachsourceofviolencehasadifferentsetofprotocolsandproceduresthatrespondersfollow,yettheunpredictablenatureofthesescenariosoftenplacesaddeddangerandpressureuponresponders.Respondersmayrushintoaresidencetotreatacriticalpatientandfindthattheyhaveplacedthemselvesinharm’swaybynotensuringproperscenesafetyandreinforcement.Thereisampleopportunitytocreatesaferpracticesandproceduresthatprotectrespondersagainsttheharmsexperiencedasaresultofunintentionalandintentionalviolence.IncreasingExposureAttheheartofthisissue,istherealityofarapidlychangingworkenvironment.Eachyear,theoverallcallvolumeplacetotheEMSsystemincreasesdramatically,therebyincreasingtheriskthatEMSresponderswillbeexposedtopotentiallyviolentencounters.In2015,29millioncallswereplacetoEMSservices,a23%increasefrom2014(NEMSIS,2015).ThisincreaserepresentsacontinuallygrowingtrendtheinUnitedStates.Asthenumberofpatientinteractionscontinuestoincrease,sotodoestheriskforexposuretoviolentincidentsandthelikelihoodthatproviderswillincurinjury.FewinterventionshavebeentargetedtoEMSresponders,leavingtheindustrystrugglingtokeepupwiththegrowingdemandsofthecommunitiestheyareserving.Inanincrediblyuntenablestaffingpractice,ourlocalcommunitypartner-thePhiladelphiaFireDepartment-respondstoover1,000EMScallsperdaywithonly200paramedicsontheroster,halfofwhomareonserviceatanytime.WeconductedamixedmethodsresearchstudywithPhiladelphiamedicsthatrevealedconcerningfeaturesoftheoccupationsuchasunderreportingofviolence-relatedincidents,absenceoftrainings,increasedstress,andmentalhealthimplications(Taylor,2016;Drexel2016).Underreportingoftheissueisagreatcauseforconcern.Oneofthelimitationsthatwenotedfromtheliteratureistheperceptionthatassaultsareainherenttotheprofessionandreportingviolentincidentsimpliesaninabilitytoperformtheirjobcompetently(Corbett,1998). Attitudes such as these have been suggested as a cause for significant underreporting of violence by EMS responders (Pozzi,1998).Asurveyof1500medicalprovidersinNewMexicofoundthat56%ofEMSrespondentsstatedthatviolenceis“justapartofthejob”(Feiner,1995).Andalthoughalargepercentagebelieveviolenceisapartofthejob,40%believedthat ifnoonewasinjuredduringthe incidentthattherewasnoneedtoreport(Feiner,1995).Otherstudiesshowhigher frequencies,upto71%,believingthatviolenceisapartoftheirjob(Pozzi,1998).InasurveyofCanadianparamedics,62%ofparticipantsstatedthatnoactionsweretakenbymost paramedics in response to the violent events (Bigham et al., 2014). In that same study, 61%of participants did not report theviolencetoasuperiororauthorityand81%didnotformallydocumenttheoccurrenceinthepatientcarereport(Bighametal.,2014).Similarly, one study found that only31%of all violent encounterswereproperlymentioned in theparamedicnarrative (Mocket al.,1998).AddingtotheproblemofviolenceexperiencedbyEMSrespondersisthepsychosocialimpactthatviolenceorthethreatofviolencecanhaveuponvictimsofviolenceandtheircolleagues.WhilerobustevidenceoftheexpectedphysicaloutcomesofviolenceagainstEMSresponderslimitedattentionisdedicatedtothepsychosocialimpactofexperiencingviolenceinthiswork.Violenceexposureinthepre-hospitalsettinghasbeenassociatedwithincreasedlevelsofstress,fear,andanxietyinEMSresponders(Gomez-Gutierrez,Bernaldo-de-Quiros,Piccini,&Cerdeira,2016).RevivingResponders,ourcommunitypartner,acquiredpilotdatafromaconveniencesampleof4,021EMSrespondersacross50Statesin2015.Respondentsreported:85%experiencedcriticalstress,37.6%contemplatedsuicide[NationalAverage(CDC)=3.7%],6.6%attemptedsuicide[Nationalaverage(CDC)=0.5%],66%ofrespondentsdidnotseekhelp,andManagementandPeersupportreducedsuicidalideation(Newlandetal.,2015).Stress,JobSatisfaction&BurnoutInadditiontothestressincurredfromviolentexposures,isthestressexperiencedasaresultofexposuretotraumaticincidentsinthefield.Between82and100%ofEMSrespondershaveexperiencedatraumaticevent(Donnelly&Siebert,2009).TraumaticeventsgreatlyimpacttheproclivityofEMSresponderstodevelopseverementalhealthconditions.ThisisrepresentedbythefactthatnumerousstudiesplaceprevalenceratesofPTSDinEMSresponderstobegreaterthan20%(Bennett,2004;Grevin,1996;Marmar,1996;Jonsson,2003;Clohessy,1999;Newland,2015).Fromour literaturereview,we found that theexposure to trauma incombinationwith theirmobileworkplace (e.g.,movingvehicles,difficultterrain,andpeople’shomes)wereperceivedasuncontrollablefeaturesoftheirprofession(B.J.Maguireetal.,2014).Stressisnotonly linked toexposure to traumatic incidents,butalso themonotonousoperational characteristicsofEMSorganizations suchaspaperwork, lackof administrative support, lowwages, longhours, irregular shits, andcynical societal attitudes towardspublic safety

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officers(Boudreaux,Mandry,&Brantley,1997).Cumulativestressassociatedwiththemonotonousdutiesorlowacuitycalls,hasledtofeelingsofdesensitizationforpatients,andtheirjobasawhole(Cannuscioetal.,2016).Ourmixedmethodsstudy,aswellasaresearchfromSwedenfoundthatviolentencountersexperiencedbyEMSrespondersalteredthe provider patient relationship (Suserud et al., 2002; Taylor et al., 2016). Evidence weighing the social and economic costsassociatedwith increased violence and burnout in EMS is basedmostly upon anecdotal evidence,with no assessments conducted tomeasurethemonetarylossofsuchviolentexposures.Someliteraturesuggestthatasviolenceincreases,theneedforpolicebackupalsoincreases,therebyincreasingresponsetimeanddelayingpotentiallycriticalcaretoapatientinneed(Nordberg,1992a).OtherconcernsincludealteredoperationsfortheprivatesectorofEMS(Nordberg,1992a).Intenttoleavetheprofessionisalsoaconcern.AsmoreEMSresponders leave the profession, numerous organizational and patient impacts have been hypothesized including increased costs fortrainingnewEMTsandparamedics,greaternumbersofinexperiencedparamedicsservingatanyonepointintime,andincreasederrorrates committedbynewand inexperiencedparamedics (Federiuk,1992;Patterson, Jones, et al., 2010). Increasingly,EMS respondersreportseekingajobchangeawayfromtheirambulancerole.Inmanycases,EMSrespondershaveindicatedlostinterestinfieldworkandhaveintentionstoleavetheprofession(Bighametal.,2014).Policies,Procedures,&PracticesThere is limited evidence regarding the availability and effectiveness of interventions designed for preventing and mitigating violence in EMS (Gates et al., 2011). Much of the current violence prevention training that exists consists of generic programs that are not tailored to the unique setting of the patient care provider, and primarily focus on self-defense techniques rather than prevention (Gates et al., 2011). Researchers note the guidelines developed for violence reduction in ED settings do not generalize well to the EMS industry (Corbett, 1998). From this information, there is an obvious need for trainings and interventions to prevent and mitigate violence in EMS. ConclusionThefindingspresentedinthisExecutiveSummaryserveasanindicationthatfurtherresearch,policies,andinterventionsareneededinordertobetteridentifyriskfactorsforviolence,circumstancessurroundingviolence,andmethodstobestmitigateviolenceinEMSsothatresourcescanbeproperlyallocatedtoprotectthehealth,safety,andwell-beingofEMSresponders.WithouteffectivepoliciesandprecautionsinplacetoreduceandpreventtheoccurrenceofviolenceagainstEMSresponders,theissuewillcontinuetodirectlyimpactEMSrespondersandsubsequentlythecommunitiestheyseektoserve.ThedevelopmentofsafetystandardsbyOSHAhasthepotentialtoreduceriskofinjuryandfatalitiesrelatedtoviolenceintheEMSprofession.