Pools program to address EMS injuries

By Robert Carruth, CSP, ARM
Risk Control Manager

and Alissa T. Willett
Wellness Program Coordinator

Strain and sprain injuries to county emergency medical responders are arguably the main source of workers' compensation losses to North Carolina counties. Since 2005, members of the NCACC Risk Management Pools have recorded more than 400 claims related to overexertion injuries to emergency responders and have incurred more than $6 million in losses. Practically all of these injuries involved lifting and handling of patients. In addition to this, many other injuries such as falls, bumps and other minor injuries are indirectly related to patient handling.

A disabling injury to an emergency responder can be devastating and career-ending. The end result is a waste to the system of resources needed to train the individual – not to mention the emotional and psychological toll that the injury can have on the individual. In addition, many enter healthcare-related fields having spent most of their career in heavy lifting environments; the cumulative effects of lifting have already begun to take a toll.

In light of these sobering statistics, the NCACC Risk Management Pools – the primary insurer of county governments in North Carolina – has embarked on a program to address this loss issue. This will be a joint effort of the Pools' Risk Control and Wellness functions.

The first step in this process involved a series of meetings that were held at locations across the state in May and early June to solicit input from local EMS administrators whose counties are members of the Risk Management Pools. A total of 21 administrators, training officers and county safety coordinators attended one of the four sessions.

The feedback was organized around five critical areas: screening of applicants, physical performance standards, wellness and behavior, equipment enhancements, and bariatric patient management.

Selection process

"Let people know the reality of the work so they'll last longer in the field."

A wide range of methods are being used to select qualified applicants, ranging from simple strength tests to medical screenings done before and after some sort of weighted cardiovascular exercise. There is also concern about liability to the county should an applicant get injured during the testing. Given this, should the testing instead be delayed until after hiring has been completed and used as a measurement on which to base future improvement?

The North Carolina Community College System is the primary provider of EMT certification in the state. According to NCACC meeting participants, the main focus of the program is on the technical medical skills needed, with little information concerning the physical (and psychological) demands of the job.

Although there is a great deal of desire to improve the pre-hire physical testing, there is also a collateral concern. In rural areas, the pool of qualified applicants is very small. In these counties, the selection criteria could restrict the applicant pool. Better post-hire training and fitness programs should address this and allow for less strict hiring standards.

Annual testing and performance standards

"With testing, everyone will work hard the month before the test in order to pass it, and then nothing will happen for 10 months until time for testing again."

Initially assuming that fitness testing would be the most important part of any program, a great deal of concern was expressed over whether it would actually work. Some larger counties have implemented testing but only after a baseline assessment is performed of the job duties. Others were concerned that by implementing annual testing, most of the personnel would ignore personal fitness, thereby risking injury in trying to perform short-term term training to prepare for the test.

Another related concern was how to address disabilities. Although a certain level of physical mobility is an essential function of the job and can be addressed in the hiring process, minor or short-term disabilities that are being accommodated may make the testing protocol unrealistic.

Finally, on the issue of veteran responders: How do we handle a situation in which an experienced responder can't meet the test standards? Would there be any sort of probationary period provided for them to address the deficiency?

Both of these latter points imply that there would need to be extensive legal review performed for any kind of testing regimen is implemented. It is possible that standards could be instituted statewide, similar to standards adopted for firefighters and law enforcement officers.

Wellness and behavior

"Many systems have tried to implement testing. They believe there should be progressive objectives – goals to reach over time."

There was strong consensus and preference for continual fitness and wellness programs among all participants. This ran counter to simply doing annual physical testing. New habits would be created, and a better culture would evolve over time. In light of this, departments need some way to motivate their responders to eat right, stretch and exercise on a regular basis. Currently, very few if any provide food for their employees, which leads to a higher consumption of high calorie snack foods and takeout meals. These, coupled with the lack of exercise between calls, have led to a high level of obesity among responders.

Physical strength is needed to perform the job, and there has to be a way to improve the fitness levels that include gym memberships, wellness education, and innovative exercise programs that can be done within the restrictions of the job.

Some incentive program would be good, with awards for those employees who maintain a consistent fitness program and practice healthy eating habits.

Finally, managers and supervisors play a key role in helping their responders stay the course. They need to ask questions when they see signs of obesity, and set an example in how to lift, move and take care of themselves.

Equipment enhancements

"It would help to give talking points to convince administration that they need to spend money on technology."

As with the other areas of discussion, there was also a wide variety of opinions concerning the use of power stretchers, which reduce the lifting and loading burden off the responder. Specifically, discussion occurred on how powered cots can help reduce injury by reducing the cumulative stress placed on the back and shoulders. In addition, the use of stair chairs has greatly aided in the transport and movement of patients in space-restricted areas.

While many view power equipment as beneficial, there are still several issues – the increased weight, which could be a detriment for its use; the cost, which may be difficult for many communities to undertake; and the transition of the patient from the original location to the cot.

Participants said that more education is needed with senior management to demonstrate the long-term benefits of using the equipment from a financial standpoint.

Bariatric patients

"People are weighing more and causing more issues with lifting."

This is an emerging issue in most all departments. These are generally individuals weighing in excess of 500 pounds. They exceed the weight capacity of the cot and cause issues with access and transport. The degree of urgency varies greatly across the state and may be higher in areas where there is a medical center nearby. In these communities, there are an increased number of patients in this category who are living in the county on a temporary basis in a hotel while treatment is being administered. This unique environment compounds the rescue challenges.

Many departments have designed processes and special equipment to use with this population. These innovations include:

• Slide sheets that the patient can be placed on, so there is no lifting required until loading.
• Specially outfitted ambulances with ramps and winches to assist loading.
• Use of fire and police first responders to aid in lifting and loading the patient.
• Construction of special ramps and decks at the home to facilitate removal of the individual.

Conclusions

Several conclusions were quickly drawn from the input provided by the attendees:

1. There is no way to create a one-size-fits-all program. A one-method solution will not work to address the issues. Counties need a cafeteria-style program with resources that they can utilize based on their individual environment.
2. A program of wellness and continual fitness is preferred over an annual physical fitness test.
3. Any successful effort must have the support and endorsement of the state EMS office, as well as the N.C. Association of EMS Administrators.
4. A grant program would be beneficial for overcoming issues related to cost, especially in smaller counties with limited resources.
5. More education is needed of county managers and boards of commissioners to show the value of investing in a program to reduce EMS injuries.

These meetings were very beneficial in helping us to work toward solutions and focus our efforts. The Risk Management Pools thank all who participated in the meetings.

As Risk Control Manager for the NCACC, Bob Carruth, a current Cabarrus County commissioner, manages the operation of the Risk Control Team for the Risk Management Pools. The team assists members with development of safety policies and programs and identification of liability exposures and controls. Carruth is a Certified Safety Professional and is certified as Associate – Risk Management. He can be contacted at (919) 719-1150 or bob.carruth@ncacc.org.

Alissa Willett serves as the NCACC's wellness program coordinator for the County Health Plan. She is available to assist County Health Plan members implement wellness programs, and advise member groups that already have programs in place. Contact Alissa at (919) 719-1125 or alissa.willett@ncacc.org.