EMS Provider Perceptions on Termination of Resuscitation in a Large,Urban EMS System

Objective: Despite the value of out-of-hospital Termination of Resuscitation (TOR) and the scientific evidence in favor of this practice, TOR has not been uniformly adopted or consistently practiced in EMS systems. Previous focus group studies have identified multiple barriers to implementation of out of hospital TOR but existing literature on EMS provider perceptions is limited. We sought to identify EMS providers' perceived barriers to performing out-of-hospital TOR in a large urban EMS system. Methods: The Chicago EMS System is a regional collaborative of EMS physicians, nurses and provider agencies, including the Chicago Fire Department (CFD), which provides exclusive emergency response for 9-1-1 calls in Chicago. CFD is an urban, fire-based EMS agency with a tiered response, with fire-fighter EMTs and paramedics providing initial care, and single role paramedics providing supplemental care and transport. A 2-page written survey was distributed to understand providers' experiences with managing OHCA and perceived barriers to TOR to inform subsequent improvements in protocol development and education. Results: Of 3500 EMS providers that received the survey, 2309 were completed (66%). Survey respondent demographics were fire-fighter/EMTB (69%), fire-fighter/paramedic (14%), and single role paramedic (17%). The most frequent barrier to field TOR was scene safety (86%). The most common safety issue identified was family reaction to TOR (68%) and many providers felt threatened by family when trying to perform

TOR (38%). Providers with a higher career numbers of OHCA were more likely to have felt threatened by the family (OR 6.70, 95% CI 2.99–15.00) and single role paramedics were more likely than FF/EMTBs to have felt threatened (OR 3.34, 95% CI 2.65–4.22). Barriers to delivering a death notification after TOR, include being uncomfortable or threatened with possible family reaction (52%) and family asking to continue the resuscitation (45%). There was lack of formal prior death notification training, the majority learned from colleagues through on the job training. Conclusions: Our study identifies scene safety, death notification delivery, and lack of formal training in death notification as barriers that EMS providers face while performing TOR in a large urban EMS system. These findings informed educational and operational initiatives to overcome the identified provider level issues and improve compliance with TOR policies.     

Prehospital evaluation and economic analysis of different coronary syndrome treatment strategies - PREDICT - Rationale, Development and Implementation

Background

Many health care disciplines use evidence-based decision making to improve patient care and system performance. While the amount and quality of emergency medical services (EMS) research in Canada has increased over the past two decades, there has not been a unified national plan to enable research, ensure efficient use of research resources, guide funding decisions and build capacity in EMS research. Other countries have used research agendas to identify barriers and opportunities in EMS research and define national research priorities. The objective of this project is to develop a national EMS research agenda for Canada that will: 1) explore what barriers to EMS research currently exist, 2) identify current strengths and opportunities that may be of benefit to advancing EMS research, 3) make recommendations to overcome barriers and capitalize on opportunities, and 4) identify national EMS research priorities.

Methods/Design

Paramedics, educators, EMS managers, medical directors, researchers and other key stakeholders from across Canada will be purposefully recruited to participate in this mixed methods study, which consists of three phases: 1) qualitative interviews with a selection of the study participants, who will be asked about their experience and opinions about the four study objectives, 2) a facilitated roundtable discussion, in which all participants will explore and discuss the study objectives, and 3) an online Delphi consensus survey, in which all participants will be asked to score the importance of each topic discovered during the interviews and roundtable as they relate to the study objectives. Results will be analyzed to determine the level of consensus achieved for each topic.

Discussion

A mixed methods approach will be used to address the four study objectives. We anticipate that the keys to success will be: 1) ensuring a representative sample of EMS stakeholders, 2) fostering an open and collaborative roundtable discussion, and 3) adhering to a predefined approach to measure consensus on each topic. Steps have been taken in the methodology to address each of these a priori concerns.     

Determinants of Pediatric EMS Utilization in Children with High-Acuity Conditions

Background: Underutilization of emergency medical services (EMS) for children with high-acuity conditions is poorly understood. Our objective was to identify differences in demographic factors and describe caregivers' knowledge, beliefs, and attitudes regarding EMS utilization for children with high-acuity conditions. Design/Methods: This was a mixed-methods study of children with high acuity conditions, defined as requiring immediate medical or surgical intervention and intensive care admission, over a one year period. Demographic data were collected through a retrospective chart review. Qualitative analysis of semi-structured interviews from a purposive sample of caregivers was conducted until thematic saturation was achieved. Results: Three hundred seventy-four charts were reviewed; 19 caregivers were interviewed (17 in-person, 2 via telephone). The 232 (62%) children not arriving by EMS tended to be younger (1.58 years vs. 2.31 years, p = 0.02), privately insured (30% vs. 19%, p = 0.04), and lived further from the hospital (16.80 miles vs. 12.45 miles, p = 0.001). Patient gender, ethnicity, comorbidities and caregiver language were not associated with EMS underutilization. Immediate invasive medical interventions were more often required for EMS utilizers (85% vs. 60%, p < 0.001). EMS utilizers were more likely to require intubation (78% vs. 47%, p < 0.001) and cardiopulmonary resuscitation (CPR) (26% vs. 2%, p < 0.001), and had shorter hospital stays (4.70 vs. 8.16 days; p-value < 0.001). Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Caretakers expected EMS would provide timely, safe transportation that expedited medical care and emotional support. Medical knowledge and prior experience with EMS influenced decision-making about arrival mode. Timeliness, cost, socioeconomic and demographic characteristics, loss of autonomy, and the logistics of EMS activation and transport were the most commonly reported barriers. Conclusions: Young age, private insurance status, and greater distance from the hospital were associated with EMS underutilization. Understanding caregiver expectations, knowledge, and perceived barriers may have important implications for the use of EMS for children. These findings reveal opportunities for improved public education on EMS systems to enhance appropriate EMS utilization for children with high acuity conditions.     

The role of the EMS safety officer

One of the basic duties of an EMS leader is to ensure the well-being of his or her organization and its members. This can be done by fulfilling the duties of the safety officer. In so doing, the leader is, in effect, serving as risk manager, consultant, adviser and coach. In many cases, the EMS manager provides a member with the opportunity to fill these roles by delegating the responsibility and authority of serving as EMS safety officer. The EMS safety officer essentially has two separate functions: that of the ISO and that of the HSO. Typically, the ISO is another trained officer appointed at specific incidents, while the HSO is primarily an administrator. Regardless of which approach is taken, the bottom line is that safety is as important to EMS providers as it is to firefighters--something that is sometimes forgotten along the way.     

Patient safety in emergency medical services: executive summary and recommendations from the Niagara Summit

Emergency medical services (EMS) personnel care for patients in challenging and dynamic environments that may contribute to an increased risk for adverse events. However, little is known about the risks to patient safety in the EMS setting. To address this knowledge gap, we conducted a systematic review of the literature, including nonrandomized, noncontrolled studies, conducted qualitative interviews of key informants, and, with the assistance of a pan-Canadian advisory board, hosted a 1-day summit of 52 experts in the field of EMS patient safety. The intent of the summit was to review available research, discuss the issues affecting prehospital patient safety, and discuss interventions that might improve the safety of the EMS industry. The primary objective was to define the strategic goals for improving patient safety in EMS. Participants represented all geographic regions of Canada and included administrators, educators, physicians, researchers, and patient safety experts. Data were collected through electronic voting and qualitative analysis of the discussions. The group reached consensus on nine recommendations to increase awareness, reduce adverse events, and suggest research and educational directions in EMS patient safety: increasing awareness of patient safety principles, improving adverse event reporting through creating nonpunitive reporting systems, supporting paramedic clinical decision making through improved research and education, policy changes, using flexible algorithms, adopting patient safety strategies from other disciplines, increasing funding for research in patient safety, salary support for paramedic researchers, and access to graduate training in prehospital research.     

Strategic deployment. Two decades of experience provide important lessons on how to deploy emergency resources

When it comes to deployment, one size (approach) doesn't fit all. Progressive public safety and EMS systems will recognize that a successful plan can thoughtfully balance system performance and human needs. Inventive people who learned how to do things better, cheaper and faster built America. Providing optimum system coverage, improved response times and quality care for patients fits the same mold. Sophisticated and accountable EMS systems readily accept this as part of their mandate.     

Disabling job injuries among urban EMS providers

OBJECTIVE: Nationwide data were collected concerning serious, disabling injuries requiring hospitalization (SDIH) or deaths among urban emergency medical services (EMS) providers. DESIGN AND SETTING: A mail survey of EMS systems was conducted among the 200 most populated U.S. cities. PARTICIPANTS: Participants were training and operations officers of urban EMS systems. MEASUREMENTS AND MAIN RESULTS: Ninety forms (45%) were returned with 88 evaluable (44%). There were 81 SDIHs for a rate of one in 31,616 dispatches. No deaths were reported. Body parts most frequently injured were the hand (22%), head (19%), foot (16%), and eye (14%). Although 90% of fire-based EMS systems (fire-EMS) provided helmets, eye protection, safety shoes, and gloves, less than half (45%) of nonfire-EMS did so. Three (4%) SDIHs resulted from acts of violence. CONCLUSION: Occupational injuries of EMS personnel are at a serious level. Fire-based EMS systems experienced a higher rate of hand SDIHs despite the provision of protective equipment. Few nonfire-EMS staff are provided with safety equipment, which may have resulted in a relatively high number of head and hand SDIHs. Fire-EMS medical directors need to take an active role in verifying that protective equipment is adequate and appropriate to allow the performance of field EMS duties without being too cumbersome. Medical directors of nonfire-EMS must be advocates for the provision of basic protective equipment aimed at mitigating SDIHs of EMS staff.     

Patient Safety in Emergency Medical Services: A Systematic Review of the Literature

Abstract

Background. Preventable harm from medical care has been extensively documented in the inpatient setting. Emergency medical services (EMS) providers care for patients in dynamic and challenging environments; prehospital emergency care is a field that represents an area of high risk for errors and harm, but has received relatively little attention in the patient safety literature. Objective. To identify the threats to patient safety unique to the EMS environment and interventions that mitigate those threats, we completed a systematic review of the literature. Methods. We searched MEDLINE, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) for combinations of key EMS and patient safety terms composed by a pan-canadian expert panel using a year limit of 1999 to 2011. We excluded commentaries, opinions, letters, abstracts, and non-english publications. Two investigators performed an independent hierarchical screening of titles, abstracts, and full-text articles blinded to source. We used the kappa statistic to examine interrater agreement. Any differences were resolved by consensus. Results. We retrieved 5,959 titles, and 88 publications met the inclusion criteria and were categorized into seven themes: adverse events and medication errors (22 articles), clinical judgment (13), communication (6), ground vehicle safety (9), aircraft safety (6), interfacility transport (16), and intubation (16). Two articles were randomized controlled trials; the remainder were systematic reviews, prospective observational studies, retrospective database/chart reviews, qualitative interviews, or surveys. The kappa statistics for titles, abstracts, and full-text articles were 0.65, 0.79, and 0.87, respectively, for the first search and 0.60, 0.74, and 0.85 for the second. Conclusions. We found a paucity of scientific literature exploring patient safety in EMS. Research is needed to improve our understanding of problem magnitude and threats to patient safety and to guide interventions.     

Language Barriers as a Reported Cause of Prehospital Care Delay in Minnesota

Objective. Although anecdotal reports exist, the frequency of language barriers encountered between EMS providers andpatients/families in the prehospital environment remains unknown. The purpose of this study was to determine the frequency of EMS provider-reported perceived delays in care due to language barrier andto characterize the nature of calls involved.Methods. Retrospective analysis of the Minnesota State Ambulance Reporting system (MNSTAR) database, a mandated statewide EMS data collection tool. All EMS run reports submitted between January 1, 2004, andJune 30, 2005, were reviewed to identify instances of reported treatment delay secondary to a language barrier.Results. During the 18-month study period, 629,738 patient encounter reports were submitted to MNSTAR, of which 2,052 identified treatment delays secondary to language. The rate of language barrier care delays in the state of Minnesota is 3.3 per 1,000 prehospital patient encounters.Conclusion. EMS responses troubled by delays in care secondary to language barriers represent a small percentage of total runs in Minnesota. However, approximately 1,370 cases per year occur.     

Strategies Used by Prehospital Providers to Overcome Language Barriers

Objective: Language barriers are commonly encountered in the prehospital setting but there is a paucity of research on how prehospital providers address language discordance. We sought to identify the communication strategies, and the limitations of those strategies, used by emergency medical services (EMS) providers when confronted with language barriers in a variety of linguistic and cultural contexts. Methods: EMS providers were queried regarding communication strategies to overcome language barriers as part of an international, multi-site, sequential explanatory, qualitative-predominant, mixed methods study of prehospital language barriers. A survey of EMS telecommunicators was administered at dispatch centers in New Mexico (United States) and Western Cape (South Africa). Semi-structured qualitative interviews of EMS field providers were conducted at agencies who respond to calls from participating dispatch centers. Survey data included quantitative data on demographics and communication strategies used to overcome language barriers as well as qualitative free-text responses on the limitations of strategies. Interviews elicited narratives of encounters with language-discordant patients and the strategies used to communicate. Data from the surveys and interviews were integrated at the point of analysis. Results: 125 telecommunicators (overall response rate of 84.5%) and a purposive sample of 27 field providers participated in the study. The characteristics of participants varied between countries and between agencies, consistent with variations in participating agencies’ hiring and training practices. Telecommunicators identified 3rd-party telephonic interpreter services as the single most effective strategy when available, but also described time delays and frustration with interpreter communications that leads them to preferentially try other strategies. In the field, all providers reported using similar strategies, relying heavily on bystanders, multilingual coworkers, and non-verbal communication. Prehospital providers described significant limitations to these strategies, including time delays, breaches of patient confidentiality, and inaccurate interpretation. Participants suggested various resources to improve communication with language-discordant patients. Conclusions: Prehospital providers rely upon similar, informal strategies for overcoming language barriers across a variety of locations, provider types, and linguistic and cultural contexts.     

Paramedic Initiated Non-Transport of Pediatric Patients

Introduction. In a time of emergency department overcrowding andincreased utilization of emergency medical services, a highly functional prehospital system will balance the needs of the individual patient with the global needs of the community. Our community addressed these issues through the development of a multitiered prehospital care system that incorporated EMS initiated non-transport of pediatric patients. Objective. To describe the outcome of pediatric patients accessing a progressive prehospital system that employed EMS initiated non-transport. Methods. A prospective observational case series was performed on pediatric patients (< 21 years old) designated EMS initiated non-transport. Patients were designated non-transport after an initial EMS protocol driven, complaint-specific clinical assessment in conjunction with medical oversight affirmation. Telephone follow-up was completed on all consecutively enrolled non-transport patients to collect information about outcome (safety) as well as overall satisfaction with the system. A five-point Likert scale was utilized to rate satisfaction. Results. There were 5,336 EMS requests during the study period. Seven hundred andfour were designated non-transport, of which 74.8% completed phone follow-up. Categories of EMS request included minor; medical illness 43.4%, trauma 55.9%, andother 1.1%. There were 13 admissions (2.4%) to the hospital after EMS initiated non-transport designation. Admissions after non-transport had trends toward younger age (p = 0.002) andmedical etiology (p = 0.006). There were no PICU admissions or deaths. Conclusion. Our EMS system provides an alternative to traditional protocols, allowing EMS initiated non-transport of pediatric patients, resulting in effective resource utilization with a high level of patient safety andfamily satisfaction.     

Knowledge translation in emergency medical services: A qualitative survey of barriers to guideline implementation

Background

The American Heart Association (AHA) released guidelines to improve survival rates from out-of-hospital cardiac arrest in 2005. We sought to identify what barriers delayed the implementation of these guidelines in EMS agencies.

Methods

We surveyed 178 EMS agencies as part of a larger quantitative survey regarding guideline implementation and conducted a single-question semi-structured interview using the Grounded Theory method. We asked “What barriers if any, delayed implementation of the (2005 AHA) guidelines in your EMS agency?” Data were coded and member validation was employed to verify our findings.

Results

176/178 agencies completed the quantitative survey. Qualitative data collection ceased after reaching theoretical saturation with 34 interviews. Ten unique barriers were identified. We categorized these 10 barriers into three themes. The theme instruction delays (reported by 41% of respondents) included three barriers: booking/training instructors (9%), receiving training materials (15%), and scheduling staff for training (18%). The second theme, defibrillator delays (38%), included two barriers; reprogramming defibrillators (24%) and receiving new defibrillators to replace non-upgradeable units (15%). The third theme was decision-making (38%) and included five barriers; coordinating with allied agencies (9%), government regulators such as state and provincial health authorities (9%), medical direction and base hospitals (9%), ROC participation (9%), and internal crises (3%).

Conclusion

Many barriers contributed to delays in the implementation of the 2005 AHA guidelines in EMS agencies. These identified barriers should be proactively addressed prior to the 2010 Guidelines to facilitate rapid translation of science into clinical practice.     

Use of ems for seriously ill children in the office: A survey of primary care physicians

Objectives. To describe how primary care physicians (PCPs) transport seriously ill children from their offices to emergency departments (EDs). Methods. The authors conducted a mail survey of PCPs in upstate New York. Results. The response rate was 60% (119/199). Sixty-six percent (79/119) of the physicians had transferred at least one child from their office to an ED via EMS. Forty-five percent (53/119) had encountered a case of suspected epiglottitis in the office. EMS was used to send 45% (24/53) of suspected epiglottitis cases to the ED, while 40% (21/53) transferred children with possible epiglottitis via family auto. Similarly, the family's auto was used to transport 26% (6/23) of the patients with suspected foreign body aspiration, 46% (32/70) with severe asthma, 59% (30/51) with severe dehydration, and 37% (14/38) with suspected meningococcemia. In contrast, the family's auto was never used for patients with active seizures. The physicians denied that they would call EMS more often if transport time were shorter (58%) or if costs were less (64%). Sixty percent of the PCPs were not sure whether EMS personnel are skilled in pediatric emergencies. Conclusion. The PCPs often failed to call EMS for seriously ill children seen in the office and, instead, used the family's auto for emergency transportation. In this survey, transport time and cost were not barriers to use of EMS. The physicians expressed a lack of confidence in EMS providers' pediatric skills. Targeting educational programs to PCPs that highlight 1) the availability, training, and skill of EMS personnel and 2) the medicolegal risks of family transportation may result in more appropriate use of EMS for children.     

Association Between Poor Sleep,Fatigue, and Safety Outcomes in Emergency Medical Services Providers

Abstract

Objective. To determine the association between poor sleep quality, fatigue, and self-reported safety outcomes among emergency medical services (EMS) workers. Methods. We used convenience sampling of EMS agencies and a cross-sectional survey design. We administered the 19-item Pittsburgh Sleep Quality Index (PSQI), 11-item Chalder Fatigue Questionnaire (CFQ), and 44-item EMS Safety Inventory (EMS-SI) to measure sleep quality, fatigue, and safety outcomes, respectively. We used a consensus process to develop the EMS-SI, which was designed to capture three composite measurements of EMS worker injury, medical errors and adverse events (AEs), and safety-compromising behaviors. We used hierarchical logistic regression to test the association between poor sleep quality, fatigue, and three composite measures of EMS worker safety outcomes. Results. We received 547 surveys from 30 EMS agencies (a 35.6% mean agency response rate). The mean PSQI score exceeded the benchmark for poor sleep (6.9, 95% confidence interval [CI] 6.6, 7.2). More than half of the respondents were classified as fatigued (55%, 95% CI 50.7, 59.3). Eighteen percent of the respondents reported an injury (17.8%, 95% CI 13.5, 22.1), 41% reported a medical error or AE (41.1%, 95% CI 36.8, 45.4), and 90% reported a safety-compromising behavior (89.6%, 95% CI 87, 92). After controlling for confounding, we identified 1.9 greater odds of injury (95% CI 1.1, 3.3), 2.2 greater odds of medical error or AE (95% CI 1.4, 3.3), and 3.6 greater odds of safety-compromising behavior (95% CI 1.5, 8.3) among fatigued respondents versus nonfatigued respondents. Conclusions. In this sample of EMS workers, poor sleep quality and fatigue are common. We provide preliminary evidence of an association between sleep quality, fatigue, and safety outcomes.     

The Emergency Medical Service personnel's perception of the transportation of young children

To our knowledge no previous studies have been made which describe the Emergency Medical Service (EMS) personnel's perceptions of transporting children and the care encounter between the child, the parent and the EMS personnel when separating the child and the parent specifically in an ambulance. The aim of this study was to gain an understanding of how EMS personnel perceive ambulance transport of children. The study was carried out in 2012 at one of three ambulance contractors in Stockholm. Twelve semi-structured interviews were conducted and the content analysis showed that transporting children induces stress and is deemed a precarious task by EMS personnel mainly because children are considered more vulnerable than adults and because of the necessity to separate the child from the parent during transport. There is a conflict between medical- and emotional wellbeing and traffic-safety during the transportation of children and a fear of insufficient ability to care for the child. The EMS personnel's vulnerability is evident in the complicated care situation associated with transporting children in an ambulance. These findings may be considered a first step in assessing if action is needed to improve care and patient safety during ambulance transportation of children.     

Consensus statement: The role of emergency medical services in primary injury prevention

Injury is a leading cause of death and disability. Preventing injuries from ever occurring is primary injury prevention (PIP). The objective of this statement is to present the consensus of a 16-member panel of leaders from the out-of-hospital emergency medical services (EMS) community on essential and desirable EMS PIP activities. Essential PIP activities for leaders and decision makers of every EMS system include: protecting individual EMS providers from injury; providing education to EMS providers in PIP fundamentals; supporting and promoting the collection and utilization of injury data; obtaining support for PIP activities; networking with other injury prevention organizations; empowering individual EMS providers to conduct PIP activities; interacting with the media to promote injury prevention; and participating in community injury prevention interventions. Essential PIP knowledge areas for EMS providers include: PIP principles; personal injury prevention and role modeling; safe emergency vehicle operation; injury risk identification; documentation of injury data; and one-on-one safety education.     

Abstracts for the 2008 NAEMSP Scientific Assembly

Abstract

Objectives. To date, most patient safety studies have been conducted in relation to the hospital rather than the prehospital setting and data regarding emergency medical services (EMS)-related errors are limited. To address this gap, a study was conducted to gain an in-depth understanding of the views of highly experienced EMS practitioners, educators, administrators, and physicians on major issues pertaining to EMS patient safety. The intent of the study was to identify key issues to give direction to the development of best practices in education, policy, and fieldwork. Methods. A qualitative study was conducted using processes described by Lincoln and Guba (1985) to enhance the quality and credibility of data and analysis. Purposive sampling was used to identify informants with knowledge and expertise regarding policy, practice, and research who could speak to the issue of patient safety. Sixteen participants, the majority of whom were Canadian, participated in in-depth interviews. Results. Two major themes were identified under the category of key issues: clinical decision making and EMS's focus and relationship with health care. An education gap has developed in EMS, and there is tension between the traditional stabilize-and-transport role and the increasingly complex role that has come about through “scope creep.” If, as expected, EMS aligns increasingly with the health sector, then change is needed in the EMS educational structure and process to develop stronger clinical decision-making skills. Conclusion. The results of this study indicate that many individual organizations and health regions are addressing issues related to patient safety in EMS, and there are important lessons to be learned from these groups. The broader issues identified, however, are system-wide and best addressed through policy change from health regions and government.     

Methicillin-resistant Staphylococcus aureus in Ohio EMS Providers: A Statewide Cross-sectional Study

The objective was to determine the nasal carriage prevalence of methicillin-resistant Staphylococcus aureus (MRSA) among emergency medical service (EMS) personnel and the associated risk factors. A cross-sectional study was conducted among Ohio EMS personnel randomly sampled from 84 urban and rural agencies. Surveys assessing demographics, occupational history, health, cohabitation status, and hygiene practice were collected with nasal swabs from those who enrolled. Survey weight adjusted analysis was performed (1) to estimate MRSA nasal carriage prevalence of Ohio EMS providers, and (2) to identify variables associated with MRSA. MRSA was detected in 4.6% (13/280) EMS personnel sampled. After employing a survey-weighted analysis the following risk factors associated with MRSA carriage were identified: those who did not practice frequent hand hygiene after glove use (OR, 10.51; 95% CI, 2.54–43.45; P = 0.0012), living with someone with a recent staphylococcal infection (OR, 9.02; 95% CI, 1.03–78.98; P = 0.0470), and individuals with low frequency of hand washing (< 8 times per shift) (OR, 4.20; 95% CI 1.02–17.27; P = 0.0468). An additional risk factor identified through the logistic regression analysis on the study population was EMS workers with an open wound or skin infection (OR, 6.75; 95% CI, 1.25–36.36; P = 0.0262). However, this was not significant in the survey-weighted analysis. The high prevalence of MRSA in Ohio EMS personnel is both an occupational hazard and patient safety concern. Implementing methods to reinforce CDC guidelines for proper hygiene could decrease MRSA found in the EMS setting. Previous literature suggests that a reduction in MRSA colonization can lead to decreases in transmission and improved health for both patients and personnel.