FOCUS ON EMS WORKFORCE
Prehosp Emerg Care Downloaded from informahealthcare.com by Fudan University on 05/17/15 For personal use only.
OVER-COMMITMENT OF EMS PERSONNEL IN NORTH CAROLINA WITH IMPLICATIONS FOR DISASTER PLANNING Cameron Watkins, MD, Frances S. Shofer, PhD, Theodore R. Delbridge, MD, MPH, Greg D. Mears, MD, Jeff Robertson, Jane H. Brice, MD, MPH ABSTRACT
overcommitment, analysis of variance and the chi-square test were used, respectively. Results. North Carolina credentials 14,717 EMS providers (8,346 EMT, 1,709 EMT-intermediate (EMT-I), 4,662 EMT-paramedic (EMT-P)). Of these, 10,928 (74%) are affiliated with a single system. Of the 3,789 committed to more than one system, 3,020 (21%) were committed to two systems, 571 (4%) to three, 138 (1%) to four, and 60 (37% of their personnel engaged in 91-1 response in more than one system. Conclusion. Many EMS personnel have multiple EMS commitments. Disaster planners and emergency managers should consider overcommitment of emergency responders when calculating the work force on which they can rely. Key words: Disasters; Emergency Medical Services/organization and administration; Emergency Medical Technician
Background. While large-scale disasters are uncommon, our society relies on emergency personnel to be available to respond and act. Faith in their availability may lead to a false sense of security. Many emergency personnel obligate themselves to more than one agency and so may be overcommitted, leaving agencies with unfilled positions in a disaster. We sought to describe the frequency of overcommitment of emergency medical services (EMS) personnel in North Carolina. Methods. We conducted a cross-sectional study utilizing the Credentialing Information System (CIS) of the North Carolina Office of EMS. The CIS database manages demographic and certification information for all EMS personnel in North Carolina. The state is divided into 100 EMS systems based on county boundaries. Utilizing de-identified provider data from the CIS, we collected system(s) affiliation(s) and level of certification. To calculate an overcommitment rate per system, we divided the number of personnel with more than one system affiliation by total number of system roster personnel. To compare urbanicity and certification level with
PREHOSPITAL EMERGENCY CARE 2015;19:247–253
Received January 28, 2014, from the Department of Emergency Medicine, University of Texas Southwestern at Austin (CW; at the time of the study School of Medicine University of North Carolina at Chapel Hill), Department of Emergency Medicine, University of Pennsylvania (FSS; at the time of the study Department of Emergency Medicine, University of North Carolina), Department of Emergency Medicine, East Carolina University (TRD), Department of Emergency Medicine, University of North Carolina (GDM), Performance Improvement Center Department of Emergency Medicine, University of North Carolina (JR), and the Department of Emergency Medicine, University of North Carolina (JHB). Revision received July 16, 2014; accepted for publication August 26, 2014.
INTRODUCTION Emergency medical services (EMS) in the United States transports more than 28 million medically ill or injured patients every year.1,2 In North Carolina alone, EMS responds to more than 1.5 million calls for assistance every year.3 Data from the North Carolina State Office of EMS suggest that the EMS workplace is understaffed. Out of 502 EMS agencies providing care within the state, there were 348 job openings at the beginning of 2014, with the majority (60%) being at the paramedic (or highest) certification level.3 This problem is not unique to North Carolina. News media report similar understaffing issues in locales such as Washington, DC,4 Toronto,5 Seneca County (OH),6 and Austin (TX).7 The EMS Workforce Agenda for the Future states, “Workforce shortages are the
Presented at National Association of EMS Physicians annual meeting. January 2011. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Address correspondence to Jane H. Brice, MD, MPH, Department of Emergency Medicine, CB #7594, University of North Carolina, Chapel Hill, NC 27599-7594. E-mail: [email protected] doi: 10.3109/10903127.2014.959218
247
Prehosp Emerg Care Downloaded from informahealthcare.com by Fudan University on 05/17/15 For personal use only.
248
PREHOSPITAL EMERGENCY CARE
most consistently identified workforce concern of EMS employers.”8 There is ample opportunity for EMS providers to seek and achieve dual or triple employment in EMS systems. Many EMS providers also volunteer with EMS agencies in their communities. Though fortunately rare in occurrence, disasters, both natural and manmade, are unavoidable facts of life. North Carolina faces disaster scenarios yearly in the form of hurricanes, ice storms, tornadoes, and snowstorms. The ability of health-care workers to respond to such crises has been questioned both in the lay press and in medical literature.9,10 Additionally, reports indicate that U.S. hospitals lack the health-care workers and medical equipment/supplies surge capacity necessary to address the overwhelming need created by a disaster.11,12 Disaster planning for emergency response agencies hinges on knowing what dedicated personnel can be deployed to an event. In North Carolina, the State Medical Asset Resource Tracking Tool requires EMS agencies to provide information on staffing, EMS service capability, emergency response vehicles, and disaster resources on a weekly basis.13 Additionally, the North Carolina Credentialing Information System (CIS) has the capability to send electronic messages to all certified EMS professionals throughout the state in a period of less than 5 minutes during a disaster.13 While this has served as an excellent tool in providing EMS resources during disasters, there may be a gap in the system.13 Emergency medical services agencies across North Carolina look to their employment rosters for personnel resources during a disaster. Recent anecdotal evidence suggests that depending on personnel rosters may be a fallacious foundation for disaster planning. EMS personnel are often engaged in services across multiple agencies and in multiple capacities. For example, a paramedic may work fulltime for a 9-1-1 response ground service, part-time for an air medical service, and volunteer with both a community-based 9-1-1 response service and a firebased 9-1-1 medical responder service. It is unclear to which agency this paramedic will respond when disaster strikes North Carolina. Each of the agencies is counting on that paramedic for its disaster planning, but he/she can only be in one place at a time. This study examined the overcommitment of emergency medical services personnel in the state of North Carolina to provide suggestions for disaster planners.
METHODS Study Design We conducted a cross-sectional study of work commitment patterns for EMS personnel in North Carolina during 2010 utilizing an electronic state-mandated personnel management system. The study was approved by the University of North Carolina School
APRIL/JUNE 2015
VOLUME 19 / NUMBER 2
of Medicine institutional review board with an exemption of informed consent. Data use agreements were enacted with the North Carolina Office of EMS to utilize the CIS.
Setting and Population North Carolina is a state of 9,848,060 people.14 EMS operations in North Carolina are overseen by the North Carolina Office of EMS, which, as part of its authority and responsibilities, provides credentialing and medical oversight. The North Carolina Office of EMS credentials three aspects of the state’s EMS system: individual EMS providers, EMS agencies, and countywide EMS systems. For this study, subjects were credentialed EMS providers of any certification level who provided emergency (9-1-1 dispatched) service in North Carolina. A credentialed provider is a person who has completed an educational program in emergency medical care approved by the North Carolina Office of EMS and has passed a certification examination at the EMT-basic, EMT-intermediate, or paramedic level in the state of North Carolina, or a person who has been granted reciprocity by the North Carolina Office of EMS for completing a similar process in another state. A credentialed agency is registered in the CIS database and has an agency permit from the state of North Carolina. Personnel who provided only convalescent, medical care transport or specialty care transport services were excluded. A credentialed EMS system is a coordinated arrangement of resources (including personnel, equipment, agencies, and facilities) organized to respond to medical emergencies and integrated with other health-care providers and networks. North Carolina EMS systems are organized at the county level and include all of the personnel and agencies providing emergency medical care within that defined geographic area. Each EMS system has a single set of medical protocols and a single medical director, and functions as a cohesive whole for disaster planning.15
Data Source North Carolina utilizes an electronic statewide personnel management system for EMS agencies and for providers credentialed to practice within the state. The CIS database is a dynamic reflection of EMS system personnel rosters in North Carolina as each EMS system must update the CIS database every time personnel are added or deleted from their roster. Personnel are unable to document or submit records to the mandated statewide electronic medical record without first being affiliated with a system within the CIS database. The CIS database contains several types of information: 1) complete rosters for every agency credentialed by the state to provide EMS care, 2) provider demographic information (age, gender, etc.), 3) provider credentialing information (level of certification and
C. Watkins
length of certification), 4) provider affiliation information (with which agency the provider is credentialed and at what level of practice provision), and 5) type of commitment of employee to agencies (part time or full time and paid or volunteer). The CIS database can be searched for providers with more than one agency affiliation to determine the rate of provider overcommitment in order to estimate the effect on disaster capacity and response.
Measurements and Data Analysis
Prehosp Emerg Care Downloaded from informahealthcare.com by Fudan University on 05/17/15 For personal use only.
249
OVER-COMMITTED EMS
For each provider, the CIS database was searched in July 2010 for the agencies and systems with which the provider was affiliated. The North Carolina Office of EMS requires that all EMS agencies operate within a county-based EMS system. All planning and medical oversight is conducted at the EMS system level. Thus, disaster planning for an EMS system will include all personnel affiliated with all agencies within the county-based EMS system. Providers who worked for multiple agencies within an EMS system were counted as committed to one EMS system for analysis. Providers who worked for agencies in two different EMS systems were counted as dually committed. An overcommitted provider was defined as any provider who worked in two or more EMS systems. Two scores were developed to assess overcommitment: 1) Individual Commitment Probability, which reflects the probability that a single provider would respond to a particular EMS system in the event of a large-scale disaster; and 2) EMS Commitment Fraction, which reflects the percentage of expected EMS providers who are likely to be available to respond during a disaster across an EMS system, a certification level, or a geographic region. Each of these was calculated as follows. 1. Individual Commitment Probability: Calculated for each provider based on the number of EMS systems with which they were affiliated as a 9-1-1 responder. A provider employed in only one EMS system was assigned a score of 1. If a provider was employed in two EMS systems, the probability of him or her being in either EMS system in a disaster is 0.5, so the provider Individual Commitment Probability for each EMS system was 0.5. Likewise, the Individual Commitment Probability for a provider working in three counties was 0.33 and so forth (4 counties = 0.25, 5 counties = 0.20, 6 counties = 0.167). 2. EMS Commitment Fraction: The EMS Commitment Fraction is calculated in two steps. The EMS Commitment Score is the added Individual Commitment Probabilities (calculated above) for all persons listed as affiliated with a defined grouping (i.e., EMS system, geography, certification level). For example, EMS system X has
400 credentialed providers, half of whom work only in that system and half who work in two different EMS systems. Half of the EMS providers would have Individual Commitment Probabilities of 1.0 and the other half 0.5. So, when totaled across the 400 providers, the EMS Commitment Score would be 200 + 100 = 300. The EMS Commitment Fraction takes the EMS Commitment Score and divides by the total number of providers credentialed in defined grouping. So for EMS system X above, the EMS Commitment Fraction would be 300 divided by 400 for a Commitment Fraction of 0.75, meaning only 0.75 of the work force could be expected to respond in a disaster. It is possible to calculate an EMS Commitment Fraction by system, region, state, and geographical classification. To maintain anonymity of EMS systems, the state of North Carolina was divided into three geographic regions (East, Central, and West) as defined by the North Carolina Office of EMS.16 The East region comprises of 37 counties with a total population of 1,702,695 persons and a population density of 99.0 persons per square mile, the Central Region contains 28 counties (population 3,563,409, density 256.3 persons per square mile), and the West Region has 35 counties (population 2,682,797, density 152.4 persons per square mile).14 The total number of providers employed, Commitment Score, and Commitment Fraction were calculated for each region. Additionally, each EMS system was coded by relative urbanicity17 (wilderness, rural, suburban, and urban18 in order to determine whether there was an association between overcommitment and population density (Figure 1). Summary data are presented as means with ranges and medians with interquartile ranges. To compare overcommitment rate by geographic region and urbanicity, analysis of variance was performed. To examine number of systems to which a provider was committed (1, 2, 3, or more) by certification level, the chi-square test was used. All analyses were performed using SAS statistical software (Version 9.3, SAS Institute, Cary, NC).
RESULTS North Carolina credentialed 14,717 EMS providers (8,346 EMT-basic, 1,709 EMT-intermediate (EMT-I), 4662 EMT-paramedic (EMT-P)) and 11,080 were employed full-time in a system. Seventy-four percent (10,928) were affiliated with a single system.
Individual Commitment Probabilities Individual Commitment Probabilities ranged from 1.0 to 0.11. A total of 3,789 providers were committed to more than one system; 3,020 (21%) were committed to two systems, 571 (4%) to three, 138 (1%) to four, and
Prehosp Emerg Care Downloaded from informahealthcare.com by Fudan University on 05/17/15 For personal use only.
250
PREHOSPITAL EMERGENCY CARE
APRIL/JUNE 2015
VOLUME 19 / NUMBER 2
FIGURE 1. North Carolina population density and regional division map.
60 (37% of their personnel engaged in 9-1-1 response in more than one system.
DISCUSSION Overall, the statewide Commitment Fraction for all EMS personnel was 0.89. Meaning at the state level, we assume we can count on 89% of our EMS providers to be available to a single EMS system in the event of a disaster. This fraction is based on the sum of Individual Probabilities and represents the best possible response. However, bearing in mind that on average 26.7% of an EMS system’s personnel and 37.6% of an EMS system’s EMT-paramedics were committed to more than one EMS system, the worst-case scenario for EMS personnel response is concerning. Despite a thorough search, we were unable to find any literature reporting the disaster capacity for EMS transport personnel. Disaster capacity has, however, been studied for hospital staff. In Cone’s survey from New Haven, Connecticut, 21% of the disaster response hospital staff had conflicting emergency response obligations compared to the 26.7% we found.19 Dausey et al. reported diminished disaster capacity
C. Watkins
251
OVER-COMMITTED EMS
TABLE 1. Commitment data for all EMS personnel
Prehosp Emerg Care Downloaded from informahealthcare.com by Fudan University on 05/17/15 For personal use only.
Total # employed in region Range of # employed for counties in region Avg # employed for counties in region Median # employed for counties in region # employed per 1,000 ppl in region Sum of County Committed Scores for region Range of County Committed Scores in region Avg County Committed Score in region Median County Committed Score for region Region score per 1,000 ppl in region Committed Fraction (CF) of the region CF range for counties in region CF average for counties in region CF median for counties in region
Central
East
West
State
6,261 39–1,556 231.9 123 1.8 5,666 31–1,465 209.9 110.8 1.6 0.91 0.79–0.95 0.87 0.85
5,470 22–544 147.8 116 3.2 4,591 21–490 124.1 94.9 2.7 0.83 0.63–0.97 0.81 0.81
4,793 19–490 133.1 77 1.8 4,458.3 16–467 123.8 70.1 1.6 0.93 0.65–0.98 0.90 0.91
14,717 19–1,556 170.9 111.5 2.1 14,715.3 16–1,465 152.6 92.2 1.8 0.89 0.63–0.98 0.86 0.88
#, number; avg, average; ppl, people.
TABLE 2. Commitment data for full-time employed EMS personnel
Total # employed in region Range of # employed for counties in region Avg # employed for counties in region Median # employed for counties in region # employed per 1,000 ppl in region Sum of County Committed Scores for region Range of County Committed Scores in region Avg County Committed Score in region Median County Committed Score for region Region score per 1,000 ppl in region Committed Fraction (CF) of the region CF range for counties in region CF average for counties in region CF median for counties in region
Central
East
West
State
4,473 24–1,323 165.7 71.0 1.3 4,138 19–1272 155.4 65 1.2 0.93 0.81–1 0.90 0.91
3,433 3–417 92.8 59.0 2.0 3,085 3–396 83.4 52.8 1.8 0.90 0.72–0.98 0.87 0.88
3,174 6–406 88.2 48.5 1.2 3,007 5–402 83.5 46.5 1.1 0.95 0.66–1 0.92 0.94
11,080 3–1,323 115.6 57.0 1.4 10,230 3–1272 107.4 50.6 1.3 0.92 0.66–1 0.89 0.91
#, number; avg, average; ppl, people.
while evaluating tabletop disaster exercises at hospital facilities.20 Denlinger reported that among 16 fire departments in the Atlanta metropolitan area, an average of 22.2% of employees held two or more public safety positions.21 The most dramatic example is one fire department in the Atlanta area, where 56.2% of the personnel work at multiple agencies.21 Emergency response personnel appear to be committed to other responsibilities many times over.
Three studies in the EMS literature discuss proportions of EMS workers that self-report additional employment outside of their primary EMS position. Patterson et al., in studying fatigue and sleep quality among EMS personnel, found a 34.2% self-reported rate of “working at more than one EMS agency.”22 The number of agencies was not quantified in this survey of a convenience sample of EMS professionals attending a western Pennsylvania conference. Frakes
TABLE 3. Commitment data for paramedics
Total # employed in region Range of # employed for counties in region Avg # employed for counties in region Median # employed for counties in region # employed per 1,000 ppl in region Sum of County Committed Scores for region Range of County Committed Scores in region Avg County Committed Score in region Median County Committed Score for region Region score per 1,000 ppl in region Committed Fraction (CF) of the region CF range for counties in region CF average for counties in region CF median for counties in region #, number; avg, average; ppl, people.
Central
East
West
State
2,027 22–394 75.1 50 0.6 1,700 16–353 62.9 40.1 0.5 0.84 0.66 – 0.92 0.81 0.80
1,628 1–193 45.2 41 0.9 1,314 1–171 36.5 31.6 0.8 0.81 0.42 –0.94 0.72 0.74
1,847 11–203 51.3 38 0.7 1,647 8–196 45.8 32.4 0.6 0.89 0.62–0.97 0.87 0.89
4,662 1–394 57.2 43.0 0.7 4,661 1–353 48.4 35.3 0.6 0.85 0.42–0.97 0.80 0.83
252
PREHOSPITAL EMERGENCY CARE
APRIL/JUNE 2015
VOLUME 19 / NUMBER 2
100
% EMS Systems
90 80
86%
37%
70 60
55%
50
44%
46%
50%
41%
40 30 21% 20
24%
15%
14%
10
4%
0%
Prehosp Emerg Care Downloaded from informahealthcare.com by Fudan University on 05/17/15 For personal use only.
0
Wilderness
Rural
Suburban
Urban
Population Density FIGURE 3. Personnel overcommitted by population density (based on interquartile ranges).
et al. studied sleep debt and rates of outside employment among a sample of air medical personnel working 24-hour shifts at helicopter air medical programs.23 Results from the 66% of surveys that were returned in a completed form (n = 133) indicated that 81.1% worked a job outside of their air medical employment. A previous survey of air medical employees working a 12-hour shift indicated 55% had additional employment.24 Finally, a national report using multiple data sources suggests that 18% of EMS personnel work more than a single job, citing two major reasons for this finding.25 EMS personnel commonly take on multiple obligations as a result of low wages, higher per diem wages, and an altruistic nature.25 In addition, Denlinger in writing of multiple employment warned of the “two-hat syndrome” (wearing two hats at the same time), in which EMS personnel may have more pressing responsibilities in an emergency event that would take precedence over participating in EMS duties.21 Multiple employment obligations particularly affect rural areas where fewer full-time positions are available.26 Rural areas especially rely heavily on volunteer and part-time EMTs who often have their primary disaster response obligation elsewhere, leaving rural areas understaffed in the case of disasters affecting the surrounding areas as well.26,27 This is part of the explanation for overcommitment in North Carolina. Of the 3,768 providers who work in volunteer positions, 1,733 have other jobs. Regional differences indicate that the largest concern for overcommitment lies in the eastern portion of the state. This is the most rural region, particularly in the northern portion of the region, likely accounting for this result. Alternatively, the western portion of the state has a large number of rural/wilderness areas, but has the highest commitment fraction in
all categories. This indicates that there are likely other factors that contribute to the commitment of providers. The number of EMS personnel with multiple jobs has implications for disaster planning. Disaster planners and emergency managers should consider overcommitment of emergency responders when calculating the work force on which they can rely.
LIMITATIONS There are several limitations to this study. The data are only able to assume the response to a statewide disaster, and are not able to analyze the effect of a disaster that is only local or in a few locations. We did not evaluate the effects of overcommitment among multiple agencies with a single county EMS system. We fully expect that this is an issue of larger magnitude than what we learned about overcommitments across county lines. For example, we are aware of numerous EMS personnel who are employed full-time by one EMS agency, and work part-time at another agency(s) in the same county. Another consideration is that some EMS personnel work in hospitals, at military installations, or in other positions that could take priority in the event of a disaster, which we were unable to assess. Physical geography, location of patients needing additional assistance during disasters, and the type of disaster may affect the ability to respond in ways this study cannot assess (e.g., flooding, earthquakes, snowstorms, fires). Additionally, it is impossible to determine where personnel will actually end up in a disaster situation whether due to personal preference or inability to participate. For example, individuals may be a victim of the disaster or are separated from their service location because of the disaster. We do not have
C. Watkins
OVER-COMMITTED EMS
data for providers who may be employed or volunteer in other states. This is especially a concern for systems that border other states.
Prehosp Emerg Care Downloaded from informahealthcare.com by Fudan University on 05/17/15 For personal use only.
RECOMMENDATIONS Thought should be put into discussing standardizing where providers will go in disaster situations. It may be possible for EMS providers to declare, in advance, with which EMS agency they will respond in the event of a disaster. This is reasonable in events for which we can plan (e.g., hurricanes). A caveat is that during unanticipated events, they may already be on duty at one of the other locations when they are called up, or may be victims to the disaster themselves. An addition to the CIS database in North Carolina, and similar systems in other states, may be indicated to account for other responsibilities providers may have in disaster situations in order to estimate the capacity of the EMS system. Examples include National Guard, in-hospital employment, other public safety jobs, and positions in neighboring jurisdictions.
CONCLUSIONS A significant portion of EMS providers have multiple and/or conflicting roles that may affect their availability for disaster response. Over a quarter of EMS providers and more than a third of EMT-paramedics in North Carolina are committed to more than one EMS system. Overcommitment is worse in rural areas and the eastern portion of the state. There is a need for EMS systems and statewide disaster planning to incorporate this information.
References 1.
Cady G, Scott T. EMS in the United States: 1995 survey of providers in the 200 most populous cities. JEMS. 1995;20(1):76–82. 2. Federal Interagency Committee on Emergency Medical Services. 2011 National EMS Assessment. U.S. Department of Transportation, National Highway Traffic Safety Administration, DOT HS 811 723, Washington, DC, 2012. Available at www.ems.gov 3. EMS Performance Improvement Center. Personal communication. January 2014. 4. Wells T. Committee on the Judiciary and Public Safety Report to the Council of the District of Columbia. June 28, 2013. Available at media.nbcbayarea.com/documents/PR+20160+FEMS+Committee+Report June+28.pdf 5. D’Souza S. Toronto EMS overwhelmed, understaffed, says report. CBC News Toronto. October 10, 2013. Available at www.cbc.ca/news/canada/toronto/toronto-emsoverwhelmed-understaffed-says-report-1.1959591 6. Berry D. Seneca County EMS dangerously understaffed. FOX19-WXIX. August 6, 2008. Available at www.fox19.com/ story/8800161/seneca-county-ems-dangerously-understaffed
253 7. George P. Austin-Travis County EMS faces first spending overrun in years. Austin American Statesman. August 26, 2012. Available at www.statesman.com/news/news/specialreports/austin-travis-county-ems-faces-first-spending-over/ nRKzR/ http://www.newsradioklbj.com/News/Story.aspx? ID = 1734903 8. National Highway Traffic Safety Administration. The Emergency Medical Services Workforce Agenda for the Future (No. DOT HS 811 473). Washington, DC: U.S. Department of Transportation. 2011. 9. Kaji AH, Koenig KL, Lewis RJ. Current hospital disaster preparedness. JAMA. 2007;298(18):2188–90. 10. Powell T, Hanfling D, Gostin LO. Emergency preparedness and public health: the lessons of Hurricane Sandy. JAMA. 2012;308(24):2569–70. 11. Niska, R, Shimizu, I. Hospital preparedness for emergency response: United States, 2008. Natl Health Stat Report. 2011;24(37):1–14. 12. Rebmann, T, Carrico R, English JF. Hospital infectious disease emergency preparedness: a survey of infection control professionals. Am J Infect Control. 2007;35(1):25–32. 13. Mears G, Pratt D, Glickman S, Brice J, Glickman L, Cabanas J. Cairns C. The North Carolina EMS Data System: a comprehensive integrated emergency medical services quality improvement program. Prehosp Emerg Care. 2009;14(1):85–94. 14. U.S. Census Bureau. North Carolina Population Estimate 2012. Available at www.census.gov. 15. North Carolina Division of Health Service Regulation Office of Emergency Medical Services. Subchapter 13p – Emergency Medical Services and Trauma Rules. Available at www.ncdhhs.gov/dhsr/EMS/pdf/emsrule.pdf 16. North Carolina Division of Health Service Regulation Office of Emergency Medical Services. Region map. Available at www.ncdhhs.gov/dhsr/EMS/regnmap.html 17. Martin WA. Urbanicity. Available at www.urbanicity. us/index.html 18. United States Census Bureau. Urban and rural classifications. Available at www.census.gov/geo/reference/urbanrural.html 19. Cone DC, Cummings BA. Hospital disaster staffing: if you call, will they come? Am J Disaster Med. 2006;1(1): 28–36. 20. Dausey DJ, Buehler JW, Lurie N. Designing and conducting tabletop exercises to assess public health preparedness for manmade and naturally occurring biological threats. BMC Public Health. 2007;7(1):92. 21. Denlinger, RF, Gonzenbach, K. “The Two-Hat Syndrome”: determining response capabilities and mutual aid limitations. Perspectives on Preparedness. No. 11, August 2002. 22. Patterson PD, Suffoletto BP, Kupas DF, Weaver MD, Hostler D. Sleep quality and fatigue among prehospital providers. Prehosp Emerg Care. 2010;14(2):187–93. 23. Frakes MA, Kelly JG. Sleep debt and outside employment patterns in helicopter air medical staff working 24-hour shifts. Air Med J. 2007;26(1):45–9. 24. Frakes MA, Kelly JG. Off-duty preparation for overnight work in rotary-wing air medical programs. Air Med J. 2005;24: 215–7. 25. National Highway Traffic Safety Administration. 9EMS Workforce for the 21st Century: A National Assessment (No. DOT HS 810 943). Washington, DC: U.S. Department of Transportation; 2008. 26. Freeman VA, Slifkin RT, Patterson PD. Recruitment and retention in rural and urban EMS: results from a national survey of local EMS directors. J Public Health Manag Pract. 2009;15(3):246–52. 27. Shearer L Rural areas battling medic shortage in Georgia. Athens Banner-Herald (Georgia) September 24, 2007.
Prehosp Emerg Care Downloaded from informahealthcare.com by Fudan University on 05/17/15 For personal use only.
OVER-COMMITMENT OF EMS PERSONNEL IN NORTH CAROLINA WITH IMPLICATIONS FOR DISASTER PLANNING Cameron Watkins, MD, Frances S. Shofer, PhD, Theodore R. Delbridge, MD, MPH, Greg D. Mears, MD, Jeff Robertson, Jane H. Brice, MD, MPH ABSTRACT
overcommitment, analysis of variance and the chi-square test were used, respectively. Results. North Carolina credentials 14,717 EMS providers (8,346 EMT, 1,709 EMT-intermediate (EMT-I), 4,662 EMT-paramedic (EMT-P)). Of these, 10,928 (74%) are affiliated with a single system. Of the 3,789 committed to more than one system, 3,020 (21%) were committed to two systems, 571 (4%) to three, 138 (1%) to four, and 60 (37% of their personnel engaged in 91-1 response in more than one system. Conclusion. Many EMS personnel have multiple EMS commitments. Disaster planners and emergency managers should consider overcommitment of emergency responders when calculating the work force on which they can rely. Key words: Disasters; Emergency Medical Services/organization and administration; Emergency Medical Technician
Background. While large-scale disasters are uncommon, our society relies on emergency personnel to be available to respond and act. Faith in their availability may lead to a false sense of security. Many emergency personnel obligate themselves to more than one agency and so may be overcommitted, leaving agencies with unfilled positions in a disaster. We sought to describe the frequency of overcommitment of emergency medical services (EMS) personnel in North Carolina. Methods. We conducted a cross-sectional study utilizing the Credentialing Information System (CIS) of the North Carolina Office of EMS. The CIS database manages demographic and certification information for all EMS personnel in North Carolina. The state is divided into 100 EMS systems based on county boundaries. Utilizing de-identified provider data from the CIS, we collected system(s) affiliation(s) and level of certification. To calculate an overcommitment rate per system, we divided the number of personnel with more than one system affiliation by total number of system roster personnel. To compare urbanicity and certification level with
PREHOSPITAL EMERGENCY CARE 2015;19:247–253
Received January 28, 2014, from the Department of Emergency Medicine, University of Texas Southwestern at Austin (CW; at the time of the study School of Medicine University of North Carolina at Chapel Hill), Department of Emergency Medicine, University of Pennsylvania (FSS; at the time of the study Department of Emergency Medicine, University of North Carolina), Department of Emergency Medicine, East Carolina University (TRD), Department of Emergency Medicine, University of North Carolina (GDM), Performance Improvement Center Department of Emergency Medicine, University of North Carolina (JR), and the Department of Emergency Medicine, University of North Carolina (JHB). Revision received July 16, 2014; accepted for publication August 26, 2014.
INTRODUCTION Emergency medical services (EMS) in the United States transports more than 28 million medically ill or injured patients every year.1,2 In North Carolina alone, EMS responds to more than 1.5 million calls for assistance every year.3 Data from the North Carolina State Office of EMS suggest that the EMS workplace is understaffed. Out of 502 EMS agencies providing care within the state, there were 348 job openings at the beginning of 2014, with the majority (60%) being at the paramedic (or highest) certification level.3 This problem is not unique to North Carolina. News media report similar understaffing issues in locales such as Washington, DC,4 Toronto,5 Seneca County (OH),6 and Austin (TX).7 The EMS Workforce Agenda for the Future states, “Workforce shortages are the
Presented at National Association of EMS Physicians annual meeting. January 2011. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Address correspondence to Jane H. Brice, MD, MPH, Department of Emergency Medicine, CB #7594, University of North Carolina, Chapel Hill, NC 27599-7594. E-mail: [email protected] doi: 10.3109/10903127.2014.959218
247
Prehosp Emerg Care Downloaded from informahealthcare.com by Fudan University on 05/17/15 For personal use only.
248
PREHOSPITAL EMERGENCY CARE
most consistently identified workforce concern of EMS employers.”8 There is ample opportunity for EMS providers to seek and achieve dual or triple employment in EMS systems. Many EMS providers also volunteer with EMS agencies in their communities. Though fortunately rare in occurrence, disasters, both natural and manmade, are unavoidable facts of life. North Carolina faces disaster scenarios yearly in the form of hurricanes, ice storms, tornadoes, and snowstorms. The ability of health-care workers to respond to such crises has been questioned both in the lay press and in medical literature.9,10 Additionally, reports indicate that U.S. hospitals lack the health-care workers and medical equipment/supplies surge capacity necessary to address the overwhelming need created by a disaster.11,12 Disaster planning for emergency response agencies hinges on knowing what dedicated personnel can be deployed to an event. In North Carolina, the State Medical Asset Resource Tracking Tool requires EMS agencies to provide information on staffing, EMS service capability, emergency response vehicles, and disaster resources on a weekly basis.13 Additionally, the North Carolina Credentialing Information System (CIS) has the capability to send electronic messages to all certified EMS professionals throughout the state in a period of less than 5 minutes during a disaster.13 While this has served as an excellent tool in providing EMS resources during disasters, there may be a gap in the system.13 Emergency medical services agencies across North Carolina look to their employment rosters for personnel resources during a disaster. Recent anecdotal evidence suggests that depending on personnel rosters may be a fallacious foundation for disaster planning. EMS personnel are often engaged in services across multiple agencies and in multiple capacities. For example, a paramedic may work fulltime for a 9-1-1 response ground service, part-time for an air medical service, and volunteer with both a community-based 9-1-1 response service and a firebased 9-1-1 medical responder service. It is unclear to which agency this paramedic will respond when disaster strikes North Carolina. Each of the agencies is counting on that paramedic for its disaster planning, but he/she can only be in one place at a time. This study examined the overcommitment of emergency medical services personnel in the state of North Carolina to provide suggestions for disaster planners.
METHODS Study Design We conducted a cross-sectional study of work commitment patterns for EMS personnel in North Carolina during 2010 utilizing an electronic state-mandated personnel management system. The study was approved by the University of North Carolina School
APRIL/JUNE 2015
VOLUME 19 / NUMBER 2
of Medicine institutional review board with an exemption of informed consent. Data use agreements were enacted with the North Carolina Office of EMS to utilize the CIS.
Setting and Population North Carolina is a state of 9,848,060 people.14 EMS operations in North Carolina are overseen by the North Carolina Office of EMS, which, as part of its authority and responsibilities, provides credentialing and medical oversight. The North Carolina Office of EMS credentials three aspects of the state’s EMS system: individual EMS providers, EMS agencies, and countywide EMS systems. For this study, subjects were credentialed EMS providers of any certification level who provided emergency (9-1-1 dispatched) service in North Carolina. A credentialed provider is a person who has completed an educational program in emergency medical care approved by the North Carolina Office of EMS and has passed a certification examination at the EMT-basic, EMT-intermediate, or paramedic level in the state of North Carolina, or a person who has been granted reciprocity by the North Carolina Office of EMS for completing a similar process in another state. A credentialed agency is registered in the CIS database and has an agency permit from the state of North Carolina. Personnel who provided only convalescent, medical care transport or specialty care transport services were excluded. A credentialed EMS system is a coordinated arrangement of resources (including personnel, equipment, agencies, and facilities) organized to respond to medical emergencies and integrated with other health-care providers and networks. North Carolina EMS systems are organized at the county level and include all of the personnel and agencies providing emergency medical care within that defined geographic area. Each EMS system has a single set of medical protocols and a single medical director, and functions as a cohesive whole for disaster planning.15
Data Source North Carolina utilizes an electronic statewide personnel management system for EMS agencies and for providers credentialed to practice within the state. The CIS database is a dynamic reflection of EMS system personnel rosters in North Carolina as each EMS system must update the CIS database every time personnel are added or deleted from their roster. Personnel are unable to document or submit records to the mandated statewide electronic medical record without first being affiliated with a system within the CIS database. The CIS database contains several types of information: 1) complete rosters for every agency credentialed by the state to provide EMS care, 2) provider demographic information (age, gender, etc.), 3) provider credentialing information (level of certification and
C. Watkins
length of certification), 4) provider affiliation information (with which agency the provider is credentialed and at what level of practice provision), and 5) type of commitment of employee to agencies (part time or full time and paid or volunteer). The CIS database can be searched for providers with more than one agency affiliation to determine the rate of provider overcommitment in order to estimate the effect on disaster capacity and response.
Measurements and Data Analysis
Prehosp Emerg Care Downloaded from informahealthcare.com by Fudan University on 05/17/15 For personal use only.
249
OVER-COMMITTED EMS
For each provider, the CIS database was searched in July 2010 for the agencies and systems with which the provider was affiliated. The North Carolina Office of EMS requires that all EMS agencies operate within a county-based EMS system. All planning and medical oversight is conducted at the EMS system level. Thus, disaster planning for an EMS system will include all personnel affiliated with all agencies within the county-based EMS system. Providers who worked for multiple agencies within an EMS system were counted as committed to one EMS system for analysis. Providers who worked for agencies in two different EMS systems were counted as dually committed. An overcommitted provider was defined as any provider who worked in two or more EMS systems. Two scores were developed to assess overcommitment: 1) Individual Commitment Probability, which reflects the probability that a single provider would respond to a particular EMS system in the event of a large-scale disaster; and 2) EMS Commitment Fraction, which reflects the percentage of expected EMS providers who are likely to be available to respond during a disaster across an EMS system, a certification level, or a geographic region. Each of these was calculated as follows. 1. Individual Commitment Probability: Calculated for each provider based on the number of EMS systems with which they were affiliated as a 9-1-1 responder. A provider employed in only one EMS system was assigned a score of 1. If a provider was employed in two EMS systems, the probability of him or her being in either EMS system in a disaster is 0.5, so the provider Individual Commitment Probability for each EMS system was 0.5. Likewise, the Individual Commitment Probability for a provider working in three counties was 0.33 and so forth (4 counties = 0.25, 5 counties = 0.20, 6 counties = 0.167). 2. EMS Commitment Fraction: The EMS Commitment Fraction is calculated in two steps. The EMS Commitment Score is the added Individual Commitment Probabilities (calculated above) for all persons listed as affiliated with a defined grouping (i.e., EMS system, geography, certification level). For example, EMS system X has
400 credentialed providers, half of whom work only in that system and half who work in two different EMS systems. Half of the EMS providers would have Individual Commitment Probabilities of 1.0 and the other half 0.5. So, when totaled across the 400 providers, the EMS Commitment Score would be 200 + 100 = 300. The EMS Commitment Fraction takes the EMS Commitment Score and divides by the total number of providers credentialed in defined grouping. So for EMS system X above, the EMS Commitment Fraction would be 300 divided by 400 for a Commitment Fraction of 0.75, meaning only 0.75 of the work force could be expected to respond in a disaster. It is possible to calculate an EMS Commitment Fraction by system, region, state, and geographical classification. To maintain anonymity of EMS systems, the state of North Carolina was divided into three geographic regions (East, Central, and West) as defined by the North Carolina Office of EMS.16 The East region comprises of 37 counties with a total population of 1,702,695 persons and a population density of 99.0 persons per square mile, the Central Region contains 28 counties (population 3,563,409, density 256.3 persons per square mile), and the West Region has 35 counties (population 2,682,797, density 152.4 persons per square mile).14 The total number of providers employed, Commitment Score, and Commitment Fraction were calculated for each region. Additionally, each EMS system was coded by relative urbanicity17 (wilderness, rural, suburban, and urban18 in order to determine whether there was an association between overcommitment and population density (Figure 1). Summary data are presented as means with ranges and medians with interquartile ranges. To compare overcommitment rate by geographic region and urbanicity, analysis of variance was performed. To examine number of systems to which a provider was committed (1, 2, 3, or more) by certification level, the chi-square test was used. All analyses were performed using SAS statistical software (Version 9.3, SAS Institute, Cary, NC).
RESULTS North Carolina credentialed 14,717 EMS providers (8,346 EMT-basic, 1,709 EMT-intermediate (EMT-I), 4662 EMT-paramedic (EMT-P)) and 11,080 were employed full-time in a system. Seventy-four percent (10,928) were affiliated with a single system.
Individual Commitment Probabilities Individual Commitment Probabilities ranged from 1.0 to 0.11. A total of 3,789 providers were committed to more than one system; 3,020 (21%) were committed to two systems, 571 (4%) to three, 138 (1%) to four, and
Prehosp Emerg Care Downloaded from informahealthcare.com by Fudan University on 05/17/15 For personal use only.
250
PREHOSPITAL EMERGENCY CARE
APRIL/JUNE 2015
VOLUME 19 / NUMBER 2
FIGURE 1. North Carolina population density and regional division map.
60 (37% of their personnel engaged in 9-1-1 response in more than one system.
DISCUSSION Overall, the statewide Commitment Fraction for all EMS personnel was 0.89. Meaning at the state level, we assume we can count on 89% of our EMS providers to be available to a single EMS system in the event of a disaster. This fraction is based on the sum of Individual Probabilities and represents the best possible response. However, bearing in mind that on average 26.7% of an EMS system’s personnel and 37.6% of an EMS system’s EMT-paramedics were committed to more than one EMS system, the worst-case scenario for EMS personnel response is concerning. Despite a thorough search, we were unable to find any literature reporting the disaster capacity for EMS transport personnel. Disaster capacity has, however, been studied for hospital staff. In Cone’s survey from New Haven, Connecticut, 21% of the disaster response hospital staff had conflicting emergency response obligations compared to the 26.7% we found.19 Dausey et al. reported diminished disaster capacity
C. Watkins
251
OVER-COMMITTED EMS
TABLE 1. Commitment data for all EMS personnel
Prehosp Emerg Care Downloaded from informahealthcare.com by Fudan University on 05/17/15 For personal use only.
Total # employed in region Range of # employed for counties in region Avg # employed for counties in region Median # employed for counties in region # employed per 1,000 ppl in region Sum of County Committed Scores for region Range of County Committed Scores in region Avg County Committed Score in region Median County Committed Score for region Region score per 1,000 ppl in region Committed Fraction (CF) of the region CF range for counties in region CF average for counties in region CF median for counties in region
Central
East
West
State
6,261 39–1,556 231.9 123 1.8 5,666 31–1,465 209.9 110.8 1.6 0.91 0.79–0.95 0.87 0.85
5,470 22–544 147.8 116 3.2 4,591 21–490 124.1 94.9 2.7 0.83 0.63–0.97 0.81 0.81
4,793 19–490 133.1 77 1.8 4,458.3 16–467 123.8 70.1 1.6 0.93 0.65–0.98 0.90 0.91
14,717 19–1,556 170.9 111.5 2.1 14,715.3 16–1,465 152.6 92.2 1.8 0.89 0.63–0.98 0.86 0.88
#, number; avg, average; ppl, people.
TABLE 2. Commitment data for full-time employed EMS personnel
Total # employed in region Range of # employed for counties in region Avg # employed for counties in region Median # employed for counties in region # employed per 1,000 ppl in region Sum of County Committed Scores for region Range of County Committed Scores in region Avg County Committed Score in region Median County Committed Score for region Region score per 1,000 ppl in region Committed Fraction (CF) of the region CF range for counties in region CF average for counties in region CF median for counties in region
Central
East
West
State
4,473 24–1,323 165.7 71.0 1.3 4,138 19–1272 155.4 65 1.2 0.93 0.81–1 0.90 0.91
3,433 3–417 92.8 59.0 2.0 3,085 3–396 83.4 52.8 1.8 0.90 0.72–0.98 0.87 0.88
3,174 6–406 88.2 48.5 1.2 3,007 5–402 83.5 46.5 1.1 0.95 0.66–1 0.92 0.94
11,080 3–1,323 115.6 57.0 1.4 10,230 3–1272 107.4 50.6 1.3 0.92 0.66–1 0.89 0.91
#, number; avg, average; ppl, people.
while evaluating tabletop disaster exercises at hospital facilities.20 Denlinger reported that among 16 fire departments in the Atlanta metropolitan area, an average of 22.2% of employees held two or more public safety positions.21 The most dramatic example is one fire department in the Atlanta area, where 56.2% of the personnel work at multiple agencies.21 Emergency response personnel appear to be committed to other responsibilities many times over.
Three studies in the EMS literature discuss proportions of EMS workers that self-report additional employment outside of their primary EMS position. Patterson et al., in studying fatigue and sleep quality among EMS personnel, found a 34.2% self-reported rate of “working at more than one EMS agency.”22 The number of agencies was not quantified in this survey of a convenience sample of EMS professionals attending a western Pennsylvania conference. Frakes
TABLE 3. Commitment data for paramedics
Total # employed in region Range of # employed for counties in region Avg # employed for counties in region Median # employed for counties in region # employed per 1,000 ppl in region Sum of County Committed Scores for region Range of County Committed Scores in region Avg County Committed Score in region Median County Committed Score for region Region score per 1,000 ppl in region Committed Fraction (CF) of the region CF range for counties in region CF average for counties in region CF median for counties in region #, number; avg, average; ppl, people.
Central
East
West
State
2,027 22–394 75.1 50 0.6 1,700 16–353 62.9 40.1 0.5 0.84 0.66 – 0.92 0.81 0.80
1,628 1–193 45.2 41 0.9 1,314 1–171 36.5 31.6 0.8 0.81 0.42 –0.94 0.72 0.74
1,847 11–203 51.3 38 0.7 1,647 8–196 45.8 32.4 0.6 0.89 0.62–0.97 0.87 0.89
4,662 1–394 57.2 43.0 0.7 4,661 1–353 48.4 35.3 0.6 0.85 0.42–0.97 0.80 0.83
252
PREHOSPITAL EMERGENCY CARE
APRIL/JUNE 2015
VOLUME 19 / NUMBER 2
100
% EMS Systems
90 80
86%
37%
70 60
55%
50
44%
46%
50%
41%
40 30 21% 20
24%
15%
14%
10
4%
0%
Prehosp Emerg Care Downloaded from informahealthcare.com by Fudan University on 05/17/15 For personal use only.
0
Wilderness
Rural
Suburban
Urban
Population Density FIGURE 3. Personnel overcommitted by population density (based on interquartile ranges).
et al. studied sleep debt and rates of outside employment among a sample of air medical personnel working 24-hour shifts at helicopter air medical programs.23 Results from the 66% of surveys that were returned in a completed form (n = 133) indicated that 81.1% worked a job outside of their air medical employment. A previous survey of air medical employees working a 12-hour shift indicated 55% had additional employment.24 Finally, a national report using multiple data sources suggests that 18% of EMS personnel work more than a single job, citing two major reasons for this finding.25 EMS personnel commonly take on multiple obligations as a result of low wages, higher per diem wages, and an altruistic nature.25 In addition, Denlinger in writing of multiple employment warned of the “two-hat syndrome” (wearing two hats at the same time), in which EMS personnel may have more pressing responsibilities in an emergency event that would take precedence over participating in EMS duties.21 Multiple employment obligations particularly affect rural areas where fewer full-time positions are available.26 Rural areas especially rely heavily on volunteer and part-time EMTs who often have their primary disaster response obligation elsewhere, leaving rural areas understaffed in the case of disasters affecting the surrounding areas as well.26,27 This is part of the explanation for overcommitment in North Carolina. Of the 3,768 providers who work in volunteer positions, 1,733 have other jobs. Regional differences indicate that the largest concern for overcommitment lies in the eastern portion of the state. This is the most rural region, particularly in the northern portion of the region, likely accounting for this result. Alternatively, the western portion of the state has a large number of rural/wilderness areas, but has the highest commitment fraction in
all categories. This indicates that there are likely other factors that contribute to the commitment of providers. The number of EMS personnel with multiple jobs has implications for disaster planning. Disaster planners and emergency managers should consider overcommitment of emergency responders when calculating the work force on which they can rely.
LIMITATIONS There are several limitations to this study. The data are only able to assume the response to a statewide disaster, and are not able to analyze the effect of a disaster that is only local or in a few locations. We did not evaluate the effects of overcommitment among multiple agencies with a single county EMS system. We fully expect that this is an issue of larger magnitude than what we learned about overcommitments across county lines. For example, we are aware of numerous EMS personnel who are employed full-time by one EMS agency, and work part-time at another agency(s) in the same county. Another consideration is that some EMS personnel work in hospitals, at military installations, or in other positions that could take priority in the event of a disaster, which we were unable to assess. Physical geography, location of patients needing additional assistance during disasters, and the type of disaster may affect the ability to respond in ways this study cannot assess (e.g., flooding, earthquakes, snowstorms, fires). Additionally, it is impossible to determine where personnel will actually end up in a disaster situation whether due to personal preference or inability to participate. For example, individuals may be a victim of the disaster or are separated from their service location because of the disaster. We do not have
C. Watkins
OVER-COMMITTED EMS
data for providers who may be employed or volunteer in other states. This is especially a concern for systems that border other states.
Prehosp Emerg Care Downloaded from informahealthcare.com by Fudan University on 05/17/15 For personal use only.
RECOMMENDATIONS Thought should be put into discussing standardizing where providers will go in disaster situations. It may be possible for EMS providers to declare, in advance, with which EMS agency they will respond in the event of a disaster. This is reasonable in events for which we can plan (e.g., hurricanes). A caveat is that during unanticipated events, they may already be on duty at one of the other locations when they are called up, or may be victims to the disaster themselves. An addition to the CIS database in North Carolina, and similar systems in other states, may be indicated to account for other responsibilities providers may have in disaster situations in order to estimate the capacity of the EMS system. Examples include National Guard, in-hospital employment, other public safety jobs, and positions in neighboring jurisdictions.
CONCLUSIONS A significant portion of EMS providers have multiple and/or conflicting roles that may affect their availability for disaster response. Over a quarter of EMS providers and more than a third of EMT-paramedics in North Carolina are committed to more than one EMS system. Overcommitment is worse in rural areas and the eastern portion of the state. There is a need for EMS systems and statewide disaster planning to incorporate this information.
References 1.
Cady G, Scott T. EMS in the United States: 1995 survey of providers in the 200 most populous cities. JEMS. 1995;20(1):76–82. 2. Federal Interagency Committee on Emergency Medical Services. 2011 National EMS Assessment. U.S. Department of Transportation, National Highway Traffic Safety Administration, DOT HS 811 723, Washington, DC, 2012. Available at www.ems.gov 3. EMS Performance Improvement Center. Personal communication. January 2014. 4. Wells T. Committee on the Judiciary and Public Safety Report to the Council of the District of Columbia. June 28, 2013. Available at media.nbcbayarea.com/documents/PR+20160+FEMS+Committee+Report June+28.pdf 5. D’Souza S. Toronto EMS overwhelmed, understaffed, says report. CBC News Toronto. October 10, 2013. Available at www.cbc.ca/news/canada/toronto/toronto-emsoverwhelmed-understaffed-says-report-1.1959591 6. Berry D. Seneca County EMS dangerously understaffed. FOX19-WXIX. August 6, 2008. Available at www.fox19.com/ story/8800161/seneca-county-ems-dangerously-understaffed
253 7. George P. Austin-Travis County EMS faces first spending overrun in years. Austin American Statesman. August 26, 2012. Available at www.statesman.com/news/news/specialreports/austin-travis-county-ems-faces-first-spending-over/ nRKzR/ http://www.newsradioklbj.com/News/Story.aspx? ID = 1734903 8. National Highway Traffic Safety Administration. The Emergency Medical Services Workforce Agenda for the Future (No. DOT HS 811 473). Washington, DC: U.S. Department of Transportation. 2011. 9. Kaji AH, Koenig KL, Lewis RJ. Current hospital disaster preparedness. JAMA. 2007;298(18):2188–90. 10. Powell T, Hanfling D, Gostin LO. Emergency preparedness and public health: the lessons of Hurricane Sandy. JAMA. 2012;308(24):2569–70. 11. Niska, R, Shimizu, I. Hospital preparedness for emergency response: United States, 2008. Natl Health Stat Report. 2011;24(37):1–14. 12. Rebmann, T, Carrico R, English JF. Hospital infectious disease emergency preparedness: a survey of infection control professionals. Am J Infect Control. 2007;35(1):25–32. 13. Mears G, Pratt D, Glickman S, Brice J, Glickman L, Cabanas J. Cairns C. The North Carolina EMS Data System: a comprehensive integrated emergency medical services quality improvement program. Prehosp Emerg Care. 2009;14(1):85–94. 14. U.S. Census Bureau. North Carolina Population Estimate 2012. Available at www.census.gov. 15. North Carolina Division of Health Service Regulation Office of Emergency Medical Services. Subchapter 13p – Emergency Medical Services and Trauma Rules. Available at www.ncdhhs.gov/dhsr/EMS/pdf/emsrule.pdf 16. North Carolina Division of Health Service Regulation Office of Emergency Medical Services. Region map. Available at www.ncdhhs.gov/dhsr/EMS/regnmap.html 17. Martin WA. Urbanicity. Available at www.urbanicity. us/index.html 18. United States Census Bureau. Urban and rural classifications. Available at www.census.gov/geo/reference/urbanrural.html 19. Cone DC, Cummings BA. Hospital disaster staffing: if you call, will they come? Am J Disaster Med. 2006;1(1): 28–36. 20. Dausey DJ, Buehler JW, Lurie N. Designing and conducting tabletop exercises to assess public health preparedness for manmade and naturally occurring biological threats. BMC Public Health. 2007;7(1):92. 21. Denlinger, RF, Gonzenbach, K. “The Two-Hat Syndrome”: determining response capabilities and mutual aid limitations. Perspectives on Preparedness. No. 11, August 2002. 22. Patterson PD, Suffoletto BP, Kupas DF, Weaver MD, Hostler D. Sleep quality and fatigue among prehospital providers. Prehosp Emerg Care. 2010;14(2):187–93. 23. Frakes MA, Kelly JG. Sleep debt and outside employment patterns in helicopter air medical staff working 24-hour shifts. Air Med J. 2007;26(1):45–9. 24. Frakes MA, Kelly JG. Off-duty preparation for overnight work in rotary-wing air medical programs. Air Med J. 2005;24: 215–7. 25. National Highway Traffic Safety Administration. 9EMS Workforce for the 21st Century: A National Assessment (No. DOT HS 810 943). Washington, DC: U.S. Department of Transportation; 2008. 26. Freeman VA, Slifkin RT, Patterson PD. Recruitment and retention in rural and urban EMS: results from a national survey of local EMS directors. J Public Health Manag Pract. 2009;15(3):246–52. 27. Shearer L Rural areas battling medic shortage in Georgia. Athens Banner-Herald (Georgia) September 24, 2007.
