Making for a safer workplace for fire and EMS providers

Researchers have developed a systems-level checklist to address stress and violence affecting fire-based EMS responders


“Workplace violence can be physical or verbal or both. Regardless of the type, your body has the same physiological response.” — Dr. Jennifer Taylor, presentation at EFOP Graduate Leadership Symposium

Violence is a major issue facing firefighters and EMS personnel. In fact, according to a U.S. Fire Administration report, in partnership with the Center for Firefighter Injury Research and Safety Trends (FIRST Center), “violence against EMS responders has been recognized as an occupational hazard since the early 1970s, and recent incidents are evidence that the problem has not been abated.” While there is limited understanding of risk factors and preventive measures, researchers continue to seek solutions to help protect first responders.

I had the opportunity recently to listen to a presentation by Jennifer Taylor, Ph.D., MPH, CPPS, at the 2022 EFOP Graduate Leadership Symposium at the National Fire Academy. Dr. Taylor – the director of the FIRST Center – focused the presentation on the Center’s work that resulted in the creation of a Systems-level Checklist to address stress and violence affecting fire-based EMS responders.

The National Guard standby as firefighters extinguish a blaze at a gas station Friday, May 29, 2020, in Minneapolis.
The National Guard standby as firefighters extinguish a blaze at a gas station Friday, May 29, 2020, in Minneapolis. (AP Photo/Julio Cortez)

Let’s review the research in detail and consider how fire and EMS agencies might consider implementing the resulting checklist.

About the research

Under Dr. Taylor’s guidance and direction, FIRE Fellows – students in the Fire Service Injury Research, Epidemiology and Evaluation Fellowship – completed this work, a project made possible by a $1.5 million Stress and Violence in fire-based EMS Responders (SAVER) grant from FEMA and the Department of Homeland Security (DHS). The fellows are Drexel University colleagues from departments within the Dornsife School of Public Health at Drexel who analyze data for fire departments and learn about the fire service through field immersion.

A systematic literature review of violence against firefighters and EMS responders in peer-reviewed and industrial journals (1978–2016) found that between 57 and 93% of EMS responders reported having experienced an act of verbal and/or physical violence at least once in their career. With this as the foundation, the primary goal for Dr. Taylor and her colleagues was to develop a systems-level checklist for violence against fire-based EMS responders. They sought to identify the predictors of violence-related injury and stress to fire-based EMS responders, and how fire departments and EMS agencies might proactively address those predictors.

One of the many data sources used by Dr. Taylor and her cohorts was the National EMS Information System (NEMSIS) – the “NFIRS for EMS,” if you will. Their review of the NEMSIS data revealed that the number EMS calls for service nationwide in the U.S. has been increasing at roughly 20% annually. Regardless of the type of organization in which EMS responders work (e.g., fire department, municipal third service, private sector company), they are increasingly expected to do more with less, as staffing levels have not kept pace with the growth in calls for service.

In “A Strained 9-1-1 System and Threats to Public Health,” researchers shared that this increased volume of EMS calls for service without a commensurate increase in staffing, along with other industry strains, is increasingly affecting EMS responders, both physiologically and psychologically. The researchers noted that, as one might expect, increased call volume and exposure to patients increases the risk for injury and illness for EMS responders.

In their study, Taylor and her group learned that an estimated 2,100 EMS workers visited U.S. hospital emergency departments in 2011 to treat an injury resulting from patient violence. Previous research by the FIRST Center confirmed the issue of patient violence by using data from the National Fire Fighter Near-Miss Reporting System, a secure and non-punitive reporting system created by the International Association of Fire Chiefs (IAFC) that collects and shares firefighter near-miss experiences.

As reported in the study, “Injury risks of EMS responders: evidence from the National Fire Fighter Near-Miss Reporting System”: We reviewed emergency medical call reports and analyzed their narrative text fields. Of 185 reports, violence (n=48) was the most identified mechanism of near-miss or injury. We found that emergency medical responders were threatened or assaulted by patients, as well as family members and bystanders. Common underlying factors included: violent patients, patients with mental health issues, and patients with particular health conditions (e.g., seizure, hypoglycemia).

SAVER Systems-level Checklist 

Through their research, Dr. Taylor and her colleagues began developing a systems-level checklist that identifies the potential for physical and verbal violence toward fire-based EMS responders. The checklist addresses each phase of emergency response, including two new phases that emerged from their literature analysis.

In July 2018, the FIRST Center brought together a group of stakeholders – 41 diverse subject-matter experts representing 27 fire service and EMS organizations, government, academia, unions and fire departments – for a two-day “Systems Checklist Consensus Conference (SC3)” to engage in consensus-building, collaboration and evaluation of the proposed checklist. At the completion of SC3, those national stakeholders had arrived at consensus on the efficacy, utility and usability of the systems-level checklist (Table 1 below). 

Table 1
Table 1

The SAVER Systems-level Checklist is more than an innovative application of traditional checklists. It represents a change in thinking, putting the onus for the safety and health of fire-based EMS personnel on the organization as opposed to the current paradigm found in most organizations that places that responsibility on the individual. This new paradigm identifies the necessary actions that fire departments and unions must institute through training, policy and environmental modifications.

A sample of Phase Elements for Phase #1: Pre-Event (Mission). (Note: This is an abbreviated sample, as there are 13 Phase Elements for Mission.)
A sample of Phase Elements for Phase #1: Pre-Event (Mission). (Note: This is an abbreviated sample, as there are 13 Phase Elements for Mission.)

Implementing the SAVER Systems-level Checklist

The SAVER Systems-level Checklist is freely available to the fire and rescue service and is ready to be implemented by a fire department at any time. Fire service leaders can download the Checklist here.

Fire and EMS departments have several options for implementing the SAVER Systems-level Checklist.

Option #1. Implement the Checklist right away and incorporate those items deemed beneficial to the department. For example, Phase 1. Pre-Event: Mission asks if the department includes in its mission statement a commitment to the health and safety of its members. A department could begin to implement the checklist by reviewing the department’s mission statement and updating as needed.

Option #2. Currently, the FIRST Team is working with the SAVER study sites in three large metropolitan fire-based EMS systems (Dallas, Philadelphia, San Diego) to put the Checklist in place and then draft the Checklist elements into formal policies that those departments will start using and evaluating. As such, you can wait and implement the resultant policies. To receive a copy of those model policies once they are developed, email your interest to Regan Murray, MPH, EMT, EMS Project Manager at FIRST.

Option #3. Wait to receive the full evaluative results of the Checklist from FIRST before you decide to implement the Checklist.

As the researchers explained: “The SAVER Systems-level Checklist is research-in-progress, so keep in mind that we do not have all the answers for you yet. If your department implements the Checklist, we are extremely interested in learning about your experience. Your feedback will help us understand how the checklist is being used by fire departments across the country and allows us to ensure that the checklist is adopted and adhered to with the highest fidelity.”

A watershed moment

The development of the SAVER Checklist represents a watershed moment for the health and safety of EMS providers, regardless of how EMS is being delivered in a community (e.g., fire-based, third-service, private sector). The COVID-19 pandemic has provided many learning opportunities for organizations that deliver EMS in their communities, not the least of which is the importance of protecting and maintaining the physiological and psychological health and well-being of our paramedics and EMTs. Providing a systems approach to minimize their exposure to violence while they are doing their job should be a goal for every organization.

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