Elsevier

Applied Ergonomics

Volume 82, January 2020, 102977
Applied Ergonomics

Paramedic equipment bags: How their position during out-of-hospital cardiopulmonary resuscitation (CPR) affect paramedic ergonomics and performance

https://doi.org/10.1016/j.apergo.2019.102977Get rights and content

Highlights

  • Effect of bags position on paramedics' performance and ergonomics was investigated.

  • In lab experiment 12 teams of paramedics performed simulation of out-of-hospital CPR.

  • Paramedics were not instructed where to position equipment bags around patient during CPR.

  • Bags locations effected CPR quality, paramedics work efficiency, effort and biomechanical loads.

  • Moving the bags resulted in spinal compression forces above recommended thresholds.

Abstract

This study investigates how the positions of paramedic equipment bags affect paramedic performance and biomechanical loads during out-of-hospital Cardiopulmonary Resuscitation (CPR). An experiment was conducted in which 12 paramedic teams (each including two paramedics) performed in-situ simulations of a cardiac-arrest scenario. CPR quality was evaluated using five standard resuscitation measures (i.e., pre- and post-shock pauses, and compression rate, depth and fraction). The spinal loads while lifting, pulling and pushing the equipment bags were assessed using digital human modeling software (Jack) and prediction equation from previous studies. The results highlight where paramedics are currently choosing to position their equipment. They also demonstrate that the positions of the equipment bags affect CPR quality as well as the paramedics' work efficiency, physiological effort and biomechanical loads. The spinal loads ranged from 1901 to 4030N; furthermore, every occasion on which an equipment bag was lifted resulted in spinal forces higher than 3400N, thus exceeding the maximum threshold stipulated by the National Institute for Occupational Safety and Health. 72% of paramedics' postures were categorized as high or very high risk for musculoskeletal disorders by the Rapid Entire Body Assessment. Guidelines related to bag positioning and equipment handling might improve CPR quality and patient outcomes, and reduce paramedics’ risk of injury.

Introduction

The work of paramedics requires a high level of technical competence and involves both quick decision-making and the ability to act accurately and swiftly (Bitan, 2017; Myers et al., 2008). Paramedics provide immediate life support such as Cardiopulmonary Resuscitation (CPR) during out-of-hospital cardiac arrest. Performing effective CPR depends on multiple measurable parameters, such as compression depth (cm) and rate (bpm), pre/post-shock pauses (sec), and the percentage of time in compressions (Sell et al., 2010; Cheskes et al., 2014; Wik et al., 2005).

Paramedics are exposed to a risk of injury that is approximately three times higher than the average for all occupations; the annual rate of paramedic injuries that result in lost working days is 349.9 per 10,000 full-time workers, in comparison to a rate of 122.2 for all private industry occupations (Maguire and Smith, 2013). The cause of 94% of the injuries is a musculoskeletal disorder, especially strains and sprains (62%) and back pain (18.8%). During their out-of-hospital work, paramedics are forced to adopt unhealthy working postures (Prairie and Corbeil, 2014) and to perform tasks that require the lifting and moving of heavy objects while in non-optimal positions (Fischer et al., 2017). The leading cause of paramedics' injuries is body movement, with 90% attributed to lifting, carrying, or handling a patient and/or equipment (Reichard et al., 2017). However, Reichard et al. (2017) investigated the number of injuries by conducting a survey; they did not perform experiments, take measurements or conduct simulations to investigate the actual biomechanical loads acting on the paramedics' bodies during patient or equipment handling. Furthermore, they did not investigate CPR quality, work efficiency or physiological effort.

Several studies have suggested ergonomics interventions (Karsh et al., 2001) to reduce the biomechanical loads and risk of injury during patient transfer (e.g., Armstrong et al., 2017; Lavender et al., 2007; Conrad et al., 2008; Prairie et al., 2016; Lad et al., 2018). Others have investigated the physiological and biomechanical loads acting on paramedics’ bodies while conducting chest compressions during CPR (Dainty and Gregory, 2017; Tsou et al., 2009, 2014; Heidenreich et al., 2006). However, none of these studies investigated the effects of equipment handling on paramedics' performance, physiology and biomechanics; nor did they mention equipment handling as a variable worthy of study.

To the best of our knowledge, no standardized guidelines or instructions exist regarding where paramedics should position their bags around the patient. Several studies have shown that equipment position affects both the performance of workers and their risk of injury (Harari et al., 2017, 2018, 2019; Ben-Gal and Bukchin, 2002; Shewchuk et al., 2017). However, to the best of our knowledge, no study has investigated whether the positions of paramedics' equipment around the patient affect the quality of CPR or the paramedics' work efficiency, effort and biomechanical loads.

The objective of the current study is threefold: First, to investigate where paramedics are currently choosing to position their equipment around the patient during out-of-hospital cardiac arrest. Second, to investigate CPR quality and paramedics' work efficiency, effort and biomechanical loads during out-of-hospital CPR. Finally, to investigate whether, and to what extent, the positions of the equipment around the patient affect CPR quality and paramedics’ work efficiency, physiological effort and biomechanical loads.

Section snippets

Methods

This study presents an experiment conducted in collaboration with Magen David Adom (MDA), which is the Israeli national emergency medical services (EMS).

Paramedics’ choices for the initial positions of the equipment bags

The heat map of the initial positions (Fig. 4) reveals that the medication bag was most frequently placed to the left of the patient, between the head and the feet (Fig. 4A). The initial position of the air-way bag was most frequently above the patient's head on the left side (Fig. 4B). The monitor's initial position was most frequently on the left side of the head (Fig. 4C). Finally, the oxygen tank was most frequently positioned on the right side of the head (Fig. 4D).

Investigation of the CPR quality measures

The mean and standard

Paramedics’ choices for the positions of the equipment bags

Our results show that the bag positions affect the CPR and ergonomics measures. Yet paramedics in the MDA (the Israeli national emergency medical services) do not receive any instructions or guidelines regarding where to position the equipment bags around the patient. Thus, the results of this study represent the paramedics' personal choices. Since all the paramedics had experience in out-of-hospital CPR, these choices (see Fig. 4, Section 3.1) are likely to represent the paramedics'

Conclusions

Currently, paramedics are not given any instructions or guidelines regarding where to position the bags around the patient during out-of-hospital CPR. Our results demonstrate that the initial positions of the equipment bags influence clinical measurements of CPR quality, as well as measures of the paramedics' work efficiency, effort and biomechanical loads. Furthermore, in some cases, due to the sub-optimal way in which the equipment bags are positioned, it seems that the paramedics waste time

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

The study was partially funded by the Israel Science Foundation (grant No. 8/998) and the Paul Ivanier Center for Production Management, Ben-Gurion University of the Negev. The authors would like to thank Ortal Markel, Tamar Lotan, and Hadar Aviram for their assistance in collecting the data, Yisrael Parmet for his help in the statistical consultation, and all the paramedics that participated in the simulations.

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