Paramedic equipment bags: How their position during out-of-hospital cardiopulmonary resuscitation (CPR) affect paramedic ergonomics and performance
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.
References (55)
- et al.
Implementing powered stretcher and load systems was a cost effective intervention to reduce the incidence rates of stretcher related injuries in a paramedic service
Appl. Ergon.
(2017) - et al.
Time to first shock by emergency medical technicians with automated external defibrillators
Prehospital Emerg. Care
(2002) - et al.
The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the Resuscitation Outcomes Consortium PRIMED trial
Resuscitation
(2014) - et al.
Effects of rescuer position on the kinematics of cardiopulmonary resuscitation (CPR) and the force of delivered compressions
Resuscitation
(2008) - et al.
Designing ergonomic interventions for EMS workers: concept generation of patient-handling devices
Appl. Ergon.
(2008) - et al.
Investigation of low back and shoulder demand during cardiopulmonary resuscitation
Appl. Ergon.
(2017) - et al.
Identifying the critical physical demanding tasks of paramedic work: towards the development of a physical employment standard
Appl. Ergon.
(2017) - et al.
Development and validation of an easy-to-use risk assessment tool for cumulative low back loading: the Lifting Fatigue Failure Tool (LiFFT)
Appl. Ergon.
(2017) - et al.
Factors determining workers' pace while conducting continuous sequential lifting, carrying, and lowering tasks
Appl. Ergon.
(2018) - et al.
The most effective rescuer's position for cardiopulmonary resuscitation provided to patients on beds: a randomized, controlled, crossover mannequin study
J. Emerg. Med.
(2014)
Comparison of ergonomic risk assessments in a repetitive high-risk sawmill occupation: saw-filer
Int. J. Ind. Ergon.
Comparing the biomechanical and psychophysical demands imposed on paramedics when using manual and powered stretchers
Appl. Ergon.
Designing ergonomic interventions for EMS workers, Part I: transporting patients down the stairs
Appl. Ergon.
Paramedics on the job: dynamic trunk motion assessment at the workplace
Appl. Ergon.
Biomechanical risk assessment during field loading of hydraulic stretchers into ambulances
Int. J. Ind. Ergon.
Intra-rater and inter-rater reliability of the rapid entire body assessment (REBA) tool
Int. J. Ind. Ergon.
Minimizing pre-and post-defibrillation pauses increases the likelihood of return of spontaneous circulation (ROSC)
Resuscitation
Energy cost models for combined lifting and carrying tasks
Int. J. Ind. Ergon.
Mechanical loading of the low back during cardiopulmonary resuscitation
Resuscitation
Electromyography activity of selected trunk muscles during cardiopulmonary resuscitation
AJEM (Am. J. Emerg. Med.)
Rapid entire body assessment: a literature review
Highlights of the 2015 American Heart Association Guidelines Update for CPR and ECC
Early administration of epinephrine (adrenaline) in patients with cardiac arrest with initial shockable rhythm in hospital: propensity score matched analysis
BMJ
The ergonomic design of workstations using virtual manufacturing and response surface methodology
IIE Trans.
Changes from within – how paramedic services can lead the way human factors is implemented in healthcare
Borg's Perceived Exertion and Pain Scales
Validity of heart rate measurements by the Garmin Forerunner 225 at different walking intensities
J. Med. Eng. Technol.
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