Violence at work and its relationship with burnout, depression and anxiety in healthcare professionals of the emergency services

The aim of this study was to examine the possible relationship between physical and psychological aggression suffered in the workplace and professional burnout, depression and anxiety suffered by healthcare professionals of the emergency services. Methods: 315 physicians, nurses, orderlies and ambulance drivers of Critical Care and Emergency Devices (CCED) in the Andalusian Public Health System, in the province of Granada (Spain) participated. They were interviewed about the exposure to violence at work and answered a battery of questions that measured burnout, depression and anxiety. Results: Physical aggression was significantly related to emotional exhaustion, personal accomplishment at work, depression and anxiety. Psychological aggression was associated with personal accomplishment. Logistic regression showed that the CCED professionals who have suffered physical aggression were 4.2 and 2.6 times more likely to have suffered anxiety and reduced personal accomplishment, respectively, than those who did not suffer physical aggression. On the other hand, feelings of anxiety and reduced personal accomplishment increase the professionals’ risk (3.4 and 2.1 times more likely, respectively) of suffering from physical aggression. Conclusion: The results suggest that exposure to violence is related to the other psychological problems tested: emotional exhaustion and personal accomplishment (two components of burnout), depression and anxiety. In addition, physical violence is a risk factor for anxiety and diminished personal accomplishment of the CCED professionals.

Outcomes in Seriously Head-Injured Patients Undergoing Pre-Hospital Tracheal Intubation vs. Emergency Department Tracheal Intubation

Background: The optimal treatment of major head injuries in the resuscitative phase of care post-injury has yet to be determined. This study measured the effect on mortality of pre-hospital intubation (PHI) vs. emergency department in tubation (EDI) of patients suffering serious head injury. Methods: In the single emergency medical services system for this Canadian province, we used a population-based trauma database, conventional logistic regression (with and without the use of a propensity score to control for selection effect bias) to evaluate the effect of PHI vs. EDI on in-hospital mortality. Inclusion criteria were age ≥ 16 years, serious head injury (Abbreviated Injury Score ≥ 3, non-penetrating trauma) and resuscitative intubation (PHI or EDI). Results: Over 5 years, 283 patients (2000-2005) met inclusion crite ria. Conventional unconditional logistic regression modelled on mortality with “PHI vs. EDI” as the intervention of interest showed an odds ratio of 2.015 (95% CI 1.062 3.825) for improved survival if these patients were intubated in the emergency department rather than in the pre-hospital phase of care. A propensity score adjustment demonstrated a similar but more conservative point estimate (OR 1.727, 95% CI: 0.993 3.004). Conclusions: This observational study demonstrated a survival advantage with EDI (versus PHI) in seriously head-injured patients in a mature, province-wide emergency medical services system.

A Scale of Parental Anxiety about Pediatric Emergency Medical Care Services of Japan: Development, Reliability, Validity, Generalizability and Usefulness

Aim: The purpose of this study was to develop a scale, “parental anxiety about pediatric emergency medical care services” (PAPEMCS), and to evaluate its psychometric properties. Methods: Participants were 14,510 parents with children 6 years old or younger in Kagawa Prefecture. Using each half of the participants, exploratory factor analysis was performed to generate items and factors for the PAPEMCS, and confirmatory factor analysis (CFA) was used to establish the construct validity. The generalizability of the PAPEMCS was evaluated by congruence tests and multigroup CFA. The usefulness of the PAPEMCS was established by the relationship between the PAPEMCS and non-urgent usage of pediatric emergency medical care services (PEMCS). Results: The PAPEMCS compromised 4 factors: “anxiety about quality of PEMCS”, “anxiety about PEMCS system”, “anxiety about public support”, and “anxiety about private support”. All reliability estimates (polychoric ordinal alpha coefficients, item-rest correlations), the item discrimination, 5 fit indices for CFA, the convergent validity (indicator reliabilities, composite reliabilities, average variance extracteds), and the discriminant validity fulfilled the acceptability thresholds. All generalizability estimates fulfilled the predetermined levels of acceptability (Tucker’s congruence coefficients, congruence tests, strict factorial invariance). The usefulness of the PAPEMCS was established by the higher scores of the PAPEMCS being related to non-urgent usage of PEMCS. Conclusions: The PAPEMCS demonstrated satisfactory reliability, validity, generalizability and usefulness. The PAPEMCS is useful to quantify the contents and extent of parental anxiety about PEMCS, and to clarify the mechanisms of non-urgent PEMCS usage.

New Roles for Psychologists in Medical Settings: Direct Services in a Hong Kong Accident and Emergency Department

Study Aim: Descriptions of the direct services of a psychologist (i.e. clinical psychology intern) in an accident and emergency department (AED) are provided as a new and rare area of professional practice. Method: Data were collected in a large, Hong Kong, government hospital over an eighteen-month period. Recipients included 281 patients, 150 medical staff members, and 44 relatives of patients. Results: Interventions with patients and their family members centered on crisis management, diagnostic assessment, psychoeducation, and consultations regarding long-term adjustment to medical infirmities. The majority of staff members sought consultations regarding work related stress such as burnout symptoms and coping with vicarious trauma experiences. Frequency tables provide information on utilization of specific services while case vignettes contextualize psychological interventions. Conclusion: There are many potential benefits of psychological service for AED patients and staff.

The impact of prehospital blood sampling on the emergency department process of patients with chest pain:a pragmatic non-randomized controlled trial

BACKGROUND:In patients with chest pain who arrive at the emergency department(ED)by ambulance,venous access is frequently established prehospital,and could be utilized to sample blood.Prehospital blood sampling may save time in the diagnostic process.In this study,the association of prehospital blood draw with blood sample arrival times,troponin turnaround times,and ED length of stay(LOS),number of blood sample mix-ups and blood sample quality were assessed.METHODS:The study was conducted from October 1,2019 to February 29,2020.In patients who were transported to the ED with acute chest pain with low suspicion for acute coronary syndrome(ACS),outcomes were compared between cases,in whom prehospital blood draw was performed,and controls,in whom blood was drawn at the ED.Regression analyses were used to assess the association of prehospital blood draw with the time intervals.RESULTS:Prehospital blood draw was performed in 100 patients.In 406 patients,blood draw was performed at the ED.Prehospital blood draw was independently associated with shorter blood sample arrival times,shorter troponin turnaround times and decreased LOS(P<0.001).No differences in the number of blood sample mix-ups and quality were observed(P>0.05).CONCLUSION:For patients with acute chest pain with low suspicion for ACS,prehospital blood sampling is associated with shorter time intervals,while there were no significant differences between the two groups in the validity of the blood samples.

Overview of the Shenzhen Emergency Medical Service Call Pattern

BACKGROUND:In Shenzhen,the Emergency Medical Service(EMS) system has been in service since 1997.This study aims to examine the operation of Shenzhen 120 EMS center and to identify the reasons of calling EMS.METHODS:In this retrospective quantitative descriptive study,the data from the Shenzhen 120 EMS registry in 2011 were analyzed.RESULTS:Shenzhen 120 EMS center is a communication command center.When the number of 120 are dialed,it is forwarded to the closest appropriate hospital for ambulance dispatch.In2011,the Shenzhen 120 EMS center received 153 160 ambulance calls,with an average of 420 calls per day.Calling emergency services was mainly due to traffic accidents.Trauma and other acute diseases constituted a majority of ambulance transports.The adult patients aged 15-60 years are the principal users of EMS.There are no recognized 'paramedic' doctors and nurses.The pre-hospital emergency service is under the operation of emergency departments of hospitals.Shenzhen at present does not have specialized pre-hospital training for doctors and nurses in posttrauma management.Moreover,specialized pre-hospital training,financial support,and public health education on proper use of EMS should be emphasized.CONCLUSION:The Shenzhen 120 EMS center has its own epidemiology characteristics.Traumatic injury and traffic accident are the main reasons for calling ambulance service.In-depth study emphasizing the distribution and characteristics of trauma patients is crucial to the future development of EMS.

Factors Influencing the Emergency Medical Service Response Time for Cardiovascular Disease in Guangzhou, China

While emergency medical service (EMS) response time (ERT) is a major factor associated with the survival of patients with cardiovascular disease (CVD), relatively few studies have explored the factors associated with ERT. This study aimed to assess the current status of ERT and to identify the factors affecting ERT in patients with CVD in China. Between January 1, 2011 and December 31, 2015, EMS responses to CVD incidents in Guangzhou, China, were examined. The primary outcome was ERT, defined as the time from receipt of an emergency call to the arrival of paramedics on the scene. Factors associated with ERT were evaluated by multivariable logistic regression. A total of 44 383 CVD incidents were analysed. The median ERT was 12.58 min (interquartile range=9.98-15.67). Among the risk factors, distance (OR=13.73, 95% CI=11.76- 16.04), level of hospital (OR=1.57, 95% CI=1.40-1.75), and site of the incident (OR=1.53, 95% CI=1.38-1.69) were the top three significant factors affecting the ERT. Our results suggest that greater attention should be given to factors affecting the ERT. It is essential to make continuous efforts to promote the development of effective interventions to reduce the response time.

Association of post-traumatic stress disorder and work performance: A survey from an emergency medical service, Karachi, Pakistan

BACKGROUND: The purpose of the study was to explore the association between posttraumatic stress disorder(PTSD) and work performance of emergency medical services personnel in Karachi, Pakistan.METHODS: Emergency medical service personnel were screened for potential PTSD using Impact of Event Scale-Revised(IES-R). Work performance was assessed on the basis of fi ve variables: number of late arrivals to work, number of days absent, number of days sick, adherence to protocol, and patient satisfaction over a period of 3 months. In order to model outcomes like the number of late arrivals to work, days absent and days late, negative binomial regression was applied, whereas logistic regression was applied for adherence to protocol and linear for patient satisfaction scores.RESULTS: Mean scores of PTSD were 24.0±12.2. No association was found between PTSD and work performance measures: number of late arrivals to work(RRadj 0.99; 0.98–1.00), days absent(RRadj 0.98; 0.96–0.99), days sick(RRadj 0.99; 0.98–1.00), adherence to protocol(ORadj 1.01; 0.99–1.04) and patient satisfaction(β 0.001%–0.03%) after adjusting for years of formal schooling, living status, coping mechanism, social support, working hours, years of experience and anxiety or depression.CONCLUSION: No statistically significant association was found between PTSD and work performance amongst EMS personnel in Karachi, Pakistan.

Facilitators of and barriers to emergency medical service use by acute ischemic stroke patients: A retrospective survey

Objective: The objective of the study was to identify facilitators and barriers to emergency medical service use among acute ischemic stroke patients in Korea.Methods: This paper presents a secondary analysis of a retrospective survey that collected data from questionnaires and medical records.Among 233 acute ischemic stroke patients enrolled in a large-scale study,160 patients who had arrived at a hospital within 72 h after symptom onset were included in the data analysis.Results: Users of emergency medical services needed a shorter time than non-users to arrive at hospital (140 min vs.625 min.,p =0.001) and were more likely to arrive at hospital within 3 h of symptom onset (51.9% vs.31.5%,p =0.013).For those who first contacted emergency medical service,the facilitators of emergency medical service use were the presence of hemiparesis (p =0.003),bilateral paralysis (p =0.040),and loss of balance (p =0.021).The predominant barrier was the failure to recognize the urgency of symptoms (p 0.006).Conclusions: The use of emergency medical services reduced prehospital delay and increased the likelihood of patient arrival at hospital within 3 h.Given that experiencing typical stroke symptoms was a facilitator of emergency medical service use yet failure to recognize the urgency of symptoms was a barrier,public awareness should be raised as regards stroke symptoms and the benefits of using emergency medical services.

Prototype for Integrating Internet of Things and Emergency Service in an IP Multimedia Subsystem for Wireless Body Area Networks

In recent years, the application of the Internet of Things （IoT） has become an emerging business. The most important concept of next-generation network for providing a common global IT platform is combining seamless networks and networked things, objects or sensors. Also, wireless body area networks （WBANs） are becoming mature with the widespread usage of the IoT. In order to support WBAN, the platform, scenario and emergency service are necessary due to the sensors in WBAN being related to wearer＆#39;s life. The sensors on the body detect a lot of information about bioinformatics and medical signals, such as heartbeat and blood. Thus, the integration of IoT and network communication in daily life is important. However, there is not only a lack of common fabric for integrating IoT with current Internet and but also no emergency call process in the current network communication envi-ronment. To overcome such situations, the prototype of integrating IoT and emergency call process is discussed. A simulated boot-strap platform to provide the discussion of open challenges and solutions for deploying IoT in Internet and the emergency commu-nication system are analyzed by using a service of 3GPP IP multimedia subsystem. Finally, the prototype for supporting WBAN with emergence service is also addressed and the performance results are useful to service providers and network operators that they can estimate their migration to IoT by referring to this experience and experiment results. Furthermore, the queuing model used to achieve the performance of emergency service in IMS and the delay time of the proposed model is analyzed.

An Audit of the Emergency Airway Service in a Regional Hospital in Singapore

Background: Emergency endotracheal intubations (EEI) performed outside of operating theatre (OT) tend to be more challenging and associated with higher risk of complications. In 2011, with the objective of improving patient outcomes, we set up an Emergency Airway Service (EAS) at our 1000-bed regional hospital, with the aim of providing specialized assistance for outside of OT difficult airway management. Method: A retrospective audit of EAS activation from 12/9/2016 and 27/10/2020 was conducted. EAS forms and electronic medical records were reviewed. We collected information on patient characteristics, EAS activation characteristics and its outcomes. Descriptive analysis method was used to present the collected data. Results: There were a total of 275 activations, of which 268 were analysed. Reasons for activation were anticipated difficult intubation (42.2% n = 113), failed intubation attempt (52.6%, n = 141) and advanced intubation equipment required (5.2% n = 14). Intubation was attempted in 261/268 (97.4%) cases by the EAS team. Of these, 255 (97.7%) cases were successful while 6 (2.3%) cases failed intubation. Of the successful intubations by the EAS team, 208/255 (81.5%) were successful on the first attempt. Out of the 6 unsuccessful intubation cases, 1 case required a rescue cricothyroidotomy and 4 cases required an open tracheostomy. Intubation was deemed easy by the EAS team in 170/261 (65.1%) cases. 64/170 (37.6%) cases were intubated with a video laryngoscope (VL). There were 85 cases (32.3%) classified as difficult intubation by the EAS specialist, 13/85 (15.3%) were intubated using only VL, 54/85 (63.5%) cases were intubated using VL with style/bougie. Conclusion: Audit results showed that providing an experienced and well-equipped team of airway specialists round-the-clock to assist in difficult and potentially difficult endotracheal intubations is justifiable and may reduce complications associated with EEI.

Fever Outpatient Service of General Hospital Applies “1 + 3 + 3” Emergency Management Mode to Deal with COVID-19 Pandemic

Purpose: To discuss the effect of “1 + 3 + 3” emergency management mode to deal with COVID-19 pandemic in fever outpatient service of general hospitals. Method: This paper analyzes and summarizes the problems encountered by fever outpatient service in dealing with the COVID-19 pandemic from three aspects of “One Team”, “Three-Key” Control and “Three Mosts”. Results: The application of “1 + 3 + 3” emergency management mode can effectively boost the orderliness and efficiency of fever outpatient service in dealing with COVID-19 pandemic. Conclusion: The “1 + 3 + 3” emergency management mode provides a new management mode and idea for dealing with COVID-19 pandemic, so the fever outpatient service of general hospitals can better improve the national overall anti-pandemic situation.

Mental Wellbeing Monitoring in a Sample of Emergency Medical Service Personnel

Background: There have been concerns regarding the mental wellbeing of emergency medical service staff, particularly when faced with multiple trauma exposures. This study aimed to describe a cross-sectional view of the mental wellbeing status of emergency medical service workers, as well as to comment on the usefulness of an electronic survey tool to reach staff that is distributed across large geographical areas. Methods: The data presented here are drawn from an anonymous, voluntary, electronic survey, made available via the internet, to emergency medical service workers in the Western Cape province of South Africa. This paper reports on four domain expressions of mental wellbeing, namely disordered mood, problematic substance use, post-traumatic stress disorder, and domestic discord. Results: Elevated rates were reported by this sample, across all four distress domains, i.e. mood disorder = 12.3%;problematic substance use = 14.9%;post-traumatic stress disorder = 11.9%;and domestic discord = 11.9%. These rates were generally similar to data from comparable emergency worker groups, and much higher than local population estimates. Conclusions: The data support earlier findings that emergency medical work is associated with increased risk for symptoms of psychological distress, which present a strong case for regular organizational monitoring of employees’ mental wellbeing. In this regard, a brief, internet delivered, survey-type tool showed promise for screening employees, in order to guide further streaming of distressed individuals towards appropriate support services. Further work is required to develop clear mechanisms for referral and intervention in order to optimize a confidential and supportive monitoring program.

Self-Reported Use of Personal Protective Equipment during the SARS-CoV-2 Pandemic in Emergency Medical Service Employees in Germany—A Survey

Background: Multicentric prospective cohort investigation survey conducted between 1st of March and 1st of April 2021on SARS-CoV-2 occupational risk for German Emergency Medical Services (EMS) personnel. Study Objectives: Primary: The objective is to take stock of the use and availability of Personal Protective Equipment (PPE) in German EMS, both at managerial and employee level, during the SARS-CoV-2 pandemic. Secondary: Generate additional data on individual perceptions of risk of infection and occurrence of infections at respective places of service. Methods: Multicentric prospective cohort investigation survey conducted online at two levels of German EMS personnel—EMS managers and EMS employees, both medical and paramedical—with questions adapted slightly to fit the respective study population. Results: A total of 34 responses were received in the managerial group;a total of 2389 responses were received in the group of employees. Self-reported PPE adherence of EMS employees for confirmed SARS-CoV-2 positive patients: use of gloves (99.8%), FFP2 or FFP3 masks (99.8%), gowns or coveralls (99.1%), goggles (89.7%), face shields (24.0%), surgical masks (0.0%). Self-reported PPE adherence of EMS employees for suspected SARS-CoV-2 positive patients: gloves (98.8%), FFP2 or FFP3 masks (total: 99.4%), gowns or coveralls (total: 95.9%), goggles (85.6%), face shields (19.2%), surgical masks (0.2%). Conclusions: Findings included an overall improved self-reported adherence to PPE compared to studies that were conducted before the pandemic. Self-reported general adherence to PPE recommendations when attending to confirmed SARS-CoV-2 positive patients was good, with the exception of goggles. Self-reported adherence to PPE recommendations dropped when attending to suspected SARS-CoV-2 positive patients.

Satisfaction at Work and Suffering in Professional Psychic Service Mobile Service Emergency (SAMU)

Background: This study aimed to evaluate the level of professional satisfaction, to identify the presence of psychic suffering and their correlations in Emergency Medical Services professionals. Methods: The study is of the exploratory, census, descriptive, transversal type, with quantitative approach. It used three instruments: A sociodemographic questionnaire;the Professional Satisfaction Index—PSI;and the Self Report Questionnaire—SRQ-20. 200 professionals took part in the research (doctors, nurses, nursing technicians and conductors). Results: The data show that the majority of professionals are aged between 40 and 49 years old and that the largest quantity of women belong to the group of nurses. As to the PSI, the majority of professionals pointed out remuneration as the most important for satisfaction. In the overall satisfaction result, the physicians were those who had the highest level of satisfaction. Regarding the SRQ-20 scores, the group of nursing technicians and nurses had the highest prevalence for psychic suffering, with 44.56% and 43.48%. In the statistical analyses between each of the components of the professional satisfaction with the SRQ-20 scores, we verified statistically significant correlations when adopting (p Conclusions: It was concluded that the discontent of workers with remuneration and managerial issues are predominant for total dissatisfaction with work and dissatisfaction exerts a strong influence on the presence of suffering in these professionals.

Emergency service results of central venous catheters:Single center,1042 patients,10-year experience

BACKGROUND Central venous catheterization is currently an important procedure in critical care.Central catheterization has important advantages in many clinical situations.It can also lead to different complications such as infection,hemorrhage,and thrombosis.It is important to investigate critically ill patients undergoing catheterization.AIM To evaluate the characteristics,such as hospitalization,demographic characteristics,post-catheterization complications,and mortality relationships,of patients in whom a central venous catheter was placed in the emergency room.METHODS A total of 1042 patients over the age of 18 who presented to the emergency department between January 2005 and December 2015 were analyzed retrospectively.The patients were divided into three groups,jugular,subclavian,and femoral,according to the area where the catheter was inserted.Complications related to catheterization were determined as pneumothorax,guidewire problems,bleeding,catheter site infection,arterial intervention,and sepsis.Considering the treatment follow-up of the patients,three groups were formed as outpatient treatment,hospitalization,and death.RESULTS The mean age of the patients was 60.99±19.85 years;423(40.6%)of them were women.Hospitalization time was 11.89±16.38 d.There was a significant correlation between the inserted catheters with gender(P=0.009)and hospitalization time(P=0.040).Also,blood glucose,blood urea nitrogen,creatinine,and serum potassium values among the biochemical values of the patients who were catheterized were significant.A significant association was observed in the analysis of patients with complications that develop according to the catheter region(P=0.001)and the outcome stage(P=0.001).In receiver operating characteristic curve analysis of hospitalization time and mortality area under curve was 0.575,the 95%confidence interval was 0.496-0.653,the sensitivity was 71%,and the specificity was 89%(P=0.040).CONCLUSION Catheter location and length of stay are important risk factors for catheter-borne infections.Because the risk of infection was lower than other catheters,jugular catheters should be preferred at entry points,and preventive measures should be taken by monitoring patients closely to reduce hospitalization infections.

Psychological Complaints at Psychological Emergency Service Associated with Referral to Extended Screening in a Psychology School Clinic

The Psychological Emergency Service(PES)at psychology school clinics is an unscheduled and free psychological service to meet urgent demands.From this service,some patients whose complaints require more time for clinical work are referred to the Extended Screening(ES),a modality composed of six extra appointments.This study aims to analyze the sociodemographic profile of patients seen on PES in a Brazilian Psychology School Clinic,and to identify the demands that motivated referral to the ES,for better qualification of the care offered.This is a descriptive analysis research,carried out based on data from the medical records of 46 patients who went through the PES and were referred to the ES at the institution,between the years 2019 and 2021.Sociodemographic data were collected and,from the session reports,a content analysis of the thematic analysis modality was performed to identify the complaints.The participants’age ranged from 18 to 65 years,with a mean of 32.28 years(sd=10.95).There was a predominance of female participants(71.74%),that completed High School(39.14%)and had an income from one to two Brazilian minimum wages(32.61%).The most frequent complaints were depressive symptoms(56.52%)and difficulties in interpersonal relationships(32.61%).The results obtained,besides allowing the survey of the social and demographic profile of the clientele of the PES at the Psychology School Clinic,and demonstrating its social relevance by providing free psychological care,also show to be of great importance for the definition of more accurate criteria for referral to the ES of patients seen on PES.

Analysis of the Effect of Humanistic Care in the Process of Pre-Hospital Emergency Care

Objective:To explore the effectiveness of humanistic care in pre-hospital emergency care.Methods:From April 2020 to January 2021,80 pre-hospital emergency patients were studied.The patients were randomly divided into two groups:a control group(n=40),which received conventional care,and an experimental group(n=40),which received humanistic care.The effects of nursing care and psychological state were compared between the two groups.Results:The experimental group showed better nursing outcomes and a more positive psychological state compared to the control group(P<0.05).Conclusion:Humanistic care in pre-hospital emergency settings is more effective in reducing patients’anxiety and depression,enhancing the operational abilities and service attitudes of nursing staff,and increasing the emergency success rate.

Trends and challenges of emergency and acute care in Chinese mainland:2005–2017

BACKGROUND:Emergency medical service system(EMSS)is essential in providing acute care services for health conditions.However,trends of emergency and acute care in China haven’t been studied systematically.METHODS:Relevant literature was carefully reviewed,including original and review articles,letters,government reports,yearbooks,both in Chinese and in English.Data on the number of emergency visits,physicians and beds in emergency departments(EDs),and the workforce of prehospital emergency care were summarized and analyzed from China Health and Family Planning Statistical Yearbooks(2006–2018).RESULTS:Over the past decade,the number of ED visits tripled from 51.9 million to 166.5 million;and utilization of pre-hospital emergency care increased from 3.2 million to 6.8 million.In response to rapid increases in demand,the number of licensed emergency physicians raised from 20,058 to 59,409;the beds’number increased from 10,783 to 42,367.For pre-hospital emergency care,the volume of health workforce increased from 3,687 to 8,671,with a 109%increase in the number of physicians from 1,774 to 3,712.However,overcrowding,the long length of stay in EDs,poor work environment,and work exhaustion were still the critical challenges faced by China’s EMSS.CONCLUSIONS:The number of emergency visits has grown with continual capability enhancement during the past decade.However,overcrowding,the long length of stay in EDs,poor work environment,and work exhaustion still need to be solved by China’s EMSS.These fi ndings and comparison with the USA could offer experiences and lessons to EMSS development worldwide,especially for developing countries.