Safety, Health, and Injury Mitigation in Firefighter Training (SHIFT)

Significance: Firefighting is a hazardous, physically demanding occupation. Firefighters must wear 50 pounds of protective gear while performing arduous tasks in dangerous environments such as climbing flights of stairs, swinging tools to breach doors and ventilate roofs, dragging heavy hose lines, and rescuing victims from burning structures. Firefighters must engage in regular exercise to maintain physical fitness to promote occupational readiness to safely and effectively perform occupational tasks. Musculoskeletal injury is an unfortunate consequence of participating in physical activities to maintain physical fitness and in responding to emergencies. A musculoskeletal injury is associated with >$57,000 of financial burden, including lost time from work, equating to more than $9 billion of costs to the U.S. fire service. These musculoskeletal injuries not only lead to lost duty time, but also reduce the firefighter’s capacity to conduct their responsibilities safely and efficiently. Unique to firefighters, diminished physical capabilities in the presence of an injury can equate to casualties for the firefighter, their fellow crew members, as well as the individuals they serve. Therefore, it is imperative we begin to identify efficient and effective strategies to decrease injury rates in the fire service. Firefighter injuries have been categorized into those occurring while performing occupational responsibilities (i.e., at fireground, training operations, non-fire emergencies, other on-duty activities) and those occurring during physical training activity. It has been suggested that up to a third of firefighter injuries and 40% of all time loss for firefighters are a result of physical training injuries. Although broad injury type is reported (such as body part affected or sprains and strains), very little information exists to specifically identify the mechanisms for occupational and physical training injuries. Other physically active populations, such as athletics and military, have been able to develop injury prevention and treatment strategies to impact injury rates positively and decrease lost time for specific injuries. These populations often employ healthcare providers (HCPs), such as athletic trainers (AT) and physical therapists (PT) that are able to document and more specifically categorize these injuries. Therefore, to successfully develop injury prevention and rehabilitative programs to mitigate musculoskeletal injuries commonly seen in the Fire Service, exploration into the impact of direct access to HCPs is needed. Firefighters typically receive care for occupational injuries through a workers’ compensation system. It has been suggested that many injuries that are managed through the workers’ compensation system result in excessive work time loss because of less efficient medical coverage for these injuries. An emerging model to promote wellness and health care efficiency that has been successfully implemented in athletic and other tactical populations, and now in occupational settings, is to provide more direct access to HCPs, such as ATs and PTs, who are experts in musculoskeletal injury assessment, treatment and prevention. The insight that HCPs and firefighters have on risk factors and mechanisms of musculoskeletal injury will provide a platform to developing effective time loss injury intervention and recommendations on the implementation of HCPs. We have obtained preliminary data on HCPs’ perspectives of firefighter injury mechanisms and will now survey firefighters to develop a comprehensive perspective of firefighter injury mechanisms. Collectively, this information will yield the development of effective injury surveillance systems. The focus of our research team is to minimize musculoskeletal injury and promote safe activity in physically active populations. The objective of our research is to better quantify musculoskeletal injury mechanisms in structural firefighters in order to inform evidence-based prevention strategies designed to decrease injury risk. The purposes of this proposal are to examine specific mechanisms of musculoskeletal injury sustained by firefighters during occupational and physical training activities and explore the role that HCPs have on improving care for these injuries. We will accomplish our objectives through the following specific aims: Specific Aim #1: Describe the injury mechanisms and risk factors associated with physical training and occupational operations in firefighters. Hypothesis 1: Qualitative analyses of semi-structured interviews with firefighters will provide insight into the suspected mechanisms for the most commonly treated time loss injuries. Specific Aim #2: Compare firefighter occupational time-loss outcomes due to musculoskeletal injury between departments that use different integrations of health care providers to manage injury. Hypothesis 2: Fire departments that have direct access to HCPs will have lower time loss and financial outcomes from occupational and physical training-based musculoskeletal injuries. Specific Aim #3: Identify the most common barriers to implementation of the model of direct access to HCP in Fire Departments. Hypothesis 3: Qualitative analyses of semi-structured interviews with strategic stakeholders will provide insight into specific barriers and limitations to implement direct access to HCPs in Fire Departments that have and do not have access to HCPs. The establishment of the mechanisms for musculoskeletal injury is a critical step before targeted interventions or prevention strategies can be developed. The understanding of how HCPs are currently being used and how their implementation may affect time loss from duty will lead to more informed recommendations for national policy and future injury mitigation strategies. Our interdisciplinary team of athletic training, physical therapy, exercise physiology, and health promotion researchers has abundant experience in quantifying musculoskeletal injuries in athletic and tactical populations, which can be applied readily to the firefighter population. Additionally, we have established a collaborative network with local and regional fire departments and organizations across the country that are eager to collaborate in research that will improve health and safety within the fire service. Our collaborative team and fire service partners provides the interdisciplinary expertise to systematically evaluate a critical gap in knowledge to a significant occupational hazard that has substantial financial and personal consequences. Approach: In Aim #1, our primary outcome is to use phenomenology to explore the lived experiences of firefighters in relation to incurred injuries during occupational tasks and physical training activity. Specifically, individual semi- structured interviews (N = 15-30) will be conducted with cohorts of firefighters who have sustained these injuries to explore perceptions and experiences related to types of injuries, the duty classification for which the injuries occurred, contributions and potential mechanisms to injuries (e.g., poor movement quality, fatigue), and strategies that could be implemented to mitigate injuries. We have collected preliminary data in a cohort of HCPs regarding their perception of firefighter injury mechanisms and conducted focus groups with firefighters regarding injury mechanisms. These data will be used to further inform and refine the interview structure. In Aim #2, our primary outcome is to perform a case-control study to compare occupational time-loss injuries and financial outcomes between departments with and without direct access to HCPs. We hypothesize that departments with access to HCP will have lower relative (per firefighter) utilization of worker’s compensation services and less time-loss than those departments without direct access. Earlier consultation and care in departments with HCPs will create higher work efficiency and a lower fiscal burden. We will conduct a review of departments with and without direct access to HCPs to compare injury event records to quantify, injury rates, type of injury, activity during injury, reported mechanism, and time loss due to injury. In Aim #3, we will conduct an Across Case Analysis of the direct access HCP model versus traditional workers’ compensation model to explore the barriers and facilitators to implementation of direct access to HCPs in fire departments. Specifically, individual semi-structured interviews will be conducted with strategic stakeholders (fire department administrators, firefighters and HCP) to create a model profile regarding barriers, policies, and budget model factors that may influence the adoption of a direct access HCP model. Revision Plans This submission is a revision to a proposal submitted in the 2021 cycle for this funding mechanism. The research team received very positive feedback from the FEMA Program Officer regarding the review by the Fire Service Panel. Our revised proposal will reflect revisions based on suggestions from two recent productive and encouraging phone calls with the Science Officer from FEMA. One comment about last year’s proposal that was conveyed to us was cautionary if project funds would be allocated as proposed since three separate projects were submitted from UK. Our proposed budget has increased as we respond to the constructive feedback from the previous proposal. We ask the committee to consider the progress we have made with FEMA since last year. Based on this work, we are extremely well-positioned to submit a highly competitive proposal with a high likelihood for success.