Selected Impacts of Urban Heat Islands on Emergency Medical Services Utilization in Rhode Island.

Objective: The objective of this study was to determine if neighborhood rates of pediatric Emergency Medical Services (EMS) encounters correlate with rates of child maltreatment reporting and if there are neighborhood-level risk factors for EMS encountering children with maltreatment reports. Methods: We conducted a retrospective cohort study using the electronic medical records of children ages <18 years who had Columbus Division of Fire EMS encounters between 2011 and 2015. We used Nationwide Children’s Hospital electronic medical records to identify child maltreatment reports. The EMS scene addresses and home addresses associated with maltreatment reports were geocoded independently and rates for each Census tract were calculated. The maltreatment reports were matched to the EMS encounters using name, gender, and date of birth. Rates of EMS encounters with children that had a maltreatment report were calculated for each Census tract. Census tract demographic information was obtained from the American Community Survey. Bayesian conditional autoregressive Poisson models were used to calculate rate ratios for census tract variables to determine their relationship to EMS encountering children with maltreatment reports. Results: A total of 44,002 EMS encounters and 4,298 maltreatment reports were included in the study. The Spearman correlation coefficient relating rates of EMS encounters to rates of maltreatment reports within census tracts was 0.72 (95% confidence interval, 0.65–0.77). Within the study period, a total of 1,134 EMS encounters were linked to 578 children with maltreatment reports. Poverty was the only independent risk factor for EMS encountering children with maltreatment reports. The multivariate analysis also identified protective factors, which included neighborhoods with higher proportions of residents who had bachelor’s degrees, spoke a language other than English, and had the same residence the previous year. Conclusion: This study showed that in Franklin County, Ohio, neighborhoods with high EMS utilization had a strong positive correlation with areas that had high rates of child maltreatment reports. We also identified four neighborhood characteristics that were independently associated with EMS encountering children at risk for maltreatment (risk factor: poverty; protective factors: residents with college educations, non-English speaking households, and residents maintaining the same residence as the previous year).

Background: Patients receiving chronic dialysis often require emergent and inpatient care; however, only a minimal amount is known about their out-of-hospital/inter-hospital use of Emergency Medical Services (EMS). The purpose of this study was to describe the utilization of EMS in a cohort of dialysis patients. Methods: We analyzed a cohort of adult (≥18 years) chronic dialysis patients within the Nova Scotia Health Authority Central Zone Renal Program who initiated chronic dialysis between January 1, 2009 and June 30, 2013 (last follow up July 1, 2015). Dialysis patient data was linked to regional EMS data. Requests for EMS, including encounter type, day of the week, and patient characteristics were described. Results: The cohort consisted of 468 patients of whom 79% (N = 361) had an EMS encounter. There were a total of 8,774 EMS encounters for the entire cohort. Patients who had an EMS encounter tended to be older (64 ± 14 years), compared to those without an encounter (55 ± 16 years, P < 0.001) and also had a higher burden of comorbidity. Transfers (including those between facilities) accounted for 89% of all encounters (N = 7,826), followed by emergency department (ED) transports (N = 749, 9%). Overall, 79% of all non-transfers underwent transport to the ED. For patients receiving thrice weekly in-center hemodialysis, the highest EMS utilization for ED transport occurred on the first hemodialysis day after the long dialysis break (22%, P < 0.01). The lowest proportion of ED transports occurred on the day after hemodialysis day 3. Conclusion: Utilization of EMS services by dialysis patients is considerable, particularly for transfers. This highlights a potential area to be targeted for reducing resource utilization. Calls requiring transport to the ED occurred most often on Mondays and Tuesdays, the day after the long-dialysis break, and may represent a time of heightened risk for in-center hemodialysis patients.

In the first two years of the COVID-19 pandemic, members of Boston Emergency Medical Services, the City of Boston’s municipal ambulance service, had 7,689 encounters with confirmed-positive Boston residents. As COVID-19 virus strains continue to infect residents in Boston and across the country, understanding the correlation between population positivity, EMS encounters, and hospitalizations can inform healthcare response. This study examines urban virus-surveillance indicators that can serve as an early warning of the volume of Emergency Medical Services (EMS) encounters with COVID-19 positive patients and subsequently how EMS encounters with confirmed COVID-19 patients can serve as an early indicator of future hospital-demand surges. With daily data from Boston EMS and three other public agencies, we evaluate the relationship between five indicators and confirmed Boston EMS COVID-19 encounters by estimating separate Auto Regressive Integrated Moving Average models and cross-correlating their residuals. This study finds a significant and positive correlation between new COVID-19 cases citywide and EMS encounters 6 days later (p < 0.01), as well as between confirmed EMS encounters with COVID-19 patients and the number of intensive care unit beds occupied 7- and 18 -days later (p < 0.01). This study provides city health leadership needed clarity on the specific ordering and associated time lag in which infections in the population increase, EMS members encounter positive patients, and hospitals deliver care.

Severe sepsis is common and highly morbid, yet the epidemiology of severe sepsis at the frontier of the health care system-pre-hospital emergency care-is unknown. We examined the epidemiology of pre-hospital severe sepsis among emergency medical services (EMS) encounters, relative to acute myocardial infarction and stroke. Retrospective study using a community-based cohort of all nonarrest, nontrauma King County EMS encounters from 2000 to 2009 who were transported to a hospital. Overall incidence rate of hospitalization with severe sepsis among EMS encounters, as well as pre-hospital characteristics, admission diagnosis, and outcomes. Among 407,176 EMS encounters, we identified 13,249 hospitalizations for severe sepsis, of whom 2,596 died in the hospital (19.6%). The crude incidence rate of severe sepsis was 3.3 per 100 EMS encounters, greater than for acute myocardial infarction or stroke (2.3 per 100 and 2.2 per 100 EMS encounters, respectively). More than 40% of all severe sepsis hospitalizations arrived at the emergency department after EMS transport, and 80% of cases were diagnosed on admission. Pre-hospital care intervals, on average, exceeded 45 minutes for those hospitalized with severe sepsis. One-half or fewer of patients with severe sepsis were transported by paramedics (n = 7,114; 54%) or received pre-hospital intravenous access (n = 4,842; 37%). EMS personnel care for a substantial and increasing number of patients with severe sepsis, and spend considerable time on scene and during transport. Given the emphasis on rapid diagnosis and intervention for sepsis, the pre-hospital interval may represent an important opportunity for recognition and care of sepsis.

Optimization of Linkage between North Carolina EMS and ED Data: EMS Naloxone Cases

Emergency Medical Services Use Among Patients Receiving Involuntary Psychiatric Holds and the Safety of an Out-of-Hospital Screening Protocol to “Medically Clear” Psychiatric Emergencies in the Field, 2011 to 2016

Rigorous assessment of occupational COVID-19 risk and personal protective equipment (PPE) use is not well-described. We evaluated 9-1-1 emergency medical services (EMS) encounters for patients with COVID-19 to assess occupational...

Pediatric Utilization of Emergency Medical Services from Outpatient Offices and Urgent Care Centers

93 Patients With Sickle Cell Disease Pain Crises Are Often Undertreated in the Out-of-Hospital Setting: A Multi-Agency Cohort Study

Introduction: An automated registry for out-of-hospital cardiac arrest can facilitate cardiac arrest research and emergency medical services (EMS) and community health quality improvement programs. A key element of a cardiac arrest registry is outcome, especially survival to hospital discharge, which is usually obtained from the hospital medical record. A crucial step in capturing survival data automatically is being able to reliably match EMS patient care reports with hospital medical records. Objective: To determine the accuracy of a probabilistic record-linkage approach to match EMS and hospital encounters and identify barriers of automation. Methods: This is a prospective feasibility study from the Dallas Fort-Worth Center for Resuscitation Research. Our cardiac arrest registry was part of the Resuscitation Outcomes Consortium (ROC) Epistry from 2006 to 2016. Since 2016, we maintained it separately from the ROC and have since enrolled over 20,000 cases. Record linkage was performed using demographic data of encounters from a single EMS agency within the registry and a community hospital in Dallas where these were transported from January 2017 to May 2018. An expectation maximization algorithm to aid in discerning matches and nonmatches was performed using the R package RecordLinkage identifying record pairs as a match, non-match, or possible match based on a pre-determined threshold. Match and Possible Match pairs were manually reviewed to assess the algorithm’s accuracy. Results: The EMS and hospital data sets had 67 and 6,050 unique encounters, respectively. The record linkage algorithm identified 40 EMS encounters as having a match (60%), 12 with a possible match (18%), and 15 with no identified match (22%). After manual review, the algorithm had a positive predictive value (PPV) of 100% (40/40) for the match group with a sensitivity of 60%. Conclusions: Applying probabilistic linkage to aid in automating a cardiac arrest registry was successful in linking over half of the EMS encounters with a PPV of 100%. When reviewing the unmatched encounters, many were adjacent to each other when sorted by time suggesting the poor sensitivity is more likely a reflection of the hospital’s data collection method as opposed to the linkage methodology.

Background: The delivery of emergency medical services (EMS) is a resource-intensive process, and prior studies suggest that EMS utilization in children may vary by socioeconomic status. The Child Opportunity Index (COI) provides a multidimensional measure of neighborhood-level resources and conditions that affect the health of children. We evaluated EMS utilization and measures of acuity among children by COI. Methods: We performed a cross-sectional study using encounters for patients less than 18 years of age from 10,067 EMS agencies in 47 US states and territories contributing to the National Emergency Medical Services Information System 2019 dataset. We compared patient demographics, EMS encounter characteristics, and care provided to children stratified by ZIP code using the COI 2.0. Results: We included 1,293,038 EMS encounters (median age 10 years, IQR 3–15 years). The distributions of encounters in the five tiers of COI were 30.6%, 20.1%, 18.0%, 16.3% and 15.1%, (from Very Low to Very High, respectively). The distribution of diagnoses between groups was similar. Most measures of EMS acuity/resource use were similar between groups, including non-transport status, cardiac arrest, vital sign abnormalities, and EMS-administered procedures and medications. Among children with respiratory-related encounters, children in the Very Low group had a greater need for nebulized medications (26.4% vs 18.3% in Very High COI children). Among children with trauma, a lower proportion in the Very Low group were given analgesia (4.0% vs 7.4% in the Very High group), though pain scores were similar in all groups. Conclusion: Pediatric EMS encounters from lower COI neighborhoods occur more frequently relative to encounters from higher COI neighborhoods. Despite these differences, children from lower COI strata generally have similar encounter characteristics to those in other COI strata, suggestive of a greater number of true out-of-hospital emergencies among children from these areas. Notable differences in care included use of respiratory medication to children with respiratory diagnoses, and administration of pain medication to children with trauma.

Objective: U.S. opioid overdoses increased nearly sixfold from 1999 to 2018, and greater than 1% of all emergency medical services (EMS) encounters now involve naloxone administration. While “treat and release” protocols may have low short-term mortality, the risk of subsequent non-fatal overdoses is not known. This study compares the risk of repeat overdose encounters between patients transported to an emergency department (ED) and those who refused transport after prehospital naloxone administration. Methods: All EMS charts within a large single-tier fire-based urban EMS system between January 1 and August 31, 2018 were reviewed if either naloxone administration or a clinical impression related to opioid overdose was documented. Charts were excluded if there was no documented evidence of an opioid toxidrome (respiratory depression or altered mental status), if there was another clear explanation for the symptoms (e.g., hypoglycemia), or if naloxone was not administered. Ten percent of charts were reviewed by a second author to assess reliability. Cox regression (survival analysis) was used to estimate the risk of a subsequent EMS encounter with naloxone administration following an index encounter with naloxone administration. Results: Of the 2143 charts reviewed, 1311 unique patients with 1600 overdose encounters involving naloxone administration were identified. Inter-rater reliability for chart inclusion was strong [κ = 0.83 (95% CI: 0.72–0.90)]. Police/bystanders administered naloxone in 208/1600 (13.0%) encounters. A substantial proportion of encounters resulted in transport refusal (674/1600, 42.1%). The final Cox model included only refusal vs. acceptance of transport to an ED during the index EMS encounter. Patient age, gender, and naloxone administration prior to EMS arrival were not statistically significant in univariate or multivariable analyses, nor were they significant confounders. Refusal of transport was associated with a hazard ratio of 1.66 (95% CI: 1.23–2.23) for subsequent EMS encounters with naloxone administration. Conclusions: Non-transport after prehospital naloxone administration is associated with an increased risk of subsequent non-fatal overdose requiring EMS intervention. Limitations include the use of a single EMS agency as patients may have had uncaptured overdose encounters in neighboring municipalities.

Social Vulnerability and Out-of-Hospital Identification of Neurologic Emergencies.

Approximately 10% of emergency medical services (EMS) encounters in the United States are behavioral health related, but pediatric behavioral health EMS encounters have not been well characterized. We sought to describe demographic, clinical, and EMS system characteristics of pediatric behavioral health EMS encounters across the United States and to evaluate factors associated with sedative medication administration and physical restraint use during these encounters. We conducted a retrospective cross-sectional study of pediatric (<18 years old) behavioral health EMS encounters from 2019 to 2020 using the National Emergency Medical Services Information System. Behavioral health encounters were defined using primary or secondary impression codes. We used multivariable logistic regression to identify factors associated with sedative medication administration and physical restraint use. Of 2,740,271 pediatric EMS encounters, 309,442 (11.3%) were for behavioral health. Of pediatric behavioral health EMS encounters, 85.2% of patients were 12-17 years old, 57.3% of patients were female, and 86.6% of encounters occurred in urban areas. Sedative medications and physical restraints were used in 2.2% and 3.0% of pediatric behavioral health EMS encounters, respectively. Sedative medication use was associated with the presence of developmental, communication, or physical disabilities relative to their absence (adjusted odds ratio [aOR] 3.38, 95% confidence interval [CI] 2.93-3.91) and with encounters in the West relative to the South (aOR 1.23, 95% CI 1.16-1.32). Physical restraint use was associated with encounters by patients 6-11 years old relative to those 12-17 years old (aOR 1.35, 95% CI 1.27-1.44), the West relative to the South (aOR 3.49, 95% CI 3.27-3.72), and private nonhospital EMS systems relative to fire departments (aOR 3.39, 95% CI 3.18-3.61). Among pediatric prehospital behavioral health EMS encounters, the use of sedative medications and physical restraint varies by demographic, clinical, and EMS system characteristics. Regional variation suggests opportunities may be available to standardize documentation and care practices during pediatric behavioral health EMS encounters.

HighlightsWhat are the main findings?AED use during EMS encounters shows clear racial and geographic inequities, with White patients and suburban/rural/frontier regions experiencing the lowest deployment rates.Disparities persist even within clinically severe encounters such as cardiac arrest and high-acuity cases, indicating that clinical need alone does not explain variation in AED use.What are the implications of the main findings?Improving AED placement, EMS deployment strategies, and community readiness, especially in underserved regions, may help reduce inequities in early defibrillation.Equity-focused EMS planning and targeted public-access defibrillation initiatives are needed to ensure that time-sensitive interventions are delivered consistently across diverse populations.Background: Out-of-hospital cardiac arrest is a major cause of mortality, and survival depends heavily on rapid defibrillation. Automated external defibrillators (AEDs) can significantly improve outcomes when used before emergency medical services (EMS) arrive, yet access to and use of these devices remain uneven across communities. This study investigates racial and geographic disparities in AED use during EMS encounters in the United States, evaluating differences across racial groups, geographic settings, cardiac arrest status, and patient acuity, irrespective of whether a bystander or EMS personnel applied the device. Methods: This descriptive study used aggregated data from the National Emergency Medical Services Information System (NEMSIS) Public Release Data Cube to compare AED use across racial, geographic, cardiac arrest, and acuity categories. AED use was defined as any documented application during the EMS encounter. Results: The dataset included 106,246 EMS encounters across six racial and ethnic groups. AEDs were applied in 16,688 encounters (15.7%), with substantial variation across demographic and geographic categories. Asian, American Indian or Alaska Native, and Black or African American patients had the highest rates of AED use, while White patients had the lowest rate despite representing the largest share of encounters. Urban areas accounted for most AED deployments, whereas suburban and frontier regions showed markedly lower use, while rural AED use was similar to urban rates. AED application was strongly associated with cardiac arrest and high patient acuity, yet racial differences persisted even within these clinically severe categories. Conclusions: AED use generally aligns with clinical indicators such as cardiac arrest and critical acuity, but meaningful racial and geographic differences were observed, reflecting descriptive patterns rather than confirmed disparities. These patterns should be interpreted cautiously, as the aggregated nature of the dataset limits the ability to determine whether differences reflect inequities, incident characteristics, or EMS system factors. These findings highlight the need for targeted strategies to expand AED access, improve device placement, and strengthen community readiness in underserved areas. Integrating AED availability into broader EMS planning and community outreach may help reduce inequities and create conditions that support improved survival outcomes. Further research using individual-level data and geospatial methods is needed to clarify the drivers of these observed differences and inform equitable prehospital care policies.