Utilization of Emergency Medical Transports and Hospital Admissions Among Persons With Behavioral Health Conditions

Emergency medical services transport and emergency department misuse among persons with behavioral health conditions is a concern. Administrative data were used to examine medical transports and hospital admissions among persons with behavioral health conditions. Data on 70,126 medical transports to emergency departments in three southeastern counties were analyzed. Compared with general medical transports, fewer behavioral health transports resulted in a hospital admission. Among behavioral health transports, persons with schizophrenia were 2.62 times more likely than those with substance use disorders to be admitted, and persons with mood disorders were 4.36 times more likely than those with substance use disorders to be admitted. Also, among behavioral health transports, rural transports were less likely than more urban transports to result in a hospital admission. More training of emergency medical services personnel and more behavioral health crisis resources, especially targeting rural areas and substance use disorders, are needed.

The Relationship Between Ski Patrols and Emergency Medical Services Systems

Clinical case: A 58-year-old woman called 9-1-1 with acute onset of chest pain that had persisted for 30 minutes. She had a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus but no previous history of myocardial infarction or heart failure. Her medications included aspirin, atorvastatin, lisinopril, and metoprolol. Paramedics were dispatched, and a prehospital ECG demonstrated 3- to 4-mm ST-segment elevation in leads I, aVL, and V2 through V6 (Figure 1). Her examination revealed a regular pulse of 90 bpm, a blood pressure of 100/60 mm Hg, clear lungs, and normal heart sounds with no murmurs. Paramedics interpreted the prehospital ECG and activated the catheterization laboratory en route to the hospital. On hospital arrival, the patient was transported directly to the catheterization laboratory. Coronary angiography demonstrated an occluded proximal left anterior descending artery, which was successfully treated with balloon angioplasty and a stent. The pertinent time intervals were as follows: paramedic dispatch to balloon time, 56 minutes; paramedic arrival at the scene to balloon time, 46 minutes; hospital door to balloon time, 23 minutes. Her biomarkers revealed a peak troponin T of 2.42 ng/mL and a peak creatine kinase muscle-brain isoenzyme of 26.8 ng/mL. An echocardiogram demonstrated normal left ventricular ejection fraction of 55%, with mild anterior hypokinesis, and the patient was discharged on hospital day 3. Figure 1. Prehospital ECG. American Heart Association national guidelines,1–3 as well as other consensus and scientific statements,4–11 recommend that emergency medical services (EMS) acquire and use prehospital ECGs to evaluate patients with suspected acute coronary syndrome. Despite these recommendations, prehospital ECGs are used in fewer than 10% of patients with ST-segment–elevation myocardial infarction (STEMI),12,13 and this rate has not substantially changed since the mid-1990s. Furthermore, even when a prehospital ECG is acquired, the information is often not …

More Science for the New Subspecialty

Interim Guidance for Emergency Medical Services Management of Out-of-Hospital Cardiac Arrest During the COVID-19 Pandemic.

ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction).

How a community responds to behavioral health emergencies is both a public health issue and social justice issue. Individuals experiencing a behavioral health crisis often receive inadequate care in emergency departments (EDs), boarding for hours or days while waiting for treatment. Such crises also account for a quarter of police shootings and >2 million jail bookings per year. Racism and implicit bias magnify these problems for people of color. Growing support for reform provides an unprecedented opportunity for meaningful change, but solutions to this complex issue will require comprehensive systemic approaches. As communities grapple with behavioral health emergencies, the question is not just whether law enforcement should respond to behavioral health emergencies but how to reduce unnecessary law enforcement contact and, if law enforcement is responding, when, how, and with what support. This policy article reviews best practices for law enforcement crisis responses, outlines the components of a comprehensive continuum-of-crisis care model that provides alternatives to law enforcement involvement and ED use, and offers strategies for collaboration and alignment between law enforcement and clinicians toward common goals. Finally, policy considerations regarding stakeholder engagement, financing, data management, legal statutes, and health equity are presented to assist communities interested in taking steps to build these needed solutions.

Advances in stroke care will have the greatest effect on stroke outcome if care is delivered within a regional stroke system designed to improve both efficiency and effectiveness. The ultimate goal of stroke care is to minimize ongoing injury, emergently recanalize acute vascular occlusions, and begin secondary measures to maximize functional recovery. These efforts will provide stroke patients with the greatest opportunity for a return to previous quality of life and decrease the overall societal burden of stroke.

EMS and Information Sharing: Challenges and Innovations in Getting Patient Data From the Ambulance to the Emergency Department and Back

To some extent or another, physicians have been involved in emergency medical services (EMS) systems in North America for decades. Over the years, physicians from different specialties have been involved with EMS, occasionally as full-time or part-time employees of the EMS system but more often on a voluntary or small contractual basis. Regardless of the employment relationship, most states and provinces now require by statute that each EMS system, particularly those providing advanced life support (ALS) services, have a designated EMS medical director. However, in the United States and most of Canada, such physicians typically oversee EMS systems by acting as administrative medical supervisors, educators, mentors, and, in some cases, even as system managers. Throughout many European countries, the physician is the primary care provider for a large percentage of the serious prehospital medical emergencies. In contrast, throughout North America, basic emergency medical technicians (EMTs) and paramedics (specially trained ALS providers) serve as the EMS system medical director's surrogates. In this system of care, such physician surrogates provide almost all of the prehospital medical care interventions without any on-scene physician presence. Nevertheless, because of their medical supervisory requirements, by statute, North American medical directors generally are still accountable for patient care. Therefore, in many areas of the United States and Canada, the responsible physicians also respond to EMS scenes on a routine basis. They do so, both announced and unannounced, independently or with EMS personnel. In this capacity, they can serve as a direct patient care resource for the EMTs, paramedics, and the patients themselves. However, by becoming an intermittent participating member of the EMS team in the unique out-of-hospital setting, these on-scene physicians can help to better scrutinize the care rendered and thus more effectively modify applicable protocols and training as needed. Historically, such practices have helped many EMS systems-not only in terms of reforming traditional protocols but also by helping to establish improved medical care priorities and even system management changes that affect patient care. In addition, active participation helps the accountable EMS physician not only to identify weaknesses in personnel skills and system approaches, but it also provides an opportunity for role modeling, both medically and managerially.

This pilot study evaluated the frequency and accuracy of diagnosis of stroke made by prehospital care system dispatchers, emergency medical technicians (EMTs), and paramedics in one emergency medical services (EMS) system. In addition, the study determined patient prehospital triage and time intervals in the transport and examination of patients given a diagnosis of stroke by this EMS system. We reviewed records of 4413 consecutive prehospital records of a two-tiered EMS system for patients with potential stroke. Hospital records were obtained for patients given a diagnosis of stroke or transient ischemic attack (TIA) by an EMS dispatcher, EMT, or paramedic. The EMS system studied serves a community of 13,000 within the greater Cincinnati area. Of 4413 EMS on-scene evaluations, the diagnosis of stroke or TIA was made by an EMT or paramedic for 96 patients (2%). Of the study population (n = 86), a final hospital discharge diagnosis of stroke or TIA was made for 62 patients (72%). EMS dispatchers correctly identified 52% and paramedics 72% of these 86 patients as having sustained a stroke or TIA. Twenty-two of the 86 patients required paramedic-level interventions, which included three intubations. Of the 24 patients whose symptoms were misdiagnosed as stroke or TIA by the paramedics, 16 (19%) had acute conditions for which effective therapies are available. Prehospital personnel arrived at the scene to examine potential stroke patients in a mean of 3 minutes after the emergency 911 call was received by the dispatcher. Patients transported by basic life support units (EMTs) arrived earlier at the hospital than did those transported by advanced life support units (paramedics) (40 +/- 1 versus 45 +/- 1 minutes, P = .004). However, patients transported by advanced life support units were seen by a physician sooner after arrival at the emergency department (10 +/- 2 versus 20 +/- 4 minutes, P = .02) and underwent computed tomography of the brain sooner (47 +/- 5 versus 69 +/- 10 minutes, P = .04). Prehospital evaluation of potential stroke patients can be accomplished promptly after the EMS system is activated. Urgent evaluation and transport of potential stroke patients is justified because paramedic-level interventions are frequently required and because almost 20% of patients with potential stroke have acute medical conditions for which effective specific therapies are available.

This article briefly reviews the evolution of medical support during wars and conflicts from ancient to modern times and discusses the effect warfare has had on the development of civilian health care and emergency medical services (EMS). Medical breakthroughs and discoveries made of necessity during military conflicts have developed into new paradigms of medical care, including novel programs of triage and health assessment, emergency battlefield treatment and stabilization, anesthesia, and other surgical and emergency procedures. The critical role of organizations that provide proper emergency care to help the sick and injured both on the battlefield and in the civilian world is also highlighted.

Patterns of Emergency Medical Transport for Suspected Acute Stroke, Acute Myocardial Infarction, and Other Diagnoses During the COVID‐19 Pandemic: A Retrospective Analysis of a Large Hospital‐Based Emergency Medical Services Agency

Increasing numbers of states are looking for ways to address behavioral health (BH) conditions among their residents. The first round of the State Innovation Models (SIM) Initiative provided financial and technical support to six states since 2013 to test the ability of state governments to lead health care system transformation. All six SIM states invested in integration of BH and primary care services. This study summarizes states' progress, challenges, and lessons learned on BH integration. Additionally, the study reports impacts on expenditure, utilization, and quality-of-care outcomes for persons with BH conditions across four SIM states. We use a mixed-methods design, drawing on focus groups and key informant interviews to reach conclusions on implementation and quantitative analysis using Medicaid claims data to assess impact. For three Medicaid accountable care organization (ACO) models funded under SIM, we used a difference-in-differences regression model to compare outcomes for model participants with BH conditions and an in-state comparison group before-and-after model implementation. For the behavioral health home (BHH) model in Maine, we used a pre-post design to assess how outcomes for model participants changed over time. Informal relationship building, tailored technical assistance, and the promotion of data sharing were key factors in making progress. After three years of implementation, the growth in total expenditures was less than the comparison group by $128 (-$253, -$3; p < 0.10) and $62 (-$87, -$36; p < 0.001) per beneficiary per month for beneficiaries with BH conditions attributed to an ACO in Minnesota and Vermont, respectively. Likewise, there were reductions in emergency department use for ACO participants in all three states after two to four years of implementation. However, there was no improvement in BH-related quality metrics for ACO beneficiaries in all three states. Although participants in the BHH model had increased expenditures after two years of implementation, use of primary care and specialty care services increased by 3% and 8%, respectively, and antidepressant medication adherence also improved. The SIM Round 1 states made considerable progress in integrating BH and primary care services, and there were promising findings for all models. Taken together, there is some evidence that Medicaid payment models can improve patterns of care for beneficiaries with BH conditions.

220 Emergent Medicine: Impact of Out-of-Hospital Red Lights and Sirens (RLS) on Time to Antibiotic Administration in Sepsis Alert Patients