Advanced Life Support Ambulance Research Articles

Intraosseous versus intravenous vascular access in upper extremity among adults with out-of-hospital cardiac arrest: cluster randomised clinical trial (VICTOR trial)

ObjectiveTo compare the effectiveness of intraosseous versus intravenous vascular access in the treatment of adult patients with out-of-hospital cardiac arrest.DesignCluster randomised controlled trial.SettingThe VICTOR (Venous Injection Compared To intraOsseous injection...

Secondary Ambulance Transfers During the Mass-Casualty Terrorist Attack in Israel on October 7, 2023.

On October 7, 2023, Israel experienced the worst terror attack in its history - 1,200 people were killed, 239 people were taken hostage, and 1,455 people were wounded. This mass-casualty event (MCE) was more specifically a mega terrorist attack. Due to the overwhelming number of victims who arrived at the two closest hospitals, it became necessary to implement secondary transfers to centers in other areas of the country. Historically, secondary transfer has been implemented in MCEs but usually for the transfer of critical patients from a Level 2 or Level 3 Trauma Center to a Level 1 Center. Magen David Adom (MDA), Israel's National Emergency Pre-Hospital Medical Organization, is designated by the Health Ministry as the incident command at any MCE. On October 7, in addition to the primary transport of victims by ambulance to hospitals throughout Israel, they secondarily transported patients from the two closest hospitals - the Soroka Medical Center (SMC; Level 1 Trauma Center) in Beersheba and the Barzilai Medical Center (BMC; Level 2 Trauma Center) in Ashkelon. Secondary transport began five hours after the event started and continued for approximately 12 hours. During this time, the terrorist infiltration was still on-going. Soroka received 650 victims and secondarily transferred 26, including five in Advanced Life Support (ALS) ambulances. Barzilai received 372 and secondarily transferred 38. These coordinated secondary transfers helped relieve the overwhelmed primary hospitals and are an essential component of any MCE strategy.

Long-term risk of death in patients with infection attended by prehospital emergency services.

To develop and validate a risk model for 1-year mortality based on variables available from early prehospital emergency attendance of patients with infection. Prospective, observational, noninterventional multicenter study in adults with suspected infection transferred to 4 Spanish hospitals by advanced life-support ambulances from June 1, 2020, through June 30, 2022. We collected demographic, physiological, clinical, and analytical data. Cox regression analysis was used to develop and validate a risk model for 1-year mortality. Four hundred ten patients were enrolled (development cohort, 287; validation cohort, 123). Cumulative mortality was 49% overall. Sepsis (infection plus a Sepsis-related Organ Failure Assessment score of 2 or higher) was diagnosed in 29.2% of survivors vs 56.7% of nonsurvivors. The risk model achieved an area under the receiver operating characteristic curve of 0.89 for 1-year mortality. The following predictors were included in the model: age; institutionalization; age-adjusted Charlson comorbidity index; PaCO2; potassium, lactate, urea nitrogen, and creatinine levels; fraction of inspired oxygen; and diagnosed sepsis. The model showed excellent ability to predict 1-year mortality based on epidemiological, analytical, and clinical variables, identifying patients at high risk of death soon after their first contact with the health care system.

On the study comparing use of basic vs advanced life support ambulances in stroke-code cases.

On the study comparing use of basic vs advanced life support ambulances in stroke-code cases.

National Ambulance Services in India: A Narrative Review

Background: A strong and effective emergency referral transport network is a prerequisite for a country's assured emergency ecosystem. Ambulances have grown exponentially since the start of National Ambulance Services under the National Health Mission (NHM) a decade ago. This paper aims to understand the referral systems, strategies and the progress and undertaken by the Government of India to upgrade and strengthen the referral transport system. Methods: We conducted a narrative review and secondary data analysis on referral transportation systems from government portals. Key Interviews were held with key stakeholders’ expertise in health systems. Results: The number of ambulances increased by 57.5 % from 2012 to 2022. Hitherto, 32.2 % of Advanced life support (ALS) ambulances have been shorted against population norms. Although the accessibility of referral services has improved, there is a significant gap in delivering timely in-transit service. Conclusions: The existing referral system requires the rational deployment of well-equipped BLS & ALS ambulances as per population norms with adequately trained staff or EMTs (Emergency Medical Technicians). A systematic plan for monitoring and accountability to ensure timely arrival within the “golden hour” is the need of the hour.

FIRECARE: An Evidence-Based Prevention Program to Reduce Burnout among Prehospital Caregivers: Benefits of a Combined Mindfulness, Heart Coherence Training, and Positive Psychology Intervention

Background Burnout among emergency health care professionals is well-described, especially during the COVID-19 pandemic. Prevention interventions, such as mindfulness, focus on the management of stress. Objective To evaluate the effects of the FIRECARE program (a mindfulness intervention, supplemented by heart coherence training and positive psychology workshops) on burnout, secondary stress, compassion fatigue, and mindfulness among advanced life support ambulance staff of the Paris Fire Brigade. Materials and methods We used a non-randomized, two-group quasi-experimental study design with a waitlist control and before-and-after measurements in each group. The intervention consisted of six, once-weekly, 2.5-h sessions that included individual daily meditation and cardiac coherence practice. The study compared intervention and waitlist control groups, and investigated baseline, post-program, and 3-month follow-up change on burnout (measuring using the ProQOL-5 scale) and mindfulness (measuring using the FMI scores). Baseline burnout (measured using the ProQOL-5) was evaluated and used in the analysis. Results Seventy-four 74 participants volunteered to participate; 66 were included in the final analysis. Of these, 60% were classified as suffering from moderate burnout, the ‘burnout cluster’. A comparison of intervention and waitlist control groups found a decrease in the burnout score in the burnout cluster (p = 0.0003; partial eta squared = 0.18). However, while secondary stress fell among the burnout cluster, it was only for participants in the intervention group; scores increased for those in the waitlist group (p = 0.003; partial eta squared = 0.12). The pre-post-intervention analysis of both groups also showed that burnout fell in the burnout cluster (p = 0.006; partial eta squared = 0.11). At 3-month follow-up, the burnout score was significantly reduced in the intervention group (p = 0.02; partial eta squared = 0.07), and both the acceptance (p = 0.007) and mindfulness scores (p = 0.05; partial eta squared = 0.05) were increased in the baseline burnout cluster. Conclusion FIRECARE may be a useful approach to preventing and reducing burnout among prehospital caregivers.

Transitioning from Direct to Video Laryngoscopy during the COVID-19 Pandemic Was Associated with a Higher Endotracheal Intubation Success Rate

Objective The objective of this study was to determine the effect of transitioning from direct laryngoscopy (DL) to video laryngoscopy (VL) on endotracheal intubation success overall and with enhanced precautions implemented during the COVID-19 pandemic. Methods We examined electronic transport records from Mayo Clinic Ambulance Service, a large advanced life support (ALS) provider serving rural, suburban, and urban areas in Minnesota and Wisconsin, USA. We determined the success of intubation attempts when using DL (March 10, 2018 to December 19, 2019), VL (December 20, 2019 to September 29, 2021), and VL with an enhanced COVID-19 guideline that restricted intubation to one attempt, performed by the most experienced clinician, who wore enhanced personal protective equipment (April 1 to December 18, 2020). Success rates at first attempt and after any attempt were assessed for association with type of laryngoscopy (VL vs DL) after adjusting for patient age group, patient weight, use of enhanced COVID-19 guideline, medical vs trauma patient, and ALS vs critical care clinician. A secondary analysis further adjusted for degree of glottic visualization. Results We identified 895 intubation attempts using DL and 893 intubation attempts using VL, which included 382 VL intubation attempts using the enhanced COVID-19 guideline. Success on first intubation attempt was 69.2% for encounters with DL, 82.9% overall with VL, and 83.2% with VL and enhanced COVID-19 protocols (DL vs overall VL: p < 0.001; COVID-19 vs non-COVID VL: p = 0.86). In multivariable analysis, use of VL was associate with higher odds of successful intubation on first attempt (odds ratio, 2.28; 95%CI, 1.73–3.01; p < 0.001) and on any attempt (odds ratio, 2.16; 95%CI, 1.58–2.96; p < 0.001) compared with DL. Inclusion of glottic visualization in the model resulted in a nonsignificant association between laryngoscopy type and successful first intubation (p = 0.41) and a significant association with the degree of glottic visualization (p < 0.001). Conclusions VL is designed to improve glottic visualization. The use of VL by a large, U.S. multistate ALS ambulance service was associated with increased odds of successful first-pass and overall attempted intubation, which was mediated by better visualization of the glottis. COVID-19 protocols were not associated with success rates.

The system-wide effects of dispatch, response and operational performance on emergency medical services during Covid-19

In this paper, we analyze the Fire Department of New York City’s pre-hospital emergency medical services dispatch data for the period of March 20, 2019–June 13, 2019, and the corresponding Covid lockdown period of March 20, 2020–June 13, 2020. A fixed effects negative binomial model is used to estimate the heterogeneity effects of average ambulance travel or response times on the daily volume of emergency calls, year, day of the week, dispatcher-assigned medical emergency call type, priority rank, ambulance crew response, borough and an offset for missing calls. We also address the limitations of other non-parametric Covid studies or parametric studies that did not properly account for over-dispersion. When our model is estimated and corrected for clustered standard errors, fixed effects, and over-dispersion, we found that Wednesday was the only day of the week that was most likely to increase travel response time with an odd ratio of 6.91%. All grouped call types that were categorized showed significant declines in average travel time, except for call types designated as allergy and an odds ratio of 21.81%. When compared to Manhattan, Staten Island ambulance response times increased with an odds ratio of 19.05% while the Bronx showed a significant decline with an odds ratio of 31.92% advanced life support (ALS) and BLS ambulances showed the biggest declines in travel time with the exception of BLS assigned ambulance types and emergency priority rank of 6. Surprisingly, in terms of capacity utilization, the dispatch system was not as overwhelmed as previously predicted as emergency call volume declined by 8.83% year over year.

Abstract 294: Is Use Of An Interactive Voice Server In An Emergency Medical Dispatch Center An Efficient And Safe Measure?

Introduction: In the first wave of COVID-19 pandemic, Emergency Medical Dispatch Centers (EMDC) faced an influx of calls. During this time, with the scope of handling emergency calls more quickly, it was decided to use an Interactive Voice Server (IVS). The objective of this study was to identify whether the implementation of an IVS is efficient and safe. Methods: From 20/03/19 until 20/04/26, an IVS was activated between 8 AM and midnight. IVS offered the caller to choose either 1- press the 'zero' key for Coronavirus Syndrome with no respiratory difficulties; or 2- stay on line for any other reason. If the caller typed "zero", the call was directed to a "crisis dispatcher" specially trained to handle COVID cases. If he stayed on line, his call was placed in the same queueing list as all emergency calls and handled by a “conventional dispatcher”. All medical dispatch files picked up during IVS activation period were included and classified in 2 groups: “IVS Yes” if caller pressed ‘zero’ and “IVS No” if not. Patient’s age, gender and profile of the caller (patient or third party) were collected. The level of severity of the patients was assessed upon the dispatcher’ decision ranging from sending an Advanced Life Support ambulance (ALS), a Basic Life Support ambulance (BLS) or no transport. Data were compared between the 2 groups with Chi-square tests. Results: 2846 callers were in the group “IVS Yes” and 12111 in “IVS No”. Main results are in table 1. Conclusion: IVS allowed almost 15% of calls to be directed to a specialized provider where they waited to be processed by staff trained within a few days to deal exclusively with COVID cases. This has led to decrease the number of calls handled by the conventional dispatch and allowed more time to respond to severe emergency calls. Moreover, because only 0.07% “IVS Yes” needed an ALS ambulance, we can assume that the use of IVS is safe. IVS is therefore an effective tool, which allows safe triage of less serious patients and frees up time to answer to severe calls.

An analysis of cost and time for non-emergency calls: A retrospective study on the Emergency Medical Services resources management

Background: Non-transported calls refer to calls received by dispatchers, ambulances dispatched, and the patient not being transported to any health facility. There is a need to analyze and scrutinize the number of such calls and the monetary cost associated with them as it will help to build an effective system to prevent wastage of money and time. Objective: The main objective of this study is to determine the cost and time lost due to the use of resources higher than required in non-emergency situations, and then a comparison is being made to determine the acceptable cost if the appropriate resources are used for such cases. Incidence of non-transported Emergency Medical Services (EMS) calls and the financial and time burdens in Jubail, classified non-urgent from 2017 to 2019, have wasted EMS resources. This information can be useful to improve EMS operations and allocate resources to control inappropriate usage. Methodology: A retrospective cross-sectional study was conducted to assess non-emergency EMS calls in Jubail, Saudi Arabia. Study data were obtained from the Royal Commission Health Services Program- Jubail (RCHSP-J) key performance indicator (KPIs) system from 2017 to 2019. Descriptive statistical measures (sum, mean, and percentage), and comparison methods were obtained. Results: The cost from 2017 to 2019 for the non-emergency calls by using the advanced life support ambulance (ALS) was 2,051,651 USD while the cost of emergency calls was 546,037 USD only. On the other hand, the time for the non-emergency calls was 6870 hours (78%) and the emergency calls were only 1769 hours (22%). Conclusion: In systems with limited resources and poor regulation; the non-emergency calls having higher costs and time more than emergency calls from 2017 to 2019, might have caused a delay in providing care for the more serious cases. This involves a significant financial waste that could have been planned to make the system work more efficiently avoiding massive waste of resources.

Effect of Placement of a Supraglottic Airway Device vs Endotracheal Intubation on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest in Taipei, Taiwan

Prehospital advanced airway management with either initial endotracheal intubation (ETI) or initial supraglottic airway (SGA) insertion in patients with out-of-hospital cardiac arrest (OHCA) remains controversial. To compare the effectiveness of ETI and SGA in patients with nontraumatic OHCA. The Supraglottic Airway Device vs Endotracheal intubation (SAVE) trial was a multicenter cluster randomized clinical trial conducted in Taipei City, Taiwan. Individuals aged 20 years or older who experienced nontraumatic OHCA requiring advanced airway management and were treated by participating emergency medical service agencies were enrolled from November 11, 2016, to December 31, 2019. The final day of follow-up was February 19, 2020. Four advanced life support ambulance teams were divided into 2 randomization clusters, with each cluster assigned to either ETI or SGA in a biweekly period. The primary outcome of the SAVE trial was sustained return of spontaneous circulation (ROSC) (≥2 hours) after resuscitation. Secondary outcomes included prehospital ROSC, survival to hospital discharge, and favorable neurologic outcome, defined as a cerebral performance category score less than or equal to 2. Prespecified subgroups and the association between time to advanced airways were explored. Per protocol and intention-to-treat analysis were performed. A total of 936 patients (517 in the ETI group and 419 in the SGA group) were included in the primary analysis (median age, 77 [IQR, 62-85] years; 569 men [60.8%]). The first-attempt airway success rates were 77% with ETI (n = 413) and 83% with SGA (n = 360). Sustained ROSC was 26.9% (n = 139) in the ETI group vs 25.8% (n = 108) in the SGA group. The odds ratio of sustained ROSC was 1.02 (95% CI, 0.98-1.06) in the ETI group vs SGA group. The odds ratio of ETA vs SGA was 1.04 (95% CI, 1.02-1.07) for prehospital ROSC, 1.00 (95% CI, 0.94-1.06) for survival to hospital discharge, and 0.99 (95% CI, 0.94-1.03) for cerebral performance category scores less than or equal to 2. In this randomized clinical trial, among patients with OHCA, initial airway management with ETI did not result in a favorable outcome of sustained ROSC compared with SGA device insertion. ClinicalTrials.gov Identifier: NCT02967952.

Providing whole blood for an urban paramedical ambulance system.

Hemorrhage is the second leading cause of death among urban trauma patients, and the provision of prehospital blood-based resuscitation can be lifesaving. We developed an efficient system to support blood-based resuscitation by an urban advanced life support ambulance system. We worked with our state health department for permission for fire department paramedics to initiate blood transfusion and built protocols for field whole blood resuscitation. Our regional trauma center transfusion service provided 2 units of O positive, low-titer, leukoreduced whole blood in an internally monitored and sealed ice box weighing 10 pounds to the fire department paramedic supervisor. When notified, the supervisor transported the blood to the sites of anticipated need. Total blood use and wastage were recorded. Following two public hearings, we obtained state-wide approval for the initiation of emergency uncrossmatched blood transfusion by paramedics. Over a 1-year period beginning August 27, 2019, 160 units of whole blood were made available for use, and 51 units were transfused to 39 patients, 30 of whom were trauma patients. Other recipients include patients in shock from massive gastrointestinal, peripartum, or other suspected bleeding. Unused units were returned to the providing transfusion service after 1 week and used for hospital patient care without loss. The estimated cost of providing blood per mission was $0.28 and per patient transfused was $1138. With appropriate attention to detail, it is possible to provide whole blood to an urban paramedical ambulance system with efficient blood component usage, minimal blood wastage, and low cost.

Prehospital stabilization of acritically ill patient with telemetric medical guidance

Es wird über die präklinische Versorgung eines 82-jährigen Patienten im septischen Schock bei akuter Pankreatitis berichtet. Initial wurde nur ein Rettungswagen alarmiert, dessen Besatzung nach der ersten Einschätzung einen Notarzt per Hubschrauber an die Einsatzstelle nachforderte. Die Besatzung entschied sich, bei absehbar langem notarztfreien Intervall, telemedizinische Unterstützung anzufordern. Trotz initialer massiver Zentralisierung und schwierigen Bedingungen vor Ort gelang es dem Team, in ständiger Rücksprache mit dem Telenotarzt, den Patienten bis zum Eintreffen des Hubschraubers so zu stabilisieren, dass ein sofortiger und komplikationsloser Transport möglich wurde.

Should Tenecteplase be Given in Clinical Practice for Acute Ischemic Stroke Thrombolysis?

Should Tenecteplase be Given in Clinical Practice for Acute Ischemic Stroke Thrombolysis?

Prehospital time of suspected stroke patients treated by emergency medical service: a nationwide study in Thailand

BackgroundThis work was to study the prehospital time among suspected stroke patients who were transported by an emergency medical service (EMS) system using a national database.MethodsNational EMS database of suspected stroke patients who were treated by EMS system across 77 provinces of Thailand between January 1, 2015, and December 31, 2018, was retrospectively analyzed. Demographic data (i.e., regions, shifts, levels of ambulance, and distance to the scene) and prehospital time (i.e., dispatch, activation, response, scene, and transportation time) were extracted. Time parameters were also categorized according to the guidelines.ResultsTotal 53,536 subjects were included in the analysis. Most of the subjects were transported during 06.00-18.00 (77.5%) and were 10 km from the ambulance parking (80.2%). Half of the subjects (50.1%) were served by advanced life support (ALS) ambulance. Median total time was 29 min (IQR 21, 39). There was a significant difference of median total time among ALS (30 min), basic (27 min), and first responder (28 min) ambulances, Holm P = 0.009. Although 91.7% and 88.3% of the subjects had dispatch time ≤ 1 min and activation time ≤ 2 min, only 48.3% had RT ≤ 8 min. However, 95% of the services were at the scene ≤ 15 min.ConclusionPrehospital time from EMS call to hospital was approximately 30 min which was mainly utilized for traveling from the ambulance parking to the scene and transporting patients from the scene to hospitals. Even though only 48% of the services had RT ≤ 8 min, 95% of them had the scene time ≤ 15 min.

Development of two-wheeler towed emergency purpose trailer for rescue operation

Ambulances are designed for quick response of emergency cases and to take a level of care for patients. Ambulances types are classified into four types based on their facilities. They are type A, type B, type C, type D. Type A is first responder. Type B is patient transport vehicle. Type C is basic life support ambulance. Type D is advanced life support ambulance. This work falls under category of type B. Type B ambulance is used to carry patient. Current work plan is to implement some main medical kit which is similar to type C ambulance. The project purpose is to focus on rural people to connect nearest health centre in the town area during emergency cases. Construction of trailed ambulance design is based on to overcome the problem faced by four wheeled ambulances in rural area. Also, the concept is based on to reduce death rate in village area and comfort ride in traffic places. Manufacturing cost of the ambulance is drastically reduced and also it could carry a patient and main necessary medical kit. Full body covered with sheet metal and patient compartment trailer unit is coupled with bike chassis frame during emergency cases. Trailer clamp is designed with adjustable length and width. Bike is uncoupled with trailer compartment and free to use when there is no emergency case.

A ripple effect in prehospital stroke patient care

ABSTRACT We examine a ripple effect in prehospital stroke care processes. Stroke patient care in prehospital stages is provided by emergency medical services (EMS). We divide EMS processes into three segments: dispatcher, field provider service without a patient (i.e., en route to the patient scene), and field provider service with a patient (i.e., transporting the patient to a hospital). We use both empirical and analytical models in this study. The results of the empirical analysis suggest that the dispatcher's stroke identification can influence the time performance of the dispatch center itself and of the subsequent downstream processes of the prehospital stroke care, indicating a potential ripple effect in the care system. Our analytical models demonstrate the impact of misidentification (i.e., a disruptive event at the dispatcher stage) and the unavailability of an Advanced Life Support (ALS) ambulance (i.e., a disruptive event at the field provider stage) on the severity of the stroke patient's prehospital condition. The models indicate that there is an optimal diagnostic time on the part of the dispatcher that minimizes the adverse consequences throughout the prehospital stages of care under disruptive events, and that a centralized system can mitigate a ripple effect in prehospital stroke care.

Provision of Hepatitis A Vaccine by Paramedics During Noncritical Patient Interactions: Lessons Learned

Background: Hepatitis A cases have been regularly increasing in Florida since 2016, after remaining relatively stable for several years. Between January 1, 2019, and October 19, 2019, 2,847 cases of hepatitis were reported to the Florida Department of Health, including 2,209 hospitalizations and 41 deaths due to infection with hepatitis A1. At least 93% of these cases was acquired within the state of Florida.1 During this outbreak, Pasco County clearly emerged as a focal point for new cases. As of week 42 of 2019, Pasco County was the second-highest county for new cases (n = 484) and the leading county for deaths due to hepatitis A infection (n = 8). Risk factors identified from hepatitis A cases reported between January 1, 2019, and October 19, 2019, included any drug use (57%), injection drug use (37%), noninjection drug use (35%), homelessness (22%), and being a man who had sexual intercourse with other men (MSM, 4%).1 Moreover, 33% of newly reported cases were interviewed and denied risk factors; 1 (20%) had recently been incarcerated or was currently incarcerated.1 Individuals with these risk factors are often individuals who also require emergency medical services (EMS). On August 1, 2019, a public health emergency (PHE) was issued for the entire state of Florida. The existence of a PHE allows for paramedics to administer vaccine (with the approval of the fire rescue medical director). Pasco County Fire Rescue routinely operates 28 advanced life support (ALS) ambulances with either a crew of 2 paramedics or a paramedic/EMT pair. On October 7, 2019, the Pasco County Board of County Commissioners (BCC) approved a Memorandum of Understanding between the Florida Department of Health in Pasco County, the Pasco County Fire Rescue Medical Director, and the BCC for ALS crews to provide hepatitis A vaccination to noncritical (ie, basic life support) patients during routine contact. This effort appears to be the first within the of Florida. Pasco County Fire Rescue (PCFR) began stocking hepatitis A vaccine on January 1, 2020 and ceased participation in the program on March 1, 2020. During the window of participation, PCFR responded to approximately 6,570 calls in which the patient would have been non-critical and eligible for hepatitis A vaccination. Twelve hepatitis A vaccinations (0.18%) were administered. Crews verbalized concerns about adding vaccination to their job description, feelings of being overwhelmed with existing emergency medical services (EMS) responsibilities, apathy regarding the potential benefit of provision of vaccine, and perception that successful participation in a vaccine campaign would lead to additional community paramedicine responsibilities. The vaccine program was terminated early due to the significant demands on EMS as SARS-CoV2 impacted Pasco County. This trial highlights the need for crew investments and buy-in for future partial or full community paramedicine initiatives.1. Florida Department of Health, Hepatitis A Surveillance State Report, Week 42.Funding: NoneDisclosures: None

196 Comparing Response Times, Intensity of Care and Outcomes between Private versus Municipal Emergency Medical Services Systems

The financial and oversight complexities associated with providing emergency medical services (EMS) in the United States ultimately led to the creation of both private and municipal-based EMS systems providing out-of-hospital medical care to our communities. For over four decades an emotional debate has spurned regarding which system can provide better coverage and quality of care to patients. Although there are many heated editorials and commentary papers on this topic, there is very little scientific research to support one method of delivery over the other. The primary objective of this study was to identify any quantitative differences in care between private and municipal EMS systems related to response times, intensity of services and patient outcomes. This IRB approved retrospective chart review included all patients presenting to a 60 bed community Emergency Department (ED) via advanced life support (ALS) ambulance between Jan 1, 2017 and March 31, 2017. Our ED receives ambulance traffic from 9 EMS agencies (7 municipal, 2 private) who provide 911 coverage for approximately 20 square miles of suburban communities. Data were collected using the hospital’s electronic records and included patient age, emergency severity index score (ESI), out-of-hospital response and transport times, IVs started, fluids and medications given, airway interventions (oxygen delivery, CPAP, Intubation), cardiac monitoring, 12 lead EKGs, ED intubations, ED mortality, hospital mortality and ICU admission. Categorical data were summarized as counts and percentages, and continuous data as means with corresponding standard deviations. Between-group mean differences were compared by calculating t-tests for independent measures. Categorical data were compared using the chi-square test for association or Fisher’s exact test. A total of 769 patients were included into the study sample with 483 in the private EMS cohort and 286 in the municipal EMS cohort. A detailed breakdown of cohort demographics, out-of-hospital response times, intensity of services, outcomes and comparisons between these groups are displayed in Table 1. A p-value ≤0.05 (two-tail) was considered statistically significant. The current operating structure of providing EMS to our communities is based around the premise that there are no significant quality and safety differences between municipal and private EMS systems. It is therefore surprising to see so many statistically and potentially clinically significant differences between these two modes of EMS delivery. Municipal EMS agencies in our community were identified to provider faster care with more intense services in nearly every out-of-hospital time and intensity of care metric. Despite these differences, no outcome disparities were identified in regards to ED and hospital mortality, ICU admissions or ED intubations. Recognizing strengths and potential weakness related to these two systems is essential as we continue to minimize any disparities in care to our communities and maximize the benefits of mutual aid within our national EMS system.

Abstract WP470: Stroke’s Pathways of Patients Transported by Advanced Life Support Ambulance: A 26 Years Registry

Introduction: Since mid-2000, stroke guidelines were revised and 18 stroke units (SU) settled in Paris area (France). Our Emergency Medical Service (EMS) in a catchment of 500 000 inhabitants registered all acute strokes where dispatch of an Advanced Life Support (ALS) ambulance was decided since 1993. Methods: Data were collected from an EMS registry (1993-2019). The study included patients 16 years old and over, with an acute stroke requiring an ALS ambulance. Collected data were gender, age (by quartile), time periods (1993-99, 2000-04, 2005-09, 2010-14, 2015-19) and receiving care facility: SU, neurosurgery, intensive care unit (ICU), emergency department (ED), radiology department (MRI or scanner) or left on scene (LOS dead or alive). Comparisons were performed with Chi-2 test. Results: This study included 2955 stroke patients, mean age was 70.7 years old, sex ratio was 0.93. Table 1 and graphic 1 results show the emergence of SU during mid-2000, with a decrease of ED transfers, while neurosurgery and ICU remained steady (p&lt;10 -3 ). This decrease of ED was more important for older age groups (≥ 75 years old). Conclusion: Older age groups benefitted more from specialized pathways including ICU and SU, with less transports to ED, but never clearly from neurosurgery. Development of SU probably explains the decreased number of younger patients in neurosurgery. Literature shows that direct pathway to SU significantly improved prognosis of stroke patients. This registry of ALS transports shows its growing use in EMS dispatch, as for ST+ myocardial infarction, while transports to ED decrease. It would be interesting to compare these results with those of faster Basic Life Support transports.