Emergency Medical Services Arrival Research Articles

Outcomes for Hemodialysis Patients Given Cardiopulmonary Resuscitation for Cardiac Arrest at Outpatient Dialysis Clinics.

Out-of-hospital cardiac arrest, the leading cause of death among patients on hemodialysis, occurs frequently within outpatient dialysis centers. Practice guidelines recommend resuscitation training for all dialysis clinic staff and on-site defibrillator availability, but the extent of staff involvement in cardiopulmonary resuscitation (CPR) efforts and its association with outcomes is unknown. We used data from the Cardiac Arrest Registry to Enhance Survival and the Centers for Medicare & Medicaid Services dialysis facility database to identify patients who had cardiac arrest within outpatient dialysis clinics between 2010 and 2016 in the southeastern United States. We compared outcomes of patients who received dialysis staff-initiated CPR with those who did not until the arrival of emergency medical services (EMS). Among 398 OHCA events in dialysis clinics, 66% of all patients presented with a nonshockable initial rhythm. Dialysis staff initiated CPR in 81.4% of events and applied defibrillators before EMS arrival in 52.3%. Staff were more likely to initiate CPR among men and witness cardiac arrests, and were more likely to provide CPR within larger dialysis clinics. Staff-initiated CPR was associated with a three-fold increase in the odds of hospital discharge and favorable neurologic status on discharge. There was no overall association between staff-initiated defibrillator use and outcomes, but there was a nonsignificant trend toward improved survival to hospital discharge in the subgroup with shockable initial cardiac arrest rhythms. Dialysis staff-initiated CPR was associated with a large increase in survival but was only performed in 81% of cardiac arrest events. Further investigations should focus on understanding the potential facilitators and barriers to CPR in the dialysis setting.

Abstract TP381: Discrepancies in Arrival Time for Acute Ischemic Stroke Patients: An Opportunity for Improvement

Background: Current guidelines and national quality improvement efforts emphasize door-to-needle (DTN) time in stroke thrombolysis. Stroke center certifying bodies depend on hospital-reported DTN to appraise compliance and award designations. However, the validation of hospital reported arrival times against ambulance arrival times has not been previously reported. Objective: To determine differences in Emergency Medical Services (EMS) reported arrival time of stroke patients versus hospital documented arrival times at 10 primary and comprehensive stroke centers in Chicago. Methods: We performed a retrospective analysis of stroke admissions using the regional Get With The Guidelines (GWTG) Stroke registry of 10 Chicago hospitals between July 1 and December 31, 2013. We matched ambulance run numbers from EMS records to those in the GWTG-Stroke EMS special initiative tab. GWTG-Stroke data included arrival time, age, sex, race, initial NIHSS score, and whether tPA was administered. EMS data included hospital arrival time in addition to age, sex, hospital name, and clinical impression. We compared GWTG-Stroke and EMS reported arrival times overall and whether any clinical factors were associated with time discrepancy. Results: Among 308 matched EMS to GWTG-Stroke records, 51 (16.6%) received tPA. Overall, EMS documented arrival time was a median 5 minutes earlier than hospital documented arrival time (range -35 to +14min). There was no significant difference in time discrepancy by tPA administration, stroke type, NIHSS score, age, sex, race, insurance status, or hospital. Median DTN based on EMS data was 88m versus 82m for hospital-reported data (p>0.05). The proportion with DTN times <60 minutes was 22% based on EMS versus 29% based on hospital arrival times. Conclusions: EMS reported arrival time is on average 5 minutes earlier than hospital documented arrival time at 10 stroke centers in Chicago. Further studies should investigate factors contributing to discrepancies in DTN times between EMS and hospitals. Such investigation may lead to facilitating efficient hand-offs between EMS and hospital providers and promote earlier notification of receiving hospital stroke team in order to initiate care at time of EMS arrival.

The intensity of pain in the prehospital setting is most strongly reflected in the respiratory rate among physiological parameters

BackgroundIn order to treat pain optimally, the Emergency Medical Service (EMS) clinician needs to be able to make a reasonable estimation of the severity of the pain. It is hypothesised that various physiological parameters will change as a response to pain. AimIn a cohort of patients who were seen by EMS clinicians, to relate the patients' estimated intensity of pain to various physiological parameters. MethodsPatients who called for EMS due to pain in a part of western Sweden were included. The intensity of pain was assessed according to the visual analogue scale (VAS) or the Numerical Rating Scale (NRS). The following were assessed the same time as pain on EMS arrival: heart rate, systolic and diastolic blood pressure, respiratory rate, moist skin and paleness. ResultsIn all, 19,908 patients (≥18 years), were studied (51% women). There were significant associations between intensity of pain and the respiratory rate (r = 0.198; p < 0.0001), heart rate (r = 0.037; p < 0.0001), systolic blood pressure (r = −0.029; p < 0.0001), moist skin (r = 0.143; p < 0.0001) and paleness (r = 0.171; p < 0.0001). The strongest association was found with respiratory rate among patients aged 18–64 years (r = 0.258; p < 0.0001). ConclusionIn the prehospital setting, there were significant but weak correlations between intensity of pain and physiological parameters.The most clinically relevant association was found with an increased respiratory rate and presence of pale and moist skin among patients aged < 65 years. Among younger patients, respiratory rate may support in the clinical evaluation of pain.

Incidence, Mortality, and Outcome-Predictors of Sudden Cardiac Arrest Complicating Myocardial Infarction Prior to Hospital Admission.

Mortality of ST-segment-elevation myocardial infarction (STEMI) decreased drastically, mainly through reduction in inhospital mortality. Prehospital sudden cardiac arrest (SCA) became one of the most feared complications. We assessed the incidence, outcome, and prognosis' predictors of prehospital SCA occurring after emergency medical services (EMS) arrival. Data were taken between 2006 and 2014 from the e-MUST study (Evaluation en Médecine d'Urgence des Strategies Thérapeutiques des infarctus du myocarde) that enrolls all STEMI managed by EMS in the Greater Paris Area, including those dead before hospital admission. Among 13 253 STEMI patients analyzed, 749 (5.6%) presented EMS-witnessed prehospital SCA. Younger age, absence of cardiovascular risk factors, symptoms of heart failure, extensive STEMI, and short pain onset-to-call and call-to-EMS arrival delays were independently associated with increased SCA risk. Mortality rate at hospital discharge was 4.0% in the nonSCA group versus 37.7% in the SCA group ( P<0.001); 26.8% of deaths occurred before hospital admission. Factors associated with increased mortality after SCA were age, heart failure, and extensive STEMI, while male sex and cardiovascular risk factors were associated with decreased mortality. Among patients admitted alive, PCI was the most important mortality-reduction predictor (odds ratio, 0.40; 95% CI, 0.25-0.63; P<0.0001). More than 1 of 20 STEMI presents prehospital SCA after EMS arrival. SCA occurrence is associated with a 10-fold higher mortality at hospital discharge compared with STEMI without SCA. PCI is the strongest survival predictor, leading to a twice-lower mortality. This highlights the persistently dramatic impact of SCA on STEMI and the major importance of PCI in this setting.

Field termination-of-resuscitation rule for refractory out-of-hospital cardiac arrests in Japan

BackgroundGuidelines for cardiopulmonary resuscitation (CPR) recommend using the universal termination-of-resuscitation (TOR) rule to identify out-of-hospital cardiac arrest (OHCA) patients eligible for field termination of resuscitation, thus avoiding medically futile transportation to the hospital. However, in Japan, emergency medical services (EMS) personnel are forbidden from terminating CPR in the field and transport almost all patients with OHCA to hospitals. We aimed to develop and validate a novel TOR rule to identify patients eligible for field termination of CPR. MethodsWe analyzed 540,478 patients with OHCA from 2011 to 2015 using a Japanese registry. Main outcome measures were specificity and positive predictive value (PPV) of the newly developed TOR rule in predicting 1-month mortality after OHCA. ResultsRecursive partitioning analysis in the development group (n=434,208) showed that EMS personnel could consider TOR if patients with OHCA met all of the following five criteria: (1) initial asystole, (2) arrest unwitnessed by a bystander, (3) age ≥81 years, (4) no bystander-administered CPR or automated external defibrillator use before EMS arrival, and (5) no return of spontaneous circulation after EMS-initiated CPR for 14min. For patients meeting these criteria, specificity and PPV for predicting 1-month mortality were 99.2% [95% confidence interval (CI), 99.0–99.3%] and 99.7% (95% CI, 99.6–99.7%), respectively, for the development group and were 99.5% (95% CI, 99.3–99.7%) and 99.8% (95% CI, 99.7–99.9%), respectively, for the validation group. Implementation of this novel rule would reduce patient transports to hospitals by 10.6% in the development group and 10.4% in the validation group. ConclusionsHaving both high specificity and PPV of >99% for predicting 1-month mortality, our developed TOR rule may be applied in the field for Japanese patients with OHCA who meet all five criteria. Prospective validation studies and establishment of prehospital EMS protocol are required before implementing this rule.

When is a bystander not a bystander any more? A European survey

ObjectiveThere is international variation in the rates of bystander cardiopulmonary resuscitation (CPR). ‘Bystander CPR’ is defined in the Utstein definitions, however, differences in interpretation may contribute to the variation reported. The aim of this cross-sectional survey was to understand how the term ‘bystander CPR’ is interpreted in Emergency Medical Service (EMS) across Europe, and to contribute to a better definition of ‘bystander’ for future reference. MethodsDuring analysis of the EuReCa ONE study, uncertainty about the definition of a ‘bystander’ emerged. Sixty scenarios were developed, addressing the interpretation of ‘bystander CPR’. An electronic version of the survey was sent to 27 EuReCa National Coordinators, who distributed it to EMS representatives in their countries. Results were descriptively analysed. Results362 questionnaires were received from 23 countries. In scenarios where a layperson arrived on scene by chance and provided CPR, up to 95% of the participants agreed that ‘bystander CPR’ had been performed. In scenarios that included community response systems, firefighters and/or police personnel, the percentage of agreement that ‘bystander CPR’ had been performed ranged widely from 16% to 91%. Even in scenarios that explicitly matched examples provided in the Utstein template there was disagreement on the definition. ConclusionIn this survey, the interpretation of ‘bystander CPR’ varied, particularly when community response systems including laypersons, firefighters, and/or police personnel were involved. It is suggested that the definition of ‘bystander CPR’ should be revised to reflect changes in treatment of OHCA, and that CPR before arrival of EMS is more accurately described.

Abstract 22: When Laws Save Lives: Impact of Legislation Requiring Cardiopulmonary Resuscitation Education in High Schools on Survival After Sudden Cardiac Arrest

Introduction: Thirty eight states have laws requiring education of high school students on cardiopulmonary resuscitation (CPR) and the use of automated external defibrillators (AED). No study has measured the association of these laws and outcomes. Hypothesis: Out of hospital cardiac arrests (OHCAs) occurring in states with CPR high school education laws will have higher bystander CPR, survival, and favorable neurological survival than states without such laws. Methods: We conducted an analysis of the Cardiac Arrest Registry to Enhance Survival database and included all nontraumatic OHCAs with at least 50% population catchment from 1/2013-12/2017 in all ages. We excluded OHCAs witnessed by 911 responders, in healthcare facilities, or nursing homes. Outcomes were bystander CPR, survival to hospital discharge and neurologically favorable survival (Cerebral Performance Category score of 1 or 2 at hospital discharge). Chi-square tests were used to assess associations. Results: The 110,902 subjects with OHCA included Male, 64.0%; &lt;18 yrs., 3.2%; &lt;35 yrs., 10.7%; &lt;50 yrs., 23.9%; White, 49.3%; Black, 19.1%; Hispanic, 2.3%; Other, 2.9%; Unknown, 26.5%. Most OHCAs occurred at home, 81.4%. 44.4% were witnessed by bystanders. 75.5% occurred in states with CPR high school education laws. A higher percent of OHCAs received bystander CPR prior to emergency medical services (EMS) arrival in states with CPR high school education laws (40.1%) compared to states without laws (37.0%) (p&lt;0.001). Bystander CPR was less common in males (40.3% vs. 37.7% for females), those &gt;50 yrs. (38.9% vs. 40.7% for ≤50 yrs.), Black and Hispanic subjects (25.7% and 34.9%, respectively, vs. 42.4% for Whites) (p&lt;0.001 for all). Overall survival to hospital discharge was 10.4%; 8.8% had a favorable neurological outcome. A higher percent survived to hospital discharge in states with CPR high school education laws (11.0%) compared to states without laws (8.7%) (p&lt;0.001). Neurologically favorable survival was more likely in states with CPR high school education laws, (9.3%) compared to states without laws (7.5%) (p&lt;0.001). Conclusions: Bystander CPR, survival to hospital discharge, and neurologically favorable survival was higher in states that had CPR high school education laws.

Abstract 140: Utilization of Mechanical CPR Is Highly Variable Within the National EMS Information System Dataset

Background: Randomized controlled trials have demonstrated neither survival benefit nor harm from use of mechanical CPR (mCPR). Retrospective analyses have shown an association between mCPR and worse survival outcomes, even when controlling for differences in patient mix and arrest duration. Nonetheless, studies have suggested mCPR use increased from 2013 to 2016. Objective: We sought to quantify the proportion of out-of-hospital cardiac arrest (OHCA) cases in the US with utilization of mCPR and use in conjunction with other procedures. Methods: Using Emergency Medical Services (EMS) call data from the National EMS Information System (NEMSIS) Dataset, we identified non-traumatic OHCA with EMS resuscitation. Procedure codes were classified as “Mechanical CPR”, “Advanced Airway”, “IO”, “IV”, “Defibrillation”, “Other” and “No Procedures”. The NEMSIS Dataset includes US Census Region, Division, and urbanicity for each call. Results: In 2016, there were 29,919,652 EMS activations reported, 151,333 met inclusion criteria and 138,555 included procedure codes. Of the OHCA cohort, the mean age was 63±20 yrs, 39% were female, 86% occurred prior to EMS arrival, 62% occurred in a home/residence, 18% in public, and 14% in healthcare facilities. mCPR was used in 10% of all cases. Reported regional utilization varied from 4.8% in the Northeast to 14.9% in the South (p&lt;0.001). mCPR did not vary significantly based on urbanicity (range: 10.4% to 11.4%, p=0.34). In multiple logistic regression controlling for age, gender, location of arrest, race and ethnicity, and region, mCPR utilization was more likely if an advanced airway was placed (OR: 1.74, CI: 1.58-1.91), and less likely if an IV or IO was placed (IV: OR 0.75, CI 0.71 - 0.79; IO: OR 0.37, CI 0.28 - 0.48). 4,928 cases contained information on survival to admission. Of these, overall survival to admission was 27%, with no significant difference between mCPR and no mCPR groups. Survival to discharge data was available for 2,476 subjects (1.8% of OHCA cohort). Survival to discharge was higher among the non-mCPR group (13.8% vs. 10.3%, p = 0.011). Conclusion: In NEMSIS, reported mCPR utilization is highly variable across the US. The overall proportion of cases receiving mCPR is lower than previous registry-based studies.

Need to Prioritize Education of the Public Regarding Stroke Symptoms and Faster Activation of the 9-1-1 System: Findings from the Florida–Puerto Rico CReSD Stroke Registry

Objective: Demographic differences (race/ethnicity/sex) in 9-1-1 emergency medical services (EMS) access and utilization have been reported for various time-dependent critical illnesses along with associated outcome disparities. However, data are lacking with respect to measuring the various components of time taken to reach definitive care facilities following the onset of acute stroke symptoms (i.e., stroke onset to 9-1-1 call, EMS response, time on-scene, transport interval) and particularly with respect to any differences across ethnicities and sex. Therefore, the specific aim of this study was to measure the various time intervals elapsing following the first symptom onset (FSO) from an acute stroke until stroke hospital arrival (SHA) and to delineate any race/ethnic/sex-related differences among any of those measurements.Methods: The Florida-Puerto Rico Stroke Registry (FLPRSR) is an on-going, voluntary stroke registry of hospitals participating in the Get with the Guidelines-Stroke initiative. The study population included patients treated at Florida hospitals participating in the FLPRSR between 2010 and 2014 who had called 9-1-1 and were managed and transported by EMS. In total, 10,481 patients (16% black, 8% Hispanic, 74% white) had complete data-sets that included birthdate/year, sex, ethnic background, date/hour/minute of FSO and date/hour/minute of EMS response, scene arrival, and SHA.Results: Median time from FSO to SHA was 339 minutes (interquartile range [IQR] of 284–442), 301 of which constituted the time elapsed from FSO to the 9-1-1 call (IQR =249–392) versus only 10 from 9-1-1 call to EMS arrival (IQR =7–14), 14 on-scene (IQR =11–18) and 12 for transport to SHA (IQR =8–19). The FSO to 9-1-1 call interval, being by far the longest interval, was longest among whites and blacks (302 minutes for both) versus 291 for Hispanics (p = 0.01). However, this 11-minute difference was not deemed clinically-significant. There were neither significant sex-related differences nor any racial/ethnic/sex differences in the relatively short EMS-related intervals.Conclusions: Following acute stroke onset, time elapsed for EMS response and transport is relatively short compared to the lengthy intervals elapsing between symptom onset and 9-1-1 system activation, regardless of demographics. Exploration of innovative strategies to improve public education regarding stroke symptoms and immediate 9-1-1 system activation are strongly recommended.

Association Between Therapeutic Hypothermia and Outcomes in Patients with Non-shockable Out-of-Hospital Cardiac Arrest Developed After Emergency Medical Service Arrival (SOS-KANTO 2012 Analysis Report).

The outcomes of patients with non-shockable out-of-hospital cardiac arrest (non-shockable OHCA) are poorer than those of patients with shockable out-of-hospital cardiac arrest (shockable OHCA). In this retrospective study, we selected patients from the SOS-KANTO 2012 study with non-shockable OHCA that developed after emergency medical service (EMS) arrival and analyzed the effect of therapeutic hypothermia (TH) on non-shockable OHCA patients. Of 16,452 patients who have definitive data on the 3-month outcome in the SOS-KANTO 2012 study, we selected 241 patients who met the following criteria: age ≥ 18years, normal spontaneous respiration or palpable pulse upon emergency medical services arrival, no ventricular fibrillation or pulseless ventricular tachycardia before hospital arrival, and achievement of spontaneous circulation without cardiopulmonary bypass. Patients were divided into two groups based on the presence or absence of TH and were analyzed. Of the 241 patients, 49 underwent TH. Univariate analysis showed that the 1-/3-month survival rates and favorable 3-month cerebral function outcome rates in the TH group were significantly better than the non-TH group (46% vs 19%, respectively, P < 0.001, 35% vs 12%, respectively, P < 0.001, 20% vs 7%, respectively, P = 0.01). Multivariate logistic regression analysis showed that TH was a significant, independent prognostic factor for cerebral function outcome. In this study, TH was an independent prognostic factor for the 3-month cerebral function outcome. Even in patients with non-shockable OHCA, TH may improve outcome if the interval from the onset of cardiopulmonary arrest is relatively short, and adequate cardiopulmonary resuscitation is initiated immediately after onset.

Automated External Defibrillator Application Before EMS Arrival in Pediatric Cardiac Arrests.

Little is known about the predictors of pre-emergency medical service (EMS) automated external defibrillator (AED) application in pediatric out-of-hospital cardiac arrests. We sought to determine patient- and neighborhood-level characteristics associated with pre-EMS AED application in the pediatric population. We reviewed prospectively collected data from the Cardiac Arrest Registry to Enhance Survival on pediatric patients (age >1 to ≤18 years old) who had out-of-hospital nontraumatic arrest (2013-2015). A total of 1398 patients were included in this analysis (64% boys, 45% white, and median age of 11 years old). An AED was applied in 28% of the cases. Factors associated with pre-EMS AED application in univariable analyses were older age (odds ratio [OR]: 1.9; 12-18 years old vs 2-11 years old; P < .001), white versus African American race (OR: 1.4; P = .04), public location (OR: 1.9; P < .001), witnessed status (OR: 1.6; P < .001), arrests presumed to be cardiac versus respiratory etiology (OR: 1.5; P = .02) or drowning etiology (OR: 2.0; P < .001), white-populated neighborhoods (OR: 1.2 per 20% increase in white race; P = .01), neighborhood median household income (OR: 1.1 per $20 000 increase; P = .02), and neighborhood level of education (OR: 1.3 per 20% increase in high school graduates; P = .006). However, only age, witnessed status, arrest location, and arrests of presumed cardiac etiology versus drowning remained significant in the multivariable model. The overall cohort survival to hospital discharge was 19%. The overall pre-EMS AED application rate in pediatric patients remains low.

Refractory out-of-hospital cardiac arrest with ongoing cardiopulmonary resuscitation at hospital arrival \u2013 survival and neurological outcome without extracorporeal cardiopulmonary resuscitation

BackgroundThe prognosis in refractory out-of-hospital cardiac arrest (OHCA) with ongoing cardiopulmonary resuscitation (CPR) at hospital arrival is often considered dismal. The use of extracorporeal cardiopulmonary resuscitation (eCPR) for perfusion enhancement during resuscitation has shown variable results. We aimed to investigate outcome in refractory OHCA patients managed conservatively without use of eCPR.MethodsWe included consecutive OHCA patients with refractory arrest or prehospital return of spontaneous circulation (ROSC) in the Copenhagen area in 2002–2011.ResultsA total of 3992 OHCA patients with resuscitation attempts were included; in 2599, treatment was terminated prehospital, and 1393 (35%) were brought to the hospital either with ROSC (n = 1285, 92%) or with refractory OHCA (n = 108, 8%). Of patients brought in with refractory OHCA, 56 (52%) achieved ROSC in the emergency department. There were no differences between patients with refractory OHCA or prehospital ROSC with regard to age, sex, comorbidities, or etiology of OHCA. Time to emergency medical services (EMS) arrival was similar, whereas time to ROSC (when ROSC was achieved) was longer in refractory OHCA patients (EMS, 6 (5–9] vs. 7 [5–10] min, p = 0.8; ROSC, 15 [9–22] vs. 27 [20–41] min, p < 0.001). Independent factors associated with transport with refractory OHCA instead of prehospital termination of therapy were OHCA in public (OR, 3.6 [95% CI, 2.2–5.8]; p < 0.001), witnessed OHCA (OR, 3.7 [2.0–7.1]; p < 0.001), shockable rhythm (OR, 3.0 [1.9–4.7]; p < 0.001), younger age (OR, 1.2 [1.1–1.2]; p < 0.001), and later calendar year (OR, 1.4 [1.2–1.6]; p < 0.001). Thirty-day survival was 20% in patients with refractory OHCA compared with 42% in patients with prehospital ROSC (p < 0.001). Four of 28 refractory OHCA patients with duration of resuscitation > 60 min achieved ROSC. No difference in favorable neurological outcome in patients surviving to discharge was found (prehospital ROSC 84% vs. refractory OHCA 86%; p = 0.7).ConclusionsSurvival after refractory OHCA with ongoing CPR at hospital arrival was significantly lower than among patients with prehospital ROSC. Despite a lower survival, the majority of survivors with both refractory OHCA and prehospital ROSC were discharged with a similar degree of favorable neurological outcome, indicating that continued efforts in spite of refractory OHCA are not in vain and may still lead to favorable outcome even without eCPR.

Trends and Characterization of Academic Emergency Department Patient Visits: A Five-year Review.

To meet the unique comparative data needs of academic emergency departments (EDs), we describe the recent 5-year national and regional trends for adult emergency patients' characteristics and operational parameters at academic emergency medical centers. Data collected from the recent 5-year period academic year (AY) 2012 through AY 2016 of the Academy of Administrators in Academic Emergency Medicine (AAAEM) and the Association of Academic Chairs of Emergency Medicine (AACEM) Academic Emergency Medicine Benchmarking Survey were analyzed for trends in 1) ED volumes and modes of arrival, 2) triage acuity level, 3) trends in ED professional fee billing, and 4) disposition patterns of ED patients including admission rates and walkouts. The AY spanned the 12-month period of July 1 through June 30. Only primary academic or academic affiliate hospitals data were included. Community and freestanding affiliated EDs were excluded. Institutional-specific data were stratified into four cohorts based on the following annual ED visit volumes: under 40,000, 40,000 to 60,000, 60,000 to 80,000, and over 80,000. Triage acuity levels were based on the Emergency Severity Index (ESI). Professional fee billing was analyzed specifically for CPT codes 99284, 99285, and 99291 (critical care). Left without being seen (LWBS), defined as leaving before a screening examine by a licensed medical provider, and screened and left (SAL), i.e., patients who were screened by a provider, but left before definitive evaluation and management, were similarly evaluated. Total walkouts were defined as the sum of LWBS and SAL. Forty-four primary academic and academic affiliate sites completed the survey for all 5 years. The mean annual patient census increased 13.4% over the study period, with the majority (80%) of sites experiencing volume growth. Acuity/illness severity, measured as ESI 1 and 2, and CPT codes 99284, 99295, and 99291 increased an aggregate 18.2 and 8.4%, respectively. Large-volume hospitals (>60,000-80,000, >80,000) admissions increased by 15 and 21.6%, respectively, primarily due to surge in 2016. Overall emergency medical services (EMS) arrivals increased 7.3% although admissions from EMS remained relatively stable. LWBS rates decreased 19.5%, but total walkouts did not appear to change. With a focus on larger academic institutions, differences were noted in the overall increases in volume and acuity. In this survey, participating institutions experienced increased volumes of patients with seemingly higher illness severity. While inroads have been made in LWBS rates, there has not been an overall decrease in total walkouts. The data reported here differed in many aspects compared to other benchmark surveys.

282 Impact of Emergency Medical Services Vehicle Use by Acute Ischemic Stroke Patients on Functional Outcomes: An Observational Study

Previous studies have documented the impact of emergency medical services (EMS) vehicle use on speedy thrombolytic treatment, but not on patient functional outcomes. We assessed the association of EMS use with likelihood and timeliness of intravenous (IV) thrombolytic treatment and functional outcomes at discharge and 90 days. Prospective observational study using Get With The Guidelines Stroke data on AIS patients with cerebrovascular imaging evidence, discharged 4/2016 to 10/2017 from a non-profit hospital’s primary stroke center unit in Columbia, South Carolina. Key outcomes of interest were: National Institutes of Health Stroke Scale (NIHSS) change from arrival to discharge (continuous variable), discharge disposition (discharged to home versus otherwise), and 90-day modified Rankin Scale, mRS 0-1 versus otherwise, (ascertained by phone calls to patients discharged from 4/2018 to 8/2017 within 75-105 days of discharge using a standardized script, supplemented by medical record data on neurology follow-up visits). Multiple logistic and linear regression analyses were used as appropriate. Of 1,166 total AIS discharges, 328 were excluded (transfer patients or hospice assigned pre-admission). Among 838 study-eligible patients, 52.4% were black, 72.2% arrived by EMS, mean admission NIHSS (available for 96.7% of patients) was 6.8 (±7.3; median 4.0, range 0 - 37), mean stroke-relevant comorbidities per patient 3.7 (±1.9), alteplase received 114 (13.6%), and 92 expired or assigned to hospice. Mean door to imaging (DTI) time was 98.8 minutes (±151.0; median 49), and mean door to needle (DTN) time for IV alteplase recipients, 46.2 minutes (±31.2; median 38.0). In bivariate analyses, EMS arrivals were older (mean age 70 years versus 63.6 for other transport), more severe (mean NIHSS 8.3 (±7.7) versus 2.9 (±3.7), more likely to have contraindications to alteplase, and had worse discharge outcomes. Adjusted for demographic and other factors, EMS use was highly associated with stroke severity (adjusted odds 4.1 for moderate stroke (NIHSS 6-15) versus mild stroke (NIHSS 0-5), and 12.3 for severe stroke (NIHSS>15), p<0.001). Adjusted for stroke severity, comorbidities, endovascular treatment and other relevant factors as appropriate, EMS arrival (relative to other transport) was associated with: 5-fold higher odds of IV alteplase, 88.5 minutes lower DTI (p<0.01; 57% reduction), and, among severe stroke patients, 5.7 points better improvement in discharge NHISS over admission NIHSS (all p<0.001). Insurance status and race were not significant factors in alteplase use, DTI or DTN. Discharge disposition was not significantly associated with arrival mode. 90-day mRS was ascertained for 430 patients (59.2% of eligible, despite 87.1% of eligibles fully pursued per protocol). The study lacked statistical power to assess EMS impact on 90-day mRS, given the effect magnitude of stroke severity on both EMS use and 90-day outcomes. However, discharge NIHSS accurately predicted 90-day mRS, (adjusted beta 0.20; score ranges of the 2 scales, 0-37 versus 0-6; model R2 = 0.42), supporting that EMS use may produce better long-term outcomes in severe stroke patients. This study breaks new ground, documenting a positive impact of EMS use on functional outcomes in severe stroke. Given evidence of equitable care regardless of insurance status/race at the study center, findings may be generalizable despite being a single-center observational study.

280 Analyzing the Impact of Low-Acuity Emergency Medical Services Arrivals on Resource Utilization in the Emergency Department

280 Analyzing the Impact of Low-Acuity Emergency Medical Services Arrivals on Resource Utilization in the Emergency Department

281 Emergency Medical System Response to in Home Delivery and Midwife Utilization in the State of Michigan

We observed that out-of-hospital deliveries locally have high complication rates. Some cases involved (non-nurse) midwives for which state licensure was not required until 2016. There is scant literature that addresses out-of-hospital deliveries and none that evaluate the interaction of emergency medical services (EMS) and midwives. Our objective was to describe utilization, complications, and outcomes of EMS attended out-of-hospital deliveries in Michigan in 2015. We queried the Michigan EMS Information System (MI-EMSIS) for out-of-hospital deliveries in 2015. We identified candidate cases, using a combination of narrative, demographic and procedural search strategies. Inclusion was birth prior to hospital arrival. We abstracted demographics, birth circumstances, complications, and birth outcome. Duplicate reviews of 20% of cases were performed to assure interrater reliability. Categories of complications were constructed post hoc. Non-viability was defined as <22 weeks gestation, fetal demise as stillborn or failure to resuscitate upon delivery, and extreme prematurity (24-28 week gestational age). First trimester miscarriages were excluded. Michigan Vital Statistics reported 1,577 out-of-hospital (excluding birthing center) births in 2015, of which 1361 were attended by midwives. We identified 228 EMS attended deliveries from 1.6 million MI-EMSIS records. Mothers’ median age was 28 (range 15-41). The majority (59.2%) were white. Most were normal vaginal deliveries on scene or enroute to hospital (92, 40.0%), or delivered prior to EMS arrival (58, 25.4%). Maternal or fetal complications were identified in 71(31.1%) deliveries. Complications included non-viable fetus (13, 5.7%), fetal demise (12, 4.8%), post-partum hemorrhage (8, 3.5%), non-transient apnea (7, 3.0%), and extreme prematurity (7, 3.0%). Midwives attended 32 (14.0%) EMS cases, with complications reported in 20 (62.5%). Complications included post-partum hemorrhage (6); non-transient apnea (4); and fetal demise (3). The complication rate with and without midwife involvement was 62.5% and 26.9%, respectively. EMS deliveries were rare and most were normal vaginal deliveries, but almost a third had complications. Midwife versus non-midwife EMS deliveries had higher complication rates. Midwife attended EMS deliveries were rare, but had high rates of complications including need for critical interventions.

Emergency medical dispatch recognition, clinical intervention and outcome of patients in traumatic cardiac arrest from major trauma: an observational study

ObjectivesThe aim of this study is to describe the demographics of reported traumatic cardiac arrest (TCA) victims, prehospital resuscitation and survival to hospital rate.SettingHelicopter Emergency Medical Service (HEMS) in south-east...

Effects of emergency medical services times on traffic injury severity: A random effects ordered probit approach

Objective: Emergency medical services (EMS) play a vital role in the postcrash effort to reduce fatalities by providing first aid treatment and transportation to medical facilities. This study aims to analyze the time required for crash reporting and EMS arrival in fatal traffic crashes and to explore the effects of EMS time on the traffic injury severity.Methods: The time required for EMS reporting, arrival, and transport to hospital was calculated by location type and roadway functional classification using 2016 Fatality Analysis Reporting System (FARS) data. Subsequently, an ordered probit model was developed to identify factors contributing to injury severity considering EMS time.Results: The average time for the crash–reporting duration is 5.38 min, the reporting–scene arrival interval is 10.52 min, and the scene–hospital interval is 34.72 min. The average crash reporting and reporting–scene arrival intervals were the longest on conventional roads in rural areas and the shortest on conventional roads in urban areas. The average scene–hospital interval was longest in conventional rural areas and the shortest on freeways/expressways in urban areas. The developed random effects ordered probit model shows that prolonged reporting–scene arrival and scene–hospital intervals result in more severe injuries. The result also presents that crash type, violation, age, location, lighting condition, and alcohol/drug involvement have significant effects on injury severity.Conclusions: The key findings from this study indicate that EMS times differ according to urban/rural location and road functional classification and that reporting–scene arrival and scene–hospital intervals have significant effects on injury severity along with various factors. It is expected that the findings from this study can be used to develop effective and practical strategic plans to minimize EMS reporting, arrival time, and transport to hospital and therefore decrease the traffic injury severity.

A five-year retrospective study of out-of-hospital cardiac arrest in a north-east Italian urban area.

The reporting and analysing of data of out-of-hospital cardiac arrests encourages the quality improvement of the emergency medical services. For this reason, the establishment of a sufficiently large patient database is intended to allow analysis of resuscitation treatments for out-of-hospital cardiac arrests and performances of different emergency medical services. The aim of this study was to describe the demographics, characteristics, outcomes and determinant factors of survival for patients who suffered an out-of-hospital cardiac arrest. this was a retrospective study including all out-of-hospital cardiac arrest cases treated by the emergency medical service in the district of Udine (Italy) from 1 January 2010-31 December 2014. A total of 1105 out-of-hospital cardiac arrest patients were attended by the emergency medical service. Of these, 489 (44.2%) underwent cardiopulmonary resuscitation, and return of spontaneous circulation was achieved in 142 patients (29%). There was a male predominance overall, and the main age was 72.6 years (standard deviation 17.9). Cardiopulmonary resuscitation before emergency medical service arrival was performed on 62 cases (44%) in the return of spontaneous circulation group, and on 115 cases (33%) in the no return of spontaneous circulation group ( p<0.024). Among the 142 cases of return of spontaneous circulation, 29 (5.9%) survived to hospital discharge. There was a smaller likelihood of return of spontaneous circulation when patients were female (odds ratio 0.61, 0.40-0.93). Patients who had an out-of-hospital cardiac arrest with an initial shockable rhythm (odds ratio 6.33, 3.86-10.39) or an age <60 years (odds ratio 2.91, 1.86-4.57) had a greater likelihood of return of spontaneous circulation. In addition, bystander cardiopulmonary resuscitation (odds ratio 1.56, 1.04-2.33) was associated with an increased chance of return of spontaneous circulation. The incidence of out-of-hospital cardiac arrest and survival rate lies within the known range. A wider database is necessary to achieve a better knowledge of out-of-hospital cardiac arrest and to drive future investments in the healthcare system.

Resident Survival Low After Cardiac Arrest in Nursing Homes

Resident Survival Low After Cardiac Arrest in Nursing Homes