Emergency Medical Services Database Research Articles

Identification of Naloxone in Emergency Medical Services Data Substantially Improves by Processing Unstructured Patient Care Narratives

ABSTRACT OBJECTIVES Structured data fields, including medication fields involving naloxone, are routinely used to identify opioid overdoses in emergency medical services (EMS) data; between January 2021 and March 2024, there were approximately 1.2 million instances of naloxone administration. in the United States. To improve the accuracy of naloxone reporting, we developed methodology for identifying naloxone administration using both structured fields and unstructured patient care narratives for events documented by EMS. METHODS We randomly sampled 30,000 records from Kentucky’s state-wide EMS database during 2019. We applied regular expressions (RegEx) capable of recognizing naloxone-related text patterns in each EMS patient’s case narrative. Additionally, we applied natural language processing (NLP) techniques to extract important contextual factors such as route and dosage from these narratives. We manually reviewed cases where the structured data and unstructured data disagreed and developed an aggregate indicator for naloxone administration using either structured or unstructured data for each patient case. RESULTS There were 437 (1.45%) records with structured documentation of naloxone. Our RegEx method identified 547 naloxone administrations in the narratives; after manual review, we determined RegEx yielded acceptable false positives (N = 31, 5.6%), false negatives (N = 23, 4.2%) and performance (precision = 0.94, recall = 0.93). In total, 552 patients had naloxone administered after combining indicators from both structured fields and verified results from unstructured narratives. The NLP approach also identified 246 (47.4%) records that specified route of administration and 358 (69.0%) records with dosage delivered. CONCLUSIONS An additional 115 (26.3%) patients receiving naloxone were identified by using unstructured case narratives compared to structured data. New surveillance methods that incorporate unstructured EMS narratives are critically needed to avoid substantial underestimation of naloxone utilization and enumeration of opioid overdoses.

The Association of Lowest Prehospital Blood Pressure with Mortality in Severe Traumatic Brain Injury from a Nationwide Emergency Medical Services Database

ABSTRACT OBJECTIVES Clinical management of traumatic brain injury (TBI) focuses on preventing secondary injury from cerebral edema and ongoing anoxic injury. Consensus guidelines recommend maintaining systolic blood pressure (SBP) > 110 mmHg. A recent prehospital study suggested lowest adjusted mortality from 130 mmHg to 180 mmHg, suggesting the ideal pressure may be higher. This study aims to explore and externally validate the association between lowest out of hospital SBP and mortality in a nationwide database. METHODS Retrospective observational study of nationwide data from the ESO© (Austin, TX) prehospital electronic health record. Inclusion criteria were an ICD-10 code for TBI, age >10 years, admission to the hospital, abbreviated injury severity head/neck sub-score ≥ 3. Data were split into 70% training and 30% test sets. Unadjusted and adjusted generalized additive models with splines for the continuous variables of SBP and age were created to assess the relationship between lowest SBP and mortality. Adjusted model covariates included age, sex, injury severity score, mechanism, polytrauma, trauma center transport (level 1, 2, or 3), hypoxia and airway management. To evaluate the independent association of lowest SBP with mortality, the adjusted marginal means for predicted probability of death at any fixed value of SBP were estimated and an optimized SBP range was identified. Age and injury severity were evaluated as possibly relevant interaction terms with SBP. RESULTS From 2018 to 2022, 44,360 encounters with ICD-10 codes for TBI were screened and 9,449 met final inclusion criteria, with 2,005 meeting the primary outcome (21.2%). Both unadjusted and adjusted analysis identified lowest prehospital SBP as a significant predictor (p < 0.001). Based on adjusted marginal means, the optimized SBP for mortality was 132 mmHg (range 110-158 mmHg). The interaction between SBP and age was significant with a higher optimized SBP of 133 mmHg (range 125-145 mmHg) for patients aged 65 and older. CONCLUSIONS Out of hospital SBP is a significant predictor of mortality in subjects with severe TBI. These results suggest an optimized SBP range 110-158 mmHg, consistent with current consensus guidelines of SBP > 110 mmHg but may suggest benefit for higher SBP targets in older patients.

Effectiveness of the community paramedicine at home (CP@home) program for frequent users of emergency medical services in Ontario: a randomized controlled trial

ObjectiveTo evaluate the impact of the Community Paramedicine at Home (CP@home) program, a community paramedicine home-visit intervention, on reducing emergency medical services (EMS) calls among frequent users.DesignA 6-month, open-label, pragmatic, randomized controlled trial with parallel intervention and control arms. An online automated platform (randomizer.org) was used to randomly allocate participants using a 1:1 allocation sequence.SettingIn homes of frequent EMS users in four paramedic services and regions across Ontario, Canada.ParticipantsEligible participants were frequent callers (≥ 3 EMS calls within six months and ≥ 1 EMS call within the previous month), or had ≥ 1 lift assist call within the previous month, or were referred by paramedics.InterventionCommunity paramedics conducted risk assessments, provided health education, referred appropriate resources, and reported to family physicians for up to three home visits. The control arm received usual care.Primary outcome measureEMS calls in 6 months during intervention.ResultsTwo thousand two hundred eighty four eligible participants were randomly allocated to the intervention and control groups, with 265 participants lost to follow-up due to inability to retrieve participant records from EMS databases. There were 1025 intervention participants (52.7% female, mean age 69.65 years [standard deviation (SD) = 19.98]) and 994 control participants (52.0% female, mean age 69.78 years [SD = 19.09]). In the post-intervention intention-to-treat analysis (zero-inflated negative binomial regression), the EMS call rate was not significantly lower in the intervention group compared to the control group (incidence rate ratio [IRR] = 0.88, 95% confidence interval [CI]: 0.76, 1.01). In the subgroup analysis, the intervention had a significant effect in the lift assist caller subgroup (IRR = 0.73, 95% CI: 0.58, 0.92), but no significant effect among the frequent caller subgroup (IRR = 0.97, 95% CI: 0.82, 1.14). The sensitivity analyses found a similar association for the lift assist caller subgroup. There was a significant subgroup effect (p-value for interaction < 0.01).ConclusionsCP@home had a significant impact on reducing EMS calls for those with a lift assist call but not for the overall sample. This program filled a healthcare gap by shifting primary care delivery, which could reduce the disproportionate number of EMS calls, thus reducing healthcare costs.Trial registrationRegistered with ClinicalTrials.gov NCT02835989 on July 14, 2016.

Numerical Cincinnati Stroke Scale versus Stroke Severity Screening Tools for the Prehospital Determination of Large Vessel Occlusion

ABSTRACT OBJECTIVES Previous research demonstrated that the numerical Cincinnati Prehospital Stroke Scale (CPSS) identifies large vessel occlusion (LVO) at similar rates compared to dedicated LVO screening tools. We aimed to compare numerical CPSS to additional stroke scales using a national Emergency Medical Services (EMS) database. METHODS Using the ESO Data Collaborative, the largest EMS database with linked hospital data, we retrospectively analyzed prehospital patient records from 2022. Each EMS record was linked to corresponding emergency department (ED) and inpatient records through a data exchange platform. Prehospital CPSS was compared to the Cincinnati Stroke Triage Assessment Tool (C-STAT), the Field Assessment Stroke Triage for Emergency Destination (FAST-ED), and the Balance Eyes Face Arm Speech Time (BE-FAST). The optimal prediction cut points for LVO screening were determined by intersecting the sensitivity and specificity curves for each scale. To compare the discriminative abilities of each scale among those diagnosed with LVO, we used the area under the receiver operating curve (AUROC). RESULTS We identified 17,442 prehospital records from 754 EMS agencies with ≥ 1 documented stroke scale of interest: 30.3% (n = 5,278) had a hospital diagnosis of stroke, of which 71.6% (n = 3,781) were ischemic; of those, 21.6% (n = 817) were diagnosed with LVO. CPSS score ≥ 2 was found to be predictive of LVO with 76.9% sensitivity, 68.0% specificity, and AUROC 0.787 (95% CI 0.722-0.801). All other tools had similar predictive abilities, with sensitivity/specificity/AUROC of: C-STAT 62.5%/76.5%/0.727 (0.555-0.899); FAST-ED 61.4%/76.1%/0.780 (0.725-0.836); BE-FAST 70.4%/67.1%/0.739 (0.697-0.788). CONCLUSIONS The less complex CPSS exhibited comparable performance to three frequently employed LVO detection tools. The EMS leadership, medical directors, and stroke system directors should weigh the complexity of stroke severity instruments and the challenges of ensuring consistent and accurate use when choosing which tool to implement. The straightforward and widely adopted CPSS may improve compliance while maintaining accuracy in LVO detection.

The Impact of Global Warming on the Rise in Heat-Related Illnesses in Emergency Medical Services.

Global warming is one of the critical problems affecting health, society, and the economy. High temperatures are linked to an increase in heat-related illnesses, which have significantly impacted the public health system, particularly emergency medical services (EMS). Analyzing the pattern of heat-related illness cases in EMS can improve resource utilization and preparedness within the public health system. A retrospective study was conducted on EMS data from Srinagarind Hospital, Thailand, covering the summer months (February to May) from 2020 to 2024. Patients with heat-related illnesses were identified in the EMS database using the 10th revision of the International Classification of Diseases (ICD-10) version 2019, specifically codes under "T67 Effects of Heat and Light", which include heat stroke, heat syncope, heat cramps, heat exhaustion, and heat fatigue. A total of 136 EMS operations from the hospital's database were analyzed. In the summer 2024 group, 95.7% (N=44) of the patients were male. The majority of EMS triage cases required resuscitation (P = 0.020). Outdoor activity was identified as a significant factor related to heat illness, with rates of 83.3%, 92.9%, 93.3%, 97.1%, and 93.5% over the five years of the study. The activation time was 1.30minutes for the summer of 2024 and 1.24minutes for the summer of 2023. Notably, the average scene time in the summer 2024 group was significantly longer at 25.2minutes, compared to 12.0minutes in the summer 2020 group (P<0.001). Outdoor activity was the most significant risk factor associated with increased heat-related illnesses. Other contributing factors included male gender, age between 20-40 years, scene temperatures above 35°C, and prolonged scene times exceeding 15minutes.

Layperson-Administered Naloxone Trends Reported in Emergency Medical Service Activations, 2020-2022

Layperson-administered naloxone (LAN) is a powerful but incompletely characterized intervention to prevent opioid-related overdose mortality. LAN trends are relevant to policy and strategic planning in naloxone distribution initiatives. To assess the 2-year LAN trend for persons in the United States receiving naloxone during emergency medical services (EMS) activations. This retrospective cross-sectional study was conducted in the United States from June 2020 to June 2022 among 65 621 195 EMS activations from 911 responses, EMS standbys, or when EMS crews functioned in an ambulance intercept role or during mutual aid to another ambulance response. Activations within health care settings and interfacility or medical transports were excluded. Data are from the National Emergency Medical Services Information System (NEMSIS), the national EMS patient care record database. From June 2020 to June 2022, NEMSIS included more than 96 million EMS activations from nearly 14 000 agencies across 54 states and territories. EMS clinician-reported LAN. The primary outcome was the trend of receiving LAN, measured by EMS clinician documentation. From June 2020 to June 2022, EMS reported 744 078 patients receiving naloxone, with 24 990 (3.4%) involving LAN. Patients were predominantly male (17 331 [69.4%]) and had a median (IQR) age of 42 (31-56) years, with the majority treated in urban homes or residences (21 692 [86.8%] urban; 13 223 [52.9%] in-home or residence). Of the total naloxone recipients, 243 985 patients (32.8%) had suspected drug overdose documentation as either the primary or secondary impression. Overall, the percentage change in naloxone administration rates decreased 6.1% over the study period (from 1140.1 [95% CI, 1135.1-1145.1] per 100 000 EMS activations to 1070.1 [95% CI, 1064.9-1075.3] per 100 000 EMS activations), while the percentage change of persons receiving LAN increased 43.5% (from 30.0 [95% CI, 29.2-30.8] per 100 000 EMS activations to 43.1 [95% CI, 42.0-44.1] per 100 000 EMS activations). In this cross-sectional study, the LAN rate increased from June 2020 to June 2022 as reported in the national EMS database. These findings help inform policies and practices aimed at mitigating the devastating impacts of the opioid epidemic and saving lives. Novel public health strategies are needed to measure the effects of this intervention nationally, evaluate approaches to expand naloxone distribution, and address naloxone usage barriers.

Assessing variations in care delivered to rural out of hospital cardiac arrest patients in the interfacility transfer setting.

There is significant variation in out-of-hospital cardiac arrest (OHCA) outcomes between different regions. We sought to evaluate outcomes of OHCA patients in the interfacility transfer (IFT) setting, between critical care transport (LifeFlight) and community Emergency Medical Services (EMS), in the state of Maine. This was a retrospective analysis of our institution's electronic medical record and the Maine EMS database. Data were collected from January 1, 2019, to December 31, 2021. Only adult OHCA encounters requiring an IFT for definitive post-cardiac-arrest care were included. Demographics, EMS agency, IFT vital signs, targeted temperature management (TTM) medications, cerebral performance category (CPC) scores, survival to discharge, and other descriptive variables were collected. Ninety-three patients met inclusion criteria, with LifeFlight transferring 30 of them (32.3%). LifeFlight was more likely to initiate TTM compared to other EMS agencies (p=0.012), have run-sheets reported (p=0.001), and serve rural areas (p=0.036). LifeFlight was associated with more epinephrine (0.034) and norepinephrine (<0.001) use. Only 37% of IFTs had physician orders, with none (0.0%) of them defining vital sign targets. No difference in survival to discharge or CPC scores was observed between LifeFlight and other EMS agencies. No significant variation in comorbidities or vital signs was observed. There was no difference in survival to discharge or CPC scores between LifeFlight and ad hoc EMS agency. LifeFlight was associated with more TTM and vasopressor utilization during IFT. Most IFT encounters did not have dedicated physician orders, and none of the orders included vital sign targets.

Quality and safety in prehospital airway management – retrospective analysis of 18,000 cases from an air rescue database in Germany

BackgroundPrehospital airway management remains crucial with regard to the quality and safety of emergency medical service (EMS) systems worldwide. In 2007, the benchmark study by Timmermann et al. hit the German EMS community hard by revealing a significant rate of undetected oesophageal intubations leading to an often-fatal outcome. Since then, much attention has been given to guideline development and training. This study evaluated the incidence and special circumstances of tube misplacement as an adverse peri-intubation event from a Helicopter Emergency Medical Services perspective.MethodsThis was a retrospective analysis of a German helicopter-based EMS database from January 1, 2012, to December 31, 2020. All registered patients were included in the primary analysis. The results were analysed using SPSS 27.0.1.0.ResultsOut of 227,459 emergency medical responses overall, a total of 18,087 (8.0%) involved invasive airway management. In 8141 (45.0%) of these patients, airway management devices were used by ground-based EMS staff, with an intubation rate of 96.6% (n = 7861), and alternative airways were used in 3.2% (n = 285). Overall, the rate of endotracheal intubation success was 94.7%, while adverse events in the form of tube misplacement were present in 5.3%, with a 1.2% rate of undetected oesophageal intubation. Overall tube misplacement and undetected oesophageal intubation occurred more often after intubation was carried out by paramedics (10.4% and 3.6%, respectively). In view of special circumstances, those errors occurred more often in the presence of trauma or cardiopulmonary resuscitation, with rates of 5.6% and 6.4%, respectively. Difficult airways with a Cormack 4 status were present in 2.1% (n = 213) of HEMS patients, accompanied by three or more intubation attempts in 5.2% (n = 11).ConclusionsPrehospital airway management success has improved significantly in recent years. However, adverse peri-intubation events such as undetected oesophageal intubation remain a persistent threat to patient safety.Trial registrationThe study was registered in the German Register for Clinical Studies (number DRKS00028068).

Development and internal validation of an algorithm for estimating mortality in patients encountered by physician-staffed helicopter emergency medical services

BackgroundSeverity of illness scoring systems are used in intensive care units to enable the calculation of adjusted outcomes for audit and benchmarking purposes. Similar tools are lacking for pre-hospital emergency medicine. Therefore, using a national helicopter emergency medical services database, we developed and internally validated a mortality prediction algorithm.MethodsWe conducted a multicentre retrospective observational register-based cohort study based on the patients treated by five physician-staffed Finnish helicopter emergency medical service units between 2012 and 2019. Only patients aged 16 and over treated by physician-staffed units were included. We analysed the relationship between 30-day mortality and physiological, patient-related and circumstantial variables. The data were imputed using multiple imputations employing chained equations. We used multivariate logistic regression to estimate the variable effects and performed derivation of multiple multivariable models with different combinations of variables. The models were combined into an algorithm to allow a risk estimation tool that accounts for missing variables. Internal validation was assessed by calculating the optimism of each performance estimate using the von Hippel method with four imputed sets.ResultsAfter exclusions, 30 186 patients were included in the analysis. 8611 (29%) patients died within the first 30 days after the incident. Eleven predictor variables (systolic blood pressure, heart rate, oxygen saturation, Glasgow Coma Scale, sex, age, emergency medical services vehicle type [helicopter vs ground unit], whether the mission was located in a medical facility or nursing home, cardiac rhythm [asystole, pulseless electrical activity, ventricular fibrillation, ventricular tachycardia vs others], time from emergency call to physician arrival and patient category) were included. Adjusted for optimism after internal validation, the algorithm had an area under the receiver operating characteristic curve of 0.921 (95% CI 0.918 to 0.924), Brier score of 0.097, calibration intercept of 0.000 (95% CI -0.040 to 0.040) and slope of 1.000 (95% CI 0.977 to 1.023).ConclusionsBased on 11 demographic, mission-specific, and physiologic variables, we developed and internally validated a novel severity of illness algorithm for use with patients encountered by physician-staffed helicopter emergency medical services, which may help in future quality improvement.

Emergency medical service response for cases of stroke-suspected seizure: A population-based study

ObjectivesWe evaluated the on-scene time of emergency medical services (EMS) for cases where discrimination between acute stroke and epileptic seizures at the initial examination was difficult and identified factors linked to delays in such scenarios. Materials and MethodsA retrospective review of cases with suspected seizure using the EMS database of fire departments across six Japanese cities between 2016 and 2021 was conducted. Patient classification was based on transport codes. We defined cases with stroke-suspected seizure as those in whom epileptic seizure was difficult to differentiate from stroke and evaluated their EMS on-scene time compared to those with epileptic seizures. ResultsAmong 30,439 cases with any seizures, 292 cases of stroke-suspected seizure and 8,737 cases of epileptic seizure were included. EMS on-scene time in cases of stroke-suspected seizure was shorter than in those with epileptic seizure after propensity score matching (15.1±7.2 min vs. 17.0±9.0 min; p = 0.007). Factors associated with delays included transport during nighttime (odds ratio [OR], 1.73, 95 % confidence interval [CI] 1.02–2.93, p = 0.041) and transport during the 2020–2021 pandemic (OR, 1.77, 95 % CI 1.08–2.90, p = 0.022). ConclusionThis study highlighted the difference between the characteristics in EMS for stroke and epileptic seizure by evaluating the response to cases with stroke-suspected seizure. Facilitating prompt and smooth transfers of such cases to an appropriate medical facility after admission could optimize the operation of specialized medical resources.

Prehospital interventions and outcomes in traumatic cardiac arrest: a population-based cohort study using the Danish Helicopter Emergency Medical Services data.

Traumatic cardiac arrest is associated with poor prognosis, and timely evidence-based treatment is paramount for increasing survival rates. Physician-staffed helicopter emergency medical service use in major trauma has demonstrated improved outcomes. However, the sparsity of data highlights the necessity for a comprehensive understanding of the epidemiology of traumatic cardiac arrest. The primary objective of the present study was to evaluate survival and return of spontaneous circulation (ROSC) and to investigate the characteristics of patients with traumatic cardiac arrest assessed by the Danish HEMS. This was a population-based cohort study based on data from the Danish helicopter emergency medical service database. The study included all patients assessed by the Danish helicopter emergency medical services between 2016 and 2021. Data were analysed using descriptive statistics, non-parametric testing and logistic regression analyses. Descriptive analysis of prehospital interventions included cardiopulmonary resuscitation, defibrillation, airway management, administration of blood products, and thoracic decompression. The primary outcome was 30-day survival, and the key secondary outcome was prehospital ROSC. A total of 223 patients with TCA were included. The median age was 54 years (IQR 34-68), and the majority were males. Overall, 23% of patients achieved prehospital ROSC, and the 30-day survival rate was 4%. Factors associated with an increased likelihood of ROSC were an initial shockable cardiac rhythm, odds ratio (OR) of 3.78 (95% CI 1.33-11.00) and endotracheal intubation, OR 7.10 (95% CI 2.55-22.85). This study highlights the low survival rates observed among patients with traumatic cardiac arrest assessed by helicopter emergency medical services. The findings support the positive impact of an initial shockable cardiac rhythm and endotracheal intubation in improving the likelihood of ROSC. The study contributes to the limited literature on traumatic cardiac arrests assessed by physician-staffed helicopter emergency services. Finally, the findings emphasise the need for further research to understand and improve outcomes in this subgroup of cardiac arrest.

Prehospital Time Intervals in Thailand during COVID-19

Objective: To determine the effect of the coronavirus disease, 2019 (COVID-19) pandemic on the prehospital time intervals of emergency medical services (EMS) in Thailand. Material and Methods: This retrospective cohort study analyzed the prehospital time intervals of EMS in Thailand; from January 1, 2019 to September 30, 2021 using data obtained from the national EMS database. Patients with incomplete medical records, prehospital time intervals &lt;1 or &gt;300 minutes, and those admitted between January 1 and March 31, 2020 were excluded. Data were compared between the following groups: Group 1, pre-COVID-19; Group 2, first- and second-wave of COVID-19; and Group 3, third-wave of COVID-19: Kruskal–Wallis, Wilcoxon rank-sum, and chi-square tests were used. Results: A total of 3,863,153 patients were enrolled into this study. The median total prehospital time was significantly longer in Group 2 when compared to Group 1, [25 (17,34) vs. 24 (17,33) minutes, p-value&lt;0.001]; longer on-scene time, [4 (2,7) vs. 3 (2,6) minutes, p-value&lt;0.001]; shorter transportation time, [10 (6,17) vs. 11 (6,18) minutes, p-value&lt;0.001]. The median total prehospital time [27 (19,37) vs. 25 (17,34) minutes, p-value&lt;0.001], response time [8 (5,14) vs. 7 (4,11) minutes, p-value&lt;0.001], and transportation time were significantly longer in Group 3 than in Group 2 [11 (6,18) vs. 10 (6,17) minutes, p-value&lt;0.001]. Conclusion: The EMS prehospital time intervals in Thailand during COVID-19 were significantly longer in both the non-trauma and trauma subgroups. Appropriate pre-hospital strategies and monitoring should be developed to manage future pandemics.

Abstract 15775: Prehospital Scene Delays in the Prehospital Care of ST-Segment Myocardial Infarction (STEMI)

Introduction: Emergency medical services (EMS) are an important link in the chain of care for patients experiencing time-sensitive cardiovascular emergencies, including ST-segment elevation myocardial infarction (STEMI). Recent quality initiatives have focused on reducing delays in STEMI care in both the prehospital and in-hospital environments. For instance, “door-to-balloon times” are tracked to ensure minimal delays from the time a STEMI patient enters a hospital to revascularization. In the prehospital realm, comparably less research has investigated factors contributing to delays in care for STEMI patients. Prolonged “scene times” - the time spent with a patient prior to transport - represents one area where focus is needed. Methods: As part of an ongoing initiative, EMS providers are encouraged to limit scene times to under 20 minutes for STEMI patients. We queried data from the Minnesota State Emergency Medical Services Regulatory Bureau (EMSRB) to ascertain what percentage of EMS encounters involving STEMI patients within the state’s MNSTAR EMS database between 2018 and 2021 had a scene time of greater than 20 minutes. Encounters involving helicopter emergency medical services (HEMS) were excluded. Results: Between 2018 and 2021, there were a total of 5178 STEMI patient encounters meeting eligibility criteria. Approximately 67.6% (n~3501) of patient encounters involved a scene time less than or equal to 20 minutes. Rural communities were associated with prolonged scene times when compared with metropolitan communities. Conclusions: Our preliminary analysis of EMS data from Minnesota shows one-third of STEMI encounters had scene times greater than 20 minutes. Thus, reducing prehospital scene times by EMS may be one method to streamline the care for STEMI patients. Further research should investigate what factors influence EMS crews to spend more than 20 minutes on scene with STEMI patients.

Linking emergency care and police department data to strengthen timely information on violence-related paediatric injuries

BackgroundCombined ED and police department (PD) data have improved violence surveillance in the UK, enabling significantly improved prevention. We sought to determine if the addition of emergency medical service (EMS)...

Paramedic Clinical Consults with a Paramedic or Nurse in an EMS Communications Center Compared to Traditional Online Physician Consults

Objectives In many emergency medical services (EMS) systems, a direct medical oversight physician is available to paramedics for mandatory and/or elective consultations. At the time of this study, a clinical support desk (CSD) was being implemented within the medical communications center of a provincial EMS system in addition to the physician resource. The CSD was initially staffed with a registered nurse or an advanced care paramedic. The objective of the current study was to compare CSD “peer to peer” consults versus physician consults with regards to consultation patterns, transport dispositions, and patient safety measures. Methods This retrospective cohort study analyzed 2 months before (September 1 to October 31, 2012) and 2 months after (September 1 to October 31, 2013) implementation of the CSD. In the before period, all clinical consults were fielded by the direct medical oversight physician. In the after period, consults were fielded by the physician, CSD or both. EMS databases were queried, and manual chart review and abstraction of audio recordings were done. Relapses back to EMS within 48 hours of non-transport were measured. Results 1621 consults were included, with 764 consults in the before period and 857 after (p = 0.02). The number of physician consults decreased from 764 before to 464 after (39.2%, p < 0.001), with the CSD taking 325 (37.9%) consults. The CSD was consulted more for police custody and trip destination. The physician was consulted more for cease resuscitation and clinical consults prior to medication administration. Overall non-transport rates were 595/764 before (77.9%), and 646/857 after (75.4%) (p = 0.2). Non-transports were 233/325 (71.7%) via the CSD, 364/464 (78.4%) via the physician, and 49/68 (72.1%) when both were involved (p = 0.07). Rate of relapse to EMS was similar before (25/524, 4.8%) and after (26/568, 4.6%) (p = 0.76), and between CSD (12/216, 5.5%) and physician consults (13/325, 4.0%) in the after period (p = 0.41). Conclusion The introduction of a novel “peer-to-peer” consult program was associated with an increased total number of consults made and reduced call volume for direct medical oversight physicians. There was no change in the patient safety measure studied.

Abstract 15609: Neighborhood Socioeconomic Disparities in Infant Out-of-Hospital Cardiac Arrest

Introduction: More than half of all pediatric cardiac arrests involve children under 1 year of age, and intervention prior to the arrival of emergency medical services (EMS) is crucial to prevent irreversible injury in out-of-hospital cardiac arrest. Hypothesis: Given other cardiac arrest disparities, we hypothesize that pre-EMS CPR and outcomes for infant cardiac arrest differ across community socioeconomic status. Methods: We examined cardiac arrests in 2019 involving patients under 1 year of age contained within a nationally-representative EMS database in the United States (NEMSIS). Data collected included if pre-EMS CPR was performed, if return of spontaneous circulation (ROSC) was achieved, and the ZIP Code where the arrest took place. We grouped arrests based on the socioeconomic characteristics of the ZIP Code where the arrest took place. This allowed us to examine whether rates of pre-EMS CPR and ROSC varied according to community-level poverty. Results: A total of 3776 pediatric cardiac arrests met inclusion criteria (Table). Within the total sample, the overall pre-EMS CPR rate was 71.2%, and the overall ROSC achievement rate was 16.6%. Pre-EMS CPR and ROSC achievement were highest in communities where less than 5% of individuals were below the poverty line and were significantly lower in communities where more than 16% of individuals within a ZIP Code were below the poverty line (p&lt;.05). Conclusions: Our data show that two important predictors of cardiac arrest survival - Pre-EMS CPR and ROSC achievement - decline significantly as the percentage of individuals below the poverty line increase. Disparities across socioeconomic status may reflect decreased CPR awareness, underperforming systems of prehospital care, or worse infant baseline health statuses. Public health efforts aimed at infant cardiac arrest may see the most benefit when focusing on socioeconomically-disadvantaged communities.

Sensitivity and specificity analyses of COVID-19 screening protocol for emergency medical services: A STARD-compliant population-based retrospective study.

During the novel coronavirus disease (COVID-19) pandemic, emergency medical services (EMS) has borne a huge burden in transporting emergency patients. However, the protocol’s effect on identifying emergency patients who are likely to have COVID-19 is unknown. We aimed to evaluate the diagnostic accuracy of a prehospital COVID-19 screening protocol for EMS.We conducted this population-based retrospective study in Nara Prefecture, Japan. The Nara Prefectural Government implemented a screening protocol for COVID-19 comprising the following symptom criteria (fever, cough, sore throat, headache, malaise, dysgeusia, or anosmia) and epidemiological criteria (contact history with confirmed COVID-19 cases or people with upper respiratory symptoms, or travel to areas with high infection rate). A patient meeting at least one criterion of each class was considered positive. We evaluated all 51,351 patients from the regional EMS database of the Nara Prefecture (emergency Medical Alliance for Total Coordination of Healthcare) who were registered from June 15, 2020 to May 31, 2021 and had results of COVID-19 reverse transcription polymerase chain reaction (RT-PCR) tests. We assessed the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of this protocol. We also assessed how these outcomes changed by adding vital signs and conducted a 10-fold and 100-fold prevalence simulation.The screening protocol was used for 246/51351 patients (0.5%). Among them, 31 tested positive after EMS transportation. This protocol’s sensitivity, specificity, PPV, and NPV were 40.8%, 99.6%, 12.6%, and 99.9%, respectively. With the addition of ≥2 vital signs (body temperature ≥37.5 °C, respiratory rate ≥20 breaths/minute, and oxygen saturation <90%), sensitivity and PPV changed to 61.8% and 1.0%, respectively, while NPV remained 99.9%. With a 10-fold and 100-fold increase in disease, the protocol PPV would be 59.0% and 94.3%, and NPV would be 99.1% and 90.7%, respectively, and with additional vital signs, PPV would be 8.9% and 53.1%, and NPV would be 99.4% and 93.2%, respectively.This COVID-19 screening protocol helped enable EMS transport for patients with COVID-19 with a PPV of 12.6%. Adding other vital sign variables may improve its diagnostic value if the prevalence rate increases.

Factors associated with EMS on-scene time and its regional difference in road traffic injuries: a population-based observational study

BackgroundThe outcome of road traffic injury (RTI) is determined by duration of prehospital time, patient’s demographics, and the type of injury and its mechanism. During the emergency medical service (EMS) prehospital time interval, on-scene time should be minimized for early treatment. This study aimed to examine the factors influencing on-scene EMS time among RTI patients.MethodsWe evaluated 19,141 cases of traffic trauma recorded between April 2014 and March 2020 in the EMS database of the Nara Wide Area Fire Department and the prehospital database of the emergency Medical Alliance for Total Coordination of Healthcare (e-MATCH). To examine the association of the number of EMS phone calls until hospital acceptance, age ≥65 years, high-risk injury, vital signs, holiday, and nighttime (0:00–8:00) with on-scene time, a generalized linear mixed model with random effects for four study regions was conducted.ResultsEMS phone calls were the biggest factor, accounting for 5.69 minutes per call, and high-risk injury accounted for an additional 2.78 minutes. Holiday, nighttime, and age ≥65 years were also associated with increased on-scene time, but there were no significant vital sign variables for on-scene time, except for the level of consciousness. Regional differences were also noted based on random effects, with a maximum difference of 2 minutes among regions.ConclusionsThe number of EMS phone calls until hospital acceptance was the most significant influencing factor in reducing on-scene time, and high-risk injury accounted for up to an additional 2.78 minutes. Considering these factors, including regional differences, can help improve the regional EMS policies and outcomes of RTI patients.

Association between physician's case volume in prehospital advanced trauma care and 30-day mortality: A registry-based analysis of 4,032 patients.

Seriously injured patients may benefit from prehospital interventions provided by a critical care physician. The relationship between case volume and outcome has been established in trauma teams in hospitals, as well as in prehospital advanced airway management. In this study, we aimed to assess if a volume-outcome relationship exists in prehospital advanced trauma care. We performed a retrospective cohort study using the national helicopter emergency medical services database, including trauma patients escorted from scene to hospital by a helicopter emergency medical services physician during January 1, 2013, to August 31, 2019. In addition, similar cases during 2012 were used to determine case volumes. We performed a multivariate logistic regression analysis, with 30-day mortality as the outcome. Age, sex, Glasgow Coma Scale, shock index, mechanism of injury, time interval from alarm to the patient and duration of transport, level of receiving hospital, and physician's trauma case volume were used as covariates. On-scene times, interventions performed, and status at hospital arrival were assessed in patients who were grouped according to physician's case volume. In total, 4,032 escorted trauma patients were included in the study. The median age was 40.2 (22.9-59.3) years, and 3,032 (75.2%) were male. Within 30 days, 498 (13.2%) of these patients had died. In the highest case volume group, advanced interventions were performed more often, and patients were less often hypotensive at handover. Data for multivariate analysis were available for 3,167 (78.5%) of the patients. Higher case volume was independently associated with lower mortality (odds ratio, 0.59; 95% confidence interval, 0.38-0.89). When a prehospital physician's case volume is higher in high-risk prehospital trauma, this seems to be associated with more active practice patterns and significantly lower 30-day mortality. The quality of prehospital critical care could be increased by ensuring sufficient case volume for the providers of such care. Prognostic and Epidemiologic; Level III.

Incidence of Dissociation With Low-Dose Pre-hospital Ketamine in Geriatric Patients With Trauma-Related Pain.

IntroductionSub-dissociative ketamine has been used increasingly for the treatment of acute pain in a wide variety of settings. While there are studies evaluating its use in the geriatric population, no studies have described its safety in the pre-hospital geriatric trauma patient. The objective of this study was to define the incidence of dissociation with low-dose pre-hospital ketamine in geriatric trauma patients.MethodsUsing our county emergency medical services database, we identified all trauma patients greater or equal to 65 years of age who received pre-hospital ketamine for pain after the implementation of a low-dose ketamine protocol. We retrospectively reviewed pre-hospital and emergency department records for demographics, traumatic injuries, Glasgow Coma Score, emergency department length of stay and disposition, and hospital length of stay. This group was compared to a similar population of trauma patients, transported prior to the ketamine protocol. The comparison group was chosen by matching the ketamine group to more than double the number of non-ketamine patients. Records were obtained from two separate trauma centers. Our primary outcome was documentation of “ketamine-related dissociation” by either the pre-hospital, emergency department or trauma provider. Secondary outcomes included emergency department length of stay and intensive care unit admission.ResultsSeventy-nine patients received ketamine with records available for analysis. One hundred ninety-three non-ketamine patients were compared to this group. There were nosignificant differences between the two groups in regards to age, weight, gender, or mechanism of injury. The injury severity score was higher in the ketamine group. Nine patients (11%) had documented dissociation after ketamine, with six of these patients back to baseline mentation by arrival to the emergency department. The emergency department length of stay was shorter in the ketamine group. The rate of intensive care unit admission was the same between both groups.ConclusionsPre-hospital sub-dissociative ketamine in geriatric trauma patients is associated with brief episodes of dissociation in a small minority of patients.