Patient Emergency Medical Services Research Articles

Scanners, schedules, and statutes: A tale of trauma, policy, and profit

EMTALA (Emergency Medicine Treatment and Labor Act) is an important federal mandate intended to improve access to emergency medical services for patients regardless of financial means. The act imposes strict guidelines on emergency departments, associated referral specialists, and ancillary services. Radiology departments must comply with all ETMALA requirements to avoid potentially incapacitating penalties to their institutions.

64 Effect of perioperative app on use of emergency medical services for patients recovering from laparotomy

64 Effect of perioperative app on use of emergency medical services for patients recovering from laparotomy

Comparison of Prognosis According to the Use of Emergency Medical Services in Patients with ST-Segment Elevation Myocardial Infarction.

PurposeThis study aimed to compare long-term clinical outcomes according to the use of emergency medical services (EMS) in patients with ST-segment elevation myocardial infarction (STEMI) who arrived at the hospital within 12 hr of symptom onset.Materials and MethodsA total of 13104 patients with acute myocardial infarction were enrolled in the Korea Acute Myocardial Infarction Registry–National Institutes of Health from October 2011 to December 2015. Of them, 2416 patients with STEMI who arrived at the hospital within 12 hr were divided into two groups: 987 patients in the EMS group and 1429 in the non-EMS group. Propensity score matching (PSM) was performed to reduce bias from confounding variables. After PSM, 796 patients in the EMS group and 796 patients in the non-EMS group were analyzed. The clinical outcomes during 3 years of clinical follow-up were compared between the two groups according to the use of EMS.ResultsThe symptom-to-door time was significantly shorter in the EMS group than in the non-EMS group. The EMS group had more patients with high Killip class compared to the non-EMS group. The rates of all-cause death and major adverse cardiac events (MACE) were not significantly different between the two groups. After PSM, the rate of all-cause death and MACE were still not significantly different between the EMS and non-EMS groups. The predictors of mortality were high Killip class, renal dysfunction, old age, long door-to-balloon time, long symptom-to-door time, and heart failure.ConclusionEMS utilization was more frequent in high-risk patients. The use of EMS shortened the symptom-to-door time, but did not improve the prognosis in this cohort.

POSB66 Cost-Effectiveness Analysis of the Helicopter Emergency Medical Services for Patients with Myocardial Infarction in Austria

Myocardial infarction (MI) is a life-threatening disease. Accordingly, a time limit of 90 minutes between initial medical contact and percutaneous coronary intervention (PCI) has been established for ST-segment elevation myocardial infarction (STEMI). Thus, many STEMI patients require airlift by helicopter emergency medical services (HEMS) to match the goal of 90 minutes. However, HEMS remains a poorly evaluated aspect of MI-care. The aim of this study was to evaluate the cost-effectiveness of HEMS airlift compared to a ground-based ambulance-transport for patients with MI to a PCI center. A Markov-model was developed based on the distinction between STEMI and non-STEMI to simulate consequences over a 10-year time-horizon. Consequences include recurrent MI, heart failure (HF) due to MI, death due to MI and recurrent MI or other reasons. Health benefits were measured in quality-adjusted life-years (QALYs) and life-years (LYs). Probabilities were derived from the literature. According to data derived from the OEAMTC Air Rescue, 6.9% of all hospital admissions are provided by HEMS. The target value for an appropriate use of HEMS was assumed to be 20%. Direct costs (2020.- €) were derived from published sources from the payer’s perspective. QALYs, LYs and costs were discounted. Monte-Carlo-simulation accounted for uncertainty. A >20% proportion of MI patients who were transported by HEMS to a PCI center is associated with savings over a 10-year time-horizon (2,140.- € to 13,640.- € per patient). Savings are due to reduced follow-up costs for rehabilitation, HF, nursing home and care allowance costs. Patients also achieve a higher life expectancy (0,17 to 0,46 LYs) and quality of life [0,13 to 0,38 QALYs). In the entire cohort of MI patients in 2020 (n=17,305), savings of 37 million euros could be achieved. 1€ spend in HEMS leads to savings of 9.7€ in the health-care and social system.

Impact of COVID-19 on Emergency Medical Services for Patients with Acute Stroke Presentation in Busan, South Korea.

The purpose of this retrospective observational study was to identify the impact of COVID-19 on emergency medical services (EMS) processing times and transfers to the emergency department (ED) among patients with acute stroke symptoms before and during the COVID-19 pandemic in Busan, South Korea. The total number of patients using EMS for acute stroke symptoms decreased by 8.2% from 1570 in the pre-COVID-19 period to 1441 during the COVID-19 period. The median (interquartile range) EMS processing time was 29.0 (23–37) min in the pre-COVID-19 period and 33.0 (25–41) minutes in the COVID-19 period (p < 0.001). There was a significant decrease in the number of patients transferred to an ED with a comprehensive stroke center (CSC) (6.37%, p < 0.001) and an increase in the number of patients transferred to two EDs nearby (2.77%, p = 0.018; 3.22%, p < 0.001). During the COVID-19 pandemic, EMS processing time increased. The number of patients transferred to ED with CSC was significantly reduced and dispersed. COVID-19 appears to have affected the stroke chain of survival by hindering entry into EDs with stroke centers, the gateway for acute stroke patients.

Применение технологий бережливого производства для оптимизации работы скорой медицинской помощи в условиях распространения COVID‑19

The pandemic of new coronavirus infection COVID‑19 has become a serious challenge for the national health systems, including Russia, setting ambitious goals aimed at preventing the spread of infection and maintaining the availability of medical care in environment of increasing pressure. The aim of the study was to develop, based on the principles of lean production, a set of measures to increase the availability of emergency medical services for patients diagnosed with or suspected of a new coronavirus infection COVID‑19 in the Tomsk Region. Standard tools of lean manufacturing are applied to the work process of the admission department of the respiratory center in RSBHI «Medical sanitary station № 2». As a result of implementation of target state map, which provides for the optimization of process of transferring a patient diagnosed or suspected of a new coronavirus infection COVID‑19 to admission department, a positive dynamics of local (5.4 times increase in the proportion of calls completed within 15 minutes after the patient was delivered to the admission department) and system (an increase of 1.3 times in the proportion of calls with the time the ambulance team reaches the patient within 20 minutes) indicators of the ambulance service was achieved. The study confirms the effectiveness of lean manufacturing tools for optimizing the work of ambulance and allows us to recommend them for use in a pandemic and other risks of emergency.

The individual and neighborhood factors associated with the use of emergency medical services in patients with ST-elevation myocardial infarction.

ObjectiveThe utilization of emergency medical services (EMS) varies widely among communities. In this study, we aimed to evaluate the relationship between the use of EMS by patients with ST-elevation myocardial infarction (STEMI) and the individual and neighborhood characteristics of these patients.MethodsWe performed a secondary analysis of data from the Cardiovascular Disease Surveillance project, which included patients diagnosed with STEMI at 29 emergency centers in South Korea. Our analysis included only patients living in Seoul, and the primary outcome measured was the use of EMS. While the clinical variables of the patients were collected from the Cardiovascular Disease Surveillance registry, the 2010 National Census data was used to identify neighborhood variables such as population density, income, age, and residence type. We used a 3-level hierarchical logistic regression to estimate the effects of neighborhood-level factors on EMS use by individual patients.ResultsWe evaluated 1,634 patients with STEMI from 2007 to 2012. The neighborhoods were grouped into 25 counties. The regional rates of EMS use varied from 18.3% to 46.5%. The final adjusted logistic model revealed that the use of EMS was significantly associated with the average number of households (neighborhood level factor) and symptoms of syncope, cardiac arrest, and history of cardiovascular disease (individual level factors).ConclusionThe individual levels factors had a greater influence on the use of EMS compared to the neighborhood-level factors.

Factors influencing patient decision delay in activation of emergency medical services for suspected ST-elevation myocardial infarction

The purpose of this study was to identify factors associated with time delay to emergency medical services for patients with suspected ST-elevation myocardial infarction. This observational study involved 1994 suspected ST-elevation myocardial infarction patients presenting to the emergency medical services in Melbourne, Australia, between October 2011-January 2014. Factors associated with delays to emergency medical services call of >1 h and emergency medical services self-referral were analyzed using multivariable logistic regression. The time of symptom onset was reported for 1819 patients (91.2%), the median symptom onset-to-call time was 52 min (interquartile range=17-176). Of all emergency medical services calls, 17% were referred by healthcare professionals. Compared to self-referred patients, patients who presented to a general practitioner or hospital had higher odds of delay >1 h to emergency medical services activation (adjusted odds ratio 7.76; 95% confidence interval 5.10-11.83; and 8.02; 3.65-17.64, respectively). The other factors associated with emergency medical services call delays of >1 h were living alone, non-English speaking background, a history of substance abuse, less severe symptoms, symptom onset at home and at rest, and self-treatment. Emergency medical services self-referred patients were more likely to be older than 75 years, have a history of ischemic heart disease or revascularization, more severe symptoms, and symptom onset at home, with activity, during the weekends and out-of-hours. Almost one-fifth of emergency medical services calls for suspected ST-elevation myocardial infarction were healthcare referrals, and this was associated with increased delays. A wide range of factors could influence a patient's decision to directly and rapidly seek emergency medical services. More efforts are needed to educate at-risk populations about early self-referral to the emergency medical services.

Factors related to use of emergency medical services in patients with acute stroke

Objective To examine the availability of emergency medical services(EMS) for patients with acute stroke and to investigate influential factors affecting the preference of patients’to EMS. Methods Consecutive information of patients with acute stroke who presented to the emergency department of Zhongnan Hospital of Wuhan University from June 1, 2014 to December 31, 2015 were analyzed. Gender, age of patients, transport modality, risk factors in cerebrovascular diseases, initial symptoms, stroke types, onset and admission time were included to make analysis in retrospective study. The participants were divided into two groups based on the preference of patients, namely EMS group and self-transport group. Wilcoxon rank sum test or Chi-squared test was used to statistical analysis as appropriate. A multiple binary logistic regression was used to determine the relationship between various patient-related factors with probability whether patients chose EMS or not. Results Among the 240 patients, only 29.2%of them asked for the EMS at the onset of symptoms (EMS group, n=70), and the rest patients called for other services(self-transport group, n=170). Logistic regression analysis revealed that the patients with the symptom of altered consciousness or convulsion (95%CI: 0.107-0.403, OR=0.208, P<0.01) were more likely to use EMS. The time consumed from onset to visit of patients with acute stroke to emergency physician was significantly shorter in EMS group (M, 60 min vs.180 min, P<0.01). Conclusion The symptom of altered consciousness or convulsion was the independent factor to determine whether patients with acute stroke preferred EMS or not. Key words: Stroke; Cerebral infarction; Emergency medical services; Pre-hospital transport

Factors influencing utilization of pre- emergency medical services in patients with acute chest pain

Objective To describe the general characteristics of patients with acute chest pain in order to analyze factors associated with patients’ utilization of emergency medical services (EMS). Methods A total of 747 eligible patients with acute chest pain admitted to emergency department of Qilu Hospital were consecutively enrolled from October 2014 to April 2015. Clinical data including demographic features, mode of arrival, past medical history, risk factors, symptoms and signs were collected prospectively by using standardized case report form. Univariate and multivariate analyses were carried out to investigate the association between the decision to use EMS and related factors including demographic features, past medical history, risk factors, symptoms and signs. Results Of the total 747 eligible patients, 414(55.4%) were male , and the mean age was (57.2 ± 15.8)year; 333(44.6%) were female, and the mean age was (61.7±14.9)year. Of them, 171 (22.9%)patients used EMS, and 143 chest pain patients with more than 75 years old were more inclined to use EMS (P<0.01), whereas 152 patients in 65-75 years age group accounted for the lowest proportion of using EMS. Men were more inclined to use EMS than women(P<0.05), and 483 patients with typical chest pain used more EMS than patients with atypical chest pain (P<0.05); Of them, 356 patients with a history of hypertension and 54 patients with a history of cerebral infarction were more inclined to use EMS (P<0.05 and P<0.01, respectively). Multivariate logistic regression analysis showed that male, older than 75 years, history of cerebral infarction were independent factors associated with EMS use (P<0.05). Conclusions This study indicated that only less than one-third of emergency department visits with acute chest pain decide to use EMS when symptoms occurred. Factors including male, older than 75 years, and a history of cerebral infarction were associated with more use of EMS. In order to promote patient asking for EMS timely, more work should be done. Key words: Acute chest pain; Emergency medical services; Influencing factors

Prehospital Lactate Measurement by Emergency Medical Services in Patients Meeting Sepsis Criteria.

IntroductionWe aimed to pilot test the delivery of sepsis education to emergency medical services (EMS) providers and the feasibility of equipping them with temporal artery thermometers (TATs) and handheld lactate meters to aid in the prehospital recognition of sepsis.MethodsThis study used a convenience sample of prehospital patients meeting established criteria for sepsis. Paramedics received education on systemic inflammatory response syndrome (SIRS) criteria, were trained in the use of TATs and hand-held lactate meters, and enrolled patients who had a recent history of infection, met ≥ 2 SIRS criteria, and were being transported to a participating hospital. Blood lactate was measured by paramedics in the prehospital setting and again in the emergency department (ED) via usual care. Paramedics entered data using an online database accessible at the point of care.ResultsPrehospital lactate values obtained by paramedics ranged from 0.8 to 9.8 mmol/L, and an elevated lactate (i.e. ≥ 4.0) was documented in 13 of 112 enrolled patients (12%). The unadjusted correlation of prehospital and ED lactate values was 0.57 (p< 0.001). The median interval between paramedic assessment of blood lactate and the electronic posting of the ED-measured lactate value in the hospital record was 111 minutes. Overall, 91 patients (81%) were hospitalized after ED evaluation, 27 (24%) were ultimately diagnosed with sepsis, and 3 (3%) died during hospitalization. Subjects with elevated prehospital lactate were somewhat more likely to have been admitted to the intensive care unit (23% vs 15%) and to have been diagnosed with sepsis (38% vs 22%) than those with normal lactate levels, but these differences were not statistically significant.ConclusionIn this pilot, EMS use of a combination of objective SIRS criteria, subjective assessment of infection, and blood lactate measurements did not achieve a level of diagnostic accuracy for sepsis that would warrant hospital prenotification and committed resources at a receiving hospital based on EMS assessment alone. Nevertheless, this work provides an early model for increasing EMS awareness and the implementation of novel devices that may enhance the prehospital assessment for sepsis. Additional translational research studies with larger numbers of patients and more robust methods are needed.

APSC2015-1312 Physician Perceptions and Recommendations About Pre-Hospital Emergency Medical Services for Patients With ST-Elevation Myocardial Infarction in Abu Dhabi

APSC2015-1312 Physician Perceptions and Recommendations About Pre-Hospital Emergency Medical Services for Patients With ST-Elevation Myocardial Infarction in Abu Dhabi

Physician perceptions and recommendations about pre-hospital emergency medical services for patients with ST-elevation acute myocardial infarction in Abu Dhabi

IntroductionPhysician perceptions about emergency medical services (EMS) are important determinants of improving pre-hospital care for cardiac emergencies. No data exist on physician attitudes towards EMS care of patients with ST-Elevation Myocardial Infarction (STEMI) in the Emirate of Abu Dhabi. ObjectivesTo describe the perceptions towards EMS among physicians caring for patients with STEMI in Abu Dhabi. MethodsWe surveyed a convenience sample of physicians involved in the care of patients with STEMI (emergency medicine, cardiology, cardiothoracic surgery and intensive care) in four government facilities with 24/7 Primary PCI in the Emirate of Abu Dhabi. Surveys were distributed using dedicated email links, and used 5-point Likert scales to assess perceptions and attitudes to EMS. ResultsOf 106 physician respondents, most were male (82%), practicing in emergency medicine (47%) or cardiology (44%) and the majority (63%) had been in practice for >10years. Less than half of the responders (42%) were “Somewhat Satisfied” (35%) or “Very Satisfied” (7%) with current EMS level of care for STEMI patients. Most respondents were “Very Likely” (67%) to advise a patient with a cardiac emergency to use EMS, but only 39% felt the same for themselves or their family. Most responders were supportive (i.e. “Strongly Agree”) of the following steps to improve EMS care: 12-lead ECG and telemetry to ED by EMS (69%), EMS triage of STEMI to PCI facilities (65%), and activation of PCI teams by EMS (58%). Only 19% were supportive of pre-hospital fibrinolytics by EMS. There were no significant differences in the responses among the specialties. ConclusionsMost physicians involved in STEMI care in Abu Dhabi are very likely to advise patients to use EMS for a cardiac emergency, but less likely to do so for themselves or their families. Different specialties had concordant opinions regarding steps to improve pre-hospital EMS care for STEMI.

Evaluation of pre-hospital administration of adrenaline (epinephrine) by emergency medical services for patients with out of hospital cardiac arrest in Japan: controlled propensity matched retrospective cohort study

Objectives To evaluate the effectiveness of pre-hospital adrenaline (epinephrine) administered by emergency medical services to patients with out of hospital cardiac arrest.Design Controlled propensity matched retrospective cohort study, in which...

Factors associated with use of emergency medical services in patients with acute stroke

PurposesThe aim of this study was to investigate the factors associated with use of emergency medical services (EMS) in patients with acute stroke. MethodsProspective data on consecutive patients with acute stroke who presented to the emergency department of a university medical center from January 1, 2010, to July 31, 2011, were analyzed. Patients were excluded if they had an unknown residence, had onset of stroke at a nursing home or hospital, or were transferred from another hospital. Variables for all patients with stroke and ischemic stroke who did and did not use EMS were compared. ResultsIn total, 1344 patients (60% male; mean age, 68.7 years) were included. Use of EMS (n = 409; 30.4%) was significantly associated with a higher level of education (≧6 years vs <6 years; odds ratio [OR], 1.69; 95% confidence interval [CI], 1.25-2.29), a higher National Institutes of Health Stroke Scale score (OR, 1.08; 95% CI, 1.05-1.11), altered consciousness (OR, 1.88; 95% CI, 1.25-2.84), and atrial fibrillation (OR, 2.43; 95% CI, 1.71-3.44) after adjustment. For patients with ischemic stroke, use of EMS was significantly higher in cases of cardioembolism (OR, 3.04; 95% CI, 1.40-6.60) and large artery atherothrombosis (OR, 2.10; 95% CI, 1.22-3.62) than lacunar infarction. ConclusionPatients with stroke who have altered consciousness, a higher level of education, a higher National Institutes of Health Stroke Scale score, atrial fibrillation, and cardioembolic stroke were more likely to use EMS.

Use of Emergency Medical Services in Patients with Acute Myocardial Infarction in China

Although guidelines strongly recommend use of the Emergency Medical Systems (EMS) by patients with acute myocardial infarction (AMI), it remains underutilized in western countries. Information about its current use in China is unclear. The objective of this study was to examine the use of the EMS by patients with AMI in China, and investigate factors affecting its use. A prospective survey study, which included 803 patients with AMI who were admitted to 21 hospitals in China between November 1, 2005 and December 31, 2006. Only 39.5% of patients called up the EMS at the onset of symptoms (EMS group, n=317), whereas the rest presented to the hospital by some other means (self-transport group, n=486, 60.5%). Predictors of EMS users were older age, symptom onset at evening, unbearable symptoms, having received training and acquired knowledge on heart attack, as well as having a higher income and medical history of heart failure or stroke. Prehospital delay (median 110 min vs. 143 min, p<0.001), door to needle time (median 85 min vs. 93 min, p<0.005) and door-to-balloon time (median 118 min vs. 160 min, p<0.001) were significantly shorter in the EMS group. The early reperfusion rate was also significantly higher in the EMS group (84.8% vs. 78.2%, p=0.019), mainly because of a greater incidence of primary percutaneous coronary intervention (68.1% vs. 61.7%, p=0.046). The emergency medical services are underutilized by patients with AMI in China. Use of the EMS may be advantageous in view of greater administration of reperfusion therapy. New public health strategies should be developed to facilitate greater use of the EMS for AMI.

Elapsed Time in Emergency Medical Services for Patients With Cardiac Complaints

Background— In patients with a major cardiac event, the first priority is to minimize time to treatment. For many patients, first contact with the health system is through emergency medical services (EMS). We set out to identify patient-level and neighborhood-level factors that were associated with elapsed time in EMS. Methods and Results— A retrospective cohort study was conducted in 10 municipalities in Dallas County, Tex, from January 1 through December 31, 2004. The data set included 5887 patients with suspected cardiac-related symptoms. The region was served by 29 hospitals and 98 EMS depots. Multivariate models included measures of distance traveled, time of day, day of week, and patient and neighborhood characteristics. The main outcomes were elapsed time in EMS (continuous; in minutes) and delay in EMS (dichotomous; &gt;15 minutes beyond median elapsed time). We found positive associations between patient characteristics and both average elapsed time and delay in EMS care. Variation in average elapsed time was not large enough to be clinically meaningful. However, approximately 11% (n=647) of patients were delayed ≥15 minutes. Women were more likely to be delayed (adjusted odds ratio, 1.52; 95% confidence interval, 1.32 to 1.74), and this association did not change after adjusting for other characteristics, including neighborhood socioeconomic composition. Conclusions— Compared with otherwise similar men, women have 50% greater odds of being delayed in the EMS setting. The determinants of delay should be a special focus of EMS studies in which time to treatment is a priority.