Emergency Medical Services Transport Research Articles

Characteristics of consecutive versus non-consecutive frequent emergency medical services transport to a single emergency department

Objective This study was to examine characteristics concerning frequent users of emergency medical services (EMS) transport by comparing patients who used EMS transport frequently for one year and those who used EMS transport for more than two years consecutively. Methods A retrospective review for frequent use of EMS transport was conducted. The patients from the fire stations that transported more than 70% of all EMS transport to the study hospital emergency department (ED) were included. The study subjects were divided into consecutive group (frequent EMS transport for ≥ two years consecutively) and non-consecutive group (frequent EMS transport for only one year). Characteristics of patients who were frequent users of EMS transport and those of all cases with EMS transport were examined. Results Of the total 205 patients and 1204 cases of frequent EMS transport, 85 (42%) patients and 755 (63%) cases were in the consecutive group. Patients in the consecutive group were more likely to have risky alcohol use, unemployed state, and medical aid type of payment for ED treatment than those in the non-consecutive group. More patients had previous experience of EMS transport to the study hospital ED in the consecutive group and the number of cases with alcohol ingestion was higher in the consecutive group. Elapsed time from EMS call to ED arrival was longer for the consecutive group. Conclusion Risky alcohol use, unemployed state, and previous experience of EMS transport were associated with consecutive and frequent use of EMS transport in frequent users of EMS transport.

Dispatch Categories as Indicators of Out-of-Hospital Time Critical Interventions and Associated Emergency Department Outcomes

Objectives Emergency medical services (EMS) systems increasingly grapple with rising call volumes and workforce shortages, forcing systems to decide which responses may be delayed. Limited research has linked dispatch codes, on-scene findings, and emergency department (ED) outcomes. This study evaluated the association between dispatch categorizations and time-critical EMS responses defined by prehospital interventions and ED outcomes. Secondarily, we proposed a framework for identifying dispatch categorizations that are safe or unsafe to hold in queue. Methods This retrospective, multi-center analysis encompassed all 9-1-1 responses from 8 accredited EMS systems between 1/1/2021 and 06/30/2023, utilizing the Medical Priority Dispatch System (MPDS). Independent variables included MPDS Protocol numbers and Determinant levels. EMS treatments and ED diagnoses/dispositions were categorized as time-critical using a multi-round consensus survey. The primary outcome was the proportion of EMS responses categorized as time-critical. A non-parametric test for trend was used to assess the proportion of time-critical responses Determinant levels. Based on group consensus, Protocol/Determinant level combinations with at least 120 responses (∼1 per week) were further categorized as safe to hold in queue (<1% time-critical intervention by EMS and <5% time-critical ED outcome) or unsafe to hold in queue (>10% time-critical intervention by EMS or >10% time-critical ED outcome). Results Of 1,715,612 EMS incidents, 6% (109,250) involved a time-critical EMS intervention. Among EMS transports with linked outcome data (543,883), 12% had time-critical ED outcomes. The proportion of time-critical EMS interventions increased with Determinant level (OMEGA: 1%, ECHO: 38%, p-trend < 0.01) as did time-critical ED outcomes (OMEGA: 3%, ECHO: 31%, p-trend < 0.01). Of 162 unique Protocols/Determinants with at least 120 uses, 30 met criteria for safe to hold in queue, accounting for 8% (142,067) of incidents. Meanwhile, 72 Protocols/Determinants met criteria for unsafe to hold, accounting for 52% (883,683) of incidents. Seven of 32 ALPHA level Protocols and 3/17 OMEGA level Protocols met the proposed criteria for unsafe to hold in queue. Conclusions In general, Determinant levels aligned with time-critical responses; however, a notable minority of lower acuity Determinant level Protocols met criteria for unsafe to hold. This suggests a more nuanced approach to dispatch prioritization, considering both Protocol and Determinant level factors.

Current status of emergency medical service use in ST-segment elevation myocardial infarction in China: Findings from China Acute Myocardial Infarction (CAMI) Registry

BackgroundThe mortality rate of myocardial infarction in China has increased dramatically in the past three decades. Although emergency medical service (EMS) played a pivotal role for the management of patients with ST-segment elevation myocardial infarction (STEMI), the corresponding data in China are limited. MethodsAn observational analysis was performed in 26,305 STEMI patients, who were documented in China acute myocardial infarction (CAMI) Registry and treated in 162 hospitals from January 1st, 2013 to January 31th, 2016. We compared the differences such as demographic factors, social factors, medical history, risk factors, socioeconomic distribution and treatment strategies between EMS transport group and self-transport group. ResultsOnly 4336 patients (16.5%) were transported by EMS. Patients with symptom onset outside, out-of-hospital cardiac arrest and presented to province-level hospital were more likely to use EMS. Besides those factors, low systolic blood pressure, severe dyspnea or syncope, and high Killip class were also positively related to EMS activation. Notably, compared to self-transport, use of EMS was associated with a shorter prehospital delay (median, 180 vs. 245 min, P < 0.0001) but similar door-to-needle time (median, 45 min vs. 52 min, P = 0.1400) and door-to-balloon time (median, 105 min vs. 103 min, P = 0.1834). ConclusionsEMS care for STEMI is greatly underused in China. EMS transport is associated with shorter onset-to-door time and higher rate of reperfusion, but not substantial reduction in treatment delays or mortality rate. Targeted efforts are needed to promote EMS use when chest pain occurs and to set up a unique regionalized STEMI network focusing on integration of prehospital care procedures in China.Trial registration:ClinicalTrials.gov (NCT01874691), retrospectively registered June 11, 2013.

Impact of pandemic-related movement restriction on public access defibrillation in Japan: a retrospective cohort study

ObjectivesTo analyse monthly changes in public access defibrillation (PAD) incidence and outcomes of out-of-hospital cardiac arrest (OHCA) during the 2020–2021 COVID-19 pandemic compared with those during the 2016–2019 prepandemic period...

Advancing Emergency Medical Services’ (EMS) Response Capability for Behavioral Health Emergencies: Los Angeles County’s Performance Improvement Initiative

ABSTRACT Introduction: Behavioral health emergencies (BHEs) are a common patient encounter for emergency medical services (EMS) clinicians and other first responders, in particular law enforcement (LE) officers. It is critical for EMS clinicians to have management strategies for BHEs, yet relatively little information exists on best practices. In 2016, the Los Angeles County EMS Agency’s Commission initiated a comprehensive evaluation of the 9-1-1 response for BHEs and developed a plan for improving the quality of care and safety for patients and first responders. Methods: A Behavioral Health Initiative Committee was assembled with broad representation from EMS, LE health agencies, and the public. Committee objectives included: 1) produce a process map of the BHE response from the time of a 9-1-1 call to patient arrival at transport destination, 2) identify and describe the different agencies that respond, 3) describe the critical decision points in the EMS and LE field responses, 4) acquire data that quantitatively and/or qualitatively describe the services available, and 5) recommend interventions for system performance improvement. Results: The committee generated comprehensive process maps for the prehospital response to BHEs, articulated principles for evaluation, and described key observations of the current system including: 9-1-1 dispatch criteria are variable and often defaults to a LE response, the LE response inadvertently criminalizes BHEs, EMS field treatment protocols for BHEs (and especially agitated patients) are limited, substance use disorder treatment lacks integration, destination options differ by transporting agency, and receiving facilities’ capabilities to address BHEs are variable. Recommendations for performance improvement interventions and initial implementation steps included: standardize dispatch protocols, shift away from a LE primary response, augment EMS treatment protocols for BHEs and the management of agitation, develop alternate destination for EMS transport. Conclusion: This paper describes a comprehensive performance improvement initiative in LAC-EMSA’s 9-1-1 response to BHEs. The initiative included a thorough current state analysis, followed by future state mapping and the implementation of interventions to reduce LE as the primary responder when an EMS response is often warranted, and to improve EMS protocols and access to resources for BHEs.

Prevalence of Low-Acuity Pediatric Emergency Medical Services Transports to a Pediatric Emergency Department in an Urban Area.

Many patients transported by Emergency Medical Services (EMS) do not have emergent resource needs. Estimates for the proportion of pediatric EMS calls for low-acuity complaints, and thus potential candidates for alternative dispositions, vary widely and are often based on physician judgment. A more accurate reference standard should include patient assessments, interventions, and dispositions. The objective of this study was to describe the prevalence and characteristics of low-acuity pediatric EMS calls in an urban area. This is a prospective observational study of children transported by EMS to a tertiary care pediatric emergency department. Patient acuity was defined using a novel composite measure that included physiologic assessments, resources used, and disposition. Bivariable and multivariable logistic regression were conducted to assess for factors associated with low-acuity status. A total of 996 patients were enrolled, of whom 32.9% (95% confidence interval, 30.0-36.0) were low acuity. Most of the sample was Black, non-Hispanic with a mean age of 7 years. When compared with adolescents, children younger than 1 year were more likely to be low acuity (adjusted odds ratio, 3.1 [1.9-5.1]). Patients in a motor vehicle crash were also more likely to be low acuity (adjusted odds ratio, 2.4 [1.2-4.6]). All other variables, including race, insurance status, chief complaint, and dispatch time, were not associated with low-acuity status. One third of pediatric patients transported to the pediatric emergency department by EMS in this urban area are for low-acuity complaints. Further research is needed to determine low-acuity rates in other jurisdictions and whether EMS providers can accurately identify low-acuity patients to develop alternative EMS disposition programs for children.

Description of the Public Safety Medical Response and Patient Encounters Within and During the Indianapolis (USA) Spring 2020 Civil Unrest.

This study describes the local Emergency Medical Services (EMS) response and patient encounters corresponding to the civil unrest occurring over a four-day period in Spring 2020 in Indianapolis, Indiana (USA). This study describes the non-conventional EMS response to civil unrest. The study included patients encountered by EMS in the area of the civil unrest occurring in Indianapolis, Indiana from May 29 through June 1, 2020. The area of civil unrest defined by Indianapolis Metropolitan Police Department covered 15 blocks by 12 blocks (roughly 4.0 square miles) and included central Indianapolis. The study analyzed records and collected demographics, scene times, interventions, dispositions, EMS clinician narratives, transport destinations, and hospital course with outcomes from receiving hospitals for patients extracted from the area of civil unrest by EMS. Twenty-nine patients were included with ages ranging from two to sixty-eight years. In total, EMS transported 72.4% (21 of 29) of the patients, with the remainder declining transport. Ballistic injuries from gun violence accounted for 10.3% (3 of 29) of injuries. Two additional fatalities from penetrating trauma occurred among patients without EMS contact within and during the civil unrest. Conditions not involving trauma occurred in 37.9% (11 of 29). Among transported patients, 33.3% (7 of 21) were admitted to the hospital and there was one fatality. While most EMS transports did not result in hospitalization, it is important to note that the majority of EMS calls did result in a transport. There was a substantial amount of non-traumatic patient encounters. Trauma in many of the encounters was relatively severe, and the findings imply the need for rapid extraction methods from dangerous areas to facilitate timely in-hospital stabilization.

Pain and Heart Failure During Transport by Emergency Medical Services and Its Associated Outcomes: Hospitalization, Mortality, and Length of Stay.

Over 22% of patients with heart failure (HF) are transported by emergency medical services (EMSs) for a primary complaint of pain. The relationship between a primary complaint of pain on hospitalization status, mortality, or length of stay following transport by EMS is understudied. The objective of this study was to determine whether a primary complaint of pain during EMS transport predicted hospitalization status, mortality, or inpatient length of stay. In this retrospective longitudinal cohort study, data were analyzed from electronic health records of 3539 patients with HF. Descriptive statistics and multivariate logistic and linear regression analyses were used to achieve study objectives. Demographics were mean age 64.83 years (standard deviation [SD] = 14.58); gender 57.3% women, 42.7% men; self-reported race 56.2% black, 43.2% white, and 0.7% other. Of 3539 patients, 2346 (66.3%) were hospitalized, 149 (4.2%) died, and the mean length of stay was 6.02 (SD = 7.55) days. A primary complaint of pain did not predict increased odds of in-hospital mortality but did predict 39% lower odds of hospitalization (p < .001), and 26.7% shorter length of stay (p < .001). Chest pain predicted 49% lower odds of hospitalization (p < .001) and 34.1% (p < .001) shorter length of stay, whereas generalized pain predicted 45% lower odds of hospitalization (p = .044) following post-hoc analysis. A primary complaint of chest pain predicted lower odds of hospitalization and shorter length of stay, possibly due to established treatment regimens. Additional research is needed to examine chronic pain rather than a primary complaint of pain.

Impact of socioeconomic status on presentation, care quality and outcomes of patients attended by emergency medical services for dyspnoea: a population-based cohort study

BackgroundLow socioeconomic status (SES) has been linked to poor outcomes in many conditions. It is unknown whether these disparities extend to individuals presenting with dyspnoea. We aimed to evaluate the...

Severity-Driven Trends in Mortality in a Large Regionalized Critical Care Transport Service

ObjectiveThe epidemiology accompanying helicopter emergency medical services (HEMS) transport has evolved as agencies have matured and become integrated into regionalized health systems, as evidenced primarily by nationwide systems in Europe. System-level congruence between Europe and the United States, where HEMS is geographically fragmentary, is unclear. In this study, we provide a temporal, epidemiologic characterization of the largest standardized private, nonprofit HEMS system in the United States, STAT MedEvac. MethodsWe obtained comprehensive timing, procedure, and vital signs data from STAT MedEvac prehospital electronic patient care records for all adult patients transported to UPMC Health System hospitals in the period of January 2012 through October 2021. We linked these data with hospital electronic health records available through June 2018 to establish length of stay and vital status at discharge. ResultsWe studied 90,960 transports and matched 62.8% (n = 57,128) to the electronic health record. The average patient age was 58.6 years ( 19 years), and most were male (57.9%). The majority of cases were interfacility transports (77.6%), and the most common general medical category was nontrauma (72.7%). Sixty-one percent of all patients received a prehospital intervention. Overall, hospital mortality was 15%, and the average hospital length of stay (LOS) was 8.8 days ( 10.0 days). Observed trends over time included increases in nontrauma transports, level of severity, and in-hospital mortality. In multivariable models, case severity and medical category correlated with the outcomes of mortality and LOS. ConclusionIn the largest standardized nonprofit HEMS system in the United States, patient mortality and hospital LOS increased over time, whereas the proportion of trauma patients and scene runs decreased.

Assessing Provider Understanding of Interfacility Emergency Medical Services Transport

Background: Interfacility  transfer between hospitals is an integral component of regional healthcare systems. The decisions referring providers make regarding emergency medical services (EMS) level of care and transport modality (ground versus air) can dramatically impact patient care, emergency departments' workflow, hospital length of stay, and EMS resource availability. Limited research has been done to assess understanding of interfacility transport by emergency medicine providers. &#x0D; Methods: We developed six patient scenarios to test knowledge of level of care and mode of interfacility transfer. Seven board-certified EMS physicians determined the optimal answer to each patient scenario. We distributed a survey with the scenarios to regional healthcare partners via a database of persons who utilize or interface with interfacility transport services. We collected answers to the patient scenarios and provider characteristics (primary practice site, sex, age, specialty, years since graducation, provider degree, EMS training received). Descriptive statistics were performed and Fisher's exact tests described differences in correct answers as they varied by specialty (emergency medicine or other specialty), provider type (physician or advanced practice provider), and reported training in EMS level of care. &#x0D; Results: Seventy-six emergency medicine providers responded, including 68 physicians and 8 advanced practice providers. The mean total score on the case scenarios was 66%, with scores ranging from 33% to 100%. The mean scores on questions testing level of care and transport modality were 67% and 70%, respectively. No significant difference was found in test scores between emergency medicine and other specialties (p=0.718) or provider level of training (p=0.799). Training in EMS level of care was correlated with higher scores on the transport modality questions (p=0.003) but not on the level of care questions (p=0.231).&#x0D; Conclusion: Variability exists in the knowledge of providers on interfacility transport throughout the state. Emergency medicine providers could benefit from education on interfacility transfer resources.

Trauma patient transport to hospital using helicopter emergency medical services or road ambulance in Sweden: a comparison of survival and prehospital time intervals

BackgroundThe benefits of helicopter emergency medical services (HEMS) transport of adults following major trauma have been examined with mixed results, with some studies reporting a survival benefit compared to regular emergency medical services (EMS). The benefit of HEMS in the context of the Swedish trauma system remains unclear.AimTo investigate differences in survival and prehospital time intervals for trauma patients in Sweden transported by HEMS compared to road ambulance EMS.MethodsA total of 74,032 trauma patients treated during 2012–2022 were identified through the Swedish Trauma Registry (SweTrau). The primary outcome was 30-day mortality and Glasgow Outcome Score at discharge from hospital (to home or rehab); secondary outcomes were the proportion of severely injured patients who triggered a trauma team activation (TTA) on arrival to hospital and the proportion of severely injured patients with GCS ≤ 8 who were subject to prehospital endotracheal intubation.Results4529 out of 74,032 patients were transported by HEMS during the study period. HEMS patients had significantly lower mortality compared to patients transported by EMS at 1.9% vs 4.3% (ISS 9–15), 5.4% vs 9.4% (ISS 16–24) and 31% vs 42% (ISS ≥ 25) (p < 0.001). Transport by HEMS was also associated with worse neurological outcome at discharge from hospital, as well as a higher rate of in-hospital TTA for severely injured patients and higher rate of prehospital intubation for severely injured patients with GCS ≤ 8. Prehospital time intervals were significantly longer for HEMS patients compared to EMS across all injury severity groups.ConclusionTrauma patients transported to hospital by HEMS had significantly lower mortality compared to those transported by EMS, despite longer prehospital time intervals and greater injury severity. However, this survival benefit may have been at the expense of a higher degree of adverse neurological outcome. Increasing the availability of HEMS to include all regions should be considered as it may be the preferrable option for transport of severely injured trauma patients in Sweden.

Evaluation of the implementation of evidence-based pediatric asthma exacerbation treatments in a regional consortium of emergency medical Services Agencies

Objective Asthma exacerbations are a frequent reason for pediatric emergency medical services (EMS) encounters. The objective of this study was to examine the implementation of evidence-based treatments for pediatric asthma in a regional consortium of EMS agencies. Methods This retrospective study applied the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) implementation framework to data from an EMS agency consortium in the Cincinnati, Ohio region. The study analyzed one year before an oral systemic corticosteroid (OCS) option was added to the agencies’ protocol, and five years after the protocol change. We constructed logistic regression models for the primary outcome of Reach, defined as the proportion of pediatric asthma patients who received a systemic corticosteroid. We modeled Maintenance (Reach measured monthly over time) using time series models. Results A total of 713 patients were included, 133 pre- and 580 post-protocol change. In terms of Reach, 3% (n = 4) of eligible patients received a systemic corticosteroid pre-OCS versus 20% (n = 116) post-OCS. Multivariable modeling of Reach revealed the study period, EMS transport time, months since implementation of OCS, and number of bronchodilators administered by EMS as significant covariates for the administration of a systemic corticosteroid. For Maintenance, it took approximately two years to reach maximal administration of systemic corticosteroids. Conclusions Indicators of asthma severity and time since the protocol change were significantly associated with EMS administration of systemic corticosteroids to pediatric asthma patients. The two-year time for maximal Reach suggests further work is required to understand how to best implement evidence-based pediatric asthma treatments in EMS.

9-1-1 Activations from Ambulatory Care Centers: A Sicker Pediatric Population.

Pediatric patients transferred by Emergency Medical Services (EMS) from urgent care (UC) and office-based physician practices to the emergency department (ED) following activation of the 9-1-1 EMS system are an under-studied population with scarce literature regarding outcomes for these children. The objectives of this study were to describe this population, explore EMS level-of-care transport decisions, and examine ED outcomes. This was a retrospective review of patients zero to <15 years of age transported by EMS from UC and office-based physician practices to the ED of two pediatric receiving centers from January 2017 through December 2019. Variables included reason for transfer, level of transport, EMS interventions and medications, ED medications/labs/imaging ordered in the first hour, ED procedures, ED disposition, and demographics. Data were analyzed with descriptive statistics, X test, point biserial correlation, two-sample z test, Mann-Whitney U test, and 2-way ANOVA. A total of 450 EMS transports were included in this study: 382 Advanced Life Support (ALS) runs and 68 Basic Life Support (BLS) runs. The median patient age was 2.66 years, 60.9% were male, and 60.7% had private insurance. Overall, 48.9% of patients were transported from an office-based physician practice and 25.1% were transported from UC. Almost one-half (48.7%) of ALS patients received an EMS intervention or medication, as did 4.41% of BLS patients. Respiratory distress was the most common reason for transport (46.9%). Supplemental oxygen was the most common EMS intervention and albuterol was the most administered EMS medication. There was no significant association between level of transport and ED disposition (P = .23). The in-patient admission rate for transported patients was significantly higher than the general ED admission rate (P <.001). This study demonstrates that pediatric patients transferred via EMS after activation of the 9-1-1 system from UC and medical offices are more acutely ill than the general pediatric ED population and are likely sicker than the general pediatric EMS population. Paramedics appear to be making appropriate level-of-care transport decisions.

Long-term prognostic significance of gasping in out-of-hospital cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation: a post hoc analysis of a multi-center prospective cohort study

BackgroundGasping during resuscitation has been reported as a favorable factor for out-of-hospital cardiac arrest. We examined whether gasping during resuscitation is independently associated with favorable neurological outcomes in patients with refractory ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) undergoing extracorporeal cardiopulmonary resuscitation ECPR.MethodsData from a 2014 study on advanced cardiac life support for ventricular fibrillation with extracorporeal circulation in Japan (SAVE-J), which examined the efficacy of ECPR for refractory VF/pVT, were analyzed. The primary endpoint was survival with a 6-month favorable neurological outcome in patients who underwent ECPR with or without gasping during resuscitation. Multivariate logistic regression analysis was performed to evaluate the association between gasping and outcomes.ResultsOf the 454 patients included in the SAVE-J study, data from 212 patients were analyzed in this study after excluding those with missing information and those who did not undergo ECPR. Gasping has been observed in 47 patients during resuscitation; 11 (23.4%) had a favorable neurological outcome at 6 months. Multivariate logistic regression analysis showed that gasping during resuscitation was independently associated with a favorable neurological outcome (odds ratio [OR], 10.58 [95% confidence interval (CI) 3.22–34.74]). The adjusted OR for gasping during emergency medical service transport and on arrival at the hospital was 27.44 (95% CI 5.65–133.41).ConclusionsGasping during resuscitation is a favorable factor in patients with refractory VF/pVT. Patients with refractory VF/pVT with continuously preserved gasping during EMS transportation to the hospital are expected to have more favorable outcomes.

137 Evaluating Outcomes and Disparities for Police “Scoop and Run” vs Emergency Medical Services Transport for Firearm Injury Patients

137 Evaluating Outcomes and Disparities for Police “Scoop and Run” vs Emergency Medical Services Transport for Firearm Injury Patients

Racial, Ethnic, and Socioeconomic Disparities in Prehospital Encounters for Children with Asthma

Objective Asthma represents one of the most common medical conditions among children encountered by emergency medical services (EMS). While care disparities for children with asthma have been observed in other healthcare settings, limited data exist characterizing disparities in prehospital care. We sought to characterize differences in prehospital treatment and transport of children with suspected asthma exacerbations by race and ethnicity, within the context of community socioeconomic status. Methods We conducted a multi-agency retrospective study of EMS encounters in 2019 for children (2–17 years) with asthma and wheezing using a national prehospital database. Our primary outcomes included EMS transport and prehospital bronchodilator or systemic corticosteroid administration. Scene socioeconomic status was evaluated using the social vulnerability index. We used generalized estimating equations to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) for prehospital bronchodilator use or steroid use by race and ethnicity, adjusting for age, presence of abnormal vital signs, community size, bronchodilator use prior to EMS arrival, and transport disposition. Results We analyzed 5,266 EMS encounters (median age 8 years). Approximately half (53%) were Black non-Hispanic and 34% were White non-Hispanic. Overall, 77% were transported by EMS. In an adjusted model, Black non-Hispanic children were 25% less likely to be transported compared to White non-Hispanic children (aOR: 0.75, 95%CI: 0.58–0.96). EMS administered at least one bronchodilator to 81% of Black non-Hispanic patients, 73% of Hispanic patients, and 68% of White, non-Hispanic patients. Relative to White non-Hispanic children, EMS bronchodilator administration was greater for Black non-Hispanic children, (aOR: 1.55, 95%CI: 1.25–1.93), after controlling for scene socioeconomic status and potential confounding variables. Systemic corticosteroids were administered in 3% of all encounters. Odds of prehospital systemic corticosteroid administration did not differ significantly by race and ethnicity. Conclusion Black non-Hispanic children comprised a larger proportion of EMS encounters for asthma and were more likely to receive a bronchodilator in adjusted analyses accounting for community socioeconomic status. However, these children were less likely to be transported by EMS. These findings may reflect disease severity not manifested by abnormal vital signs, management, and other social factors that warrant further investigation.

Emergency department crowding increases 10-day mortality for non-critical patients: a retrospective observational study

The current evidence suggests that higher levels of crowding in the Emergency Department (ED) have a negative impact on patient outcomes, including mortality. However, only limited data are available about the association between crowding and mortality, especially for patients discharged from the ED. The primary objective of this study was to establish the association between ED crowding and overall 10-day mortality for non-critical patients. The secondary objective was to perform a subgroup analysis of mortality risk separately for both admitted and discharged patients. An observational single-centre retrospective study was conducted in the Tampere University Hospital ED from January 2018 to February 2020. The ED Occupancy Ratio (EDOR) was used to describe the level of crowding and it was calculated both at patient’s arrival and at the maximum point during the stay in the ED. Age, gender, Emergency Medical Service transport, triage acuity, and shift were considered as confounding factors in the analyses. A total of 103,196 ED visits were included. The overall 10-day mortality rate was 1.0% (n = 1022). After controlling for confounding factors, the highest quartile of crowding was identified as an independent risk factor for 10-day mortality. The results were essentially similar whether using the EDOR at arrival (OR 1.31, 95% CI 1.07–1.61, p = 0.009) or the maximum EDOR (OR 1.27, 95% CI 1.04–1.56, p = 0.020). A more precise, mortality-associated threshold of crowding was identified at EDOR 0.9. The subgroup analysis did not yield any statistically significant findings. The risk for 10-day mortality increased among non-critical ED patients treated during the highest EDOR quartile.

A Retrospective Geospatial Simulation Study of Helicopter Emergency Medical Services’ Potential Time Benefit Over Ground Ambulance Transport in Northern South Africa

ObjectiveOne of the most important benefits of helicopter emergency medical services (HEMS) is a time benefit, either through expedited access to the casualty or a reduction in the transport time to definitive care. However, HEMS utilization does not come without risk to the public and crew or at an insignificant cost. Cost is an essential consideration for health policy decisions, especially in low- to middle-income countries, such as South Africa. The aim of this study was to determine whether there is a time benefit of HEMS dispatch in South Africa compared with simulated driving time. A secondary aim was to determine the distance from the incident site to the hospital at which a time benefit can be guaranteed. MethodsA retrospective study was undertaken by comparing the prehospital times of patients who underwent HEMS transportation with simulated ground emergency medical services (GEMS) transportation times. Handwritten patient records of actual flights were reviewed and analyzed. The actual flight times recorded were used to calculate the helicopter transport time, activation to scene time, scene time, and scene to hospital time. Times were assigned based on a nonsimultaneous dispatch model, as is used in South Africa. For each helicopter mission, Google Maps (Google Inc, Mountain View, CA) was used to simulate the fastest ground route from the same location of the incident to the same receiving hospital corrected for typical traffic trends. The actual HEMS and simulated GEMS times were compared using the paired t-test. Linear regression analysis was performed to determine a minimum driving distance at which HEMS provides a time benefit. ResultsA total of 118 HEMS transports were analyzed, the majority of which were trauma related (n = 115, 97%). HEMS transport resulted in a mean time deficit of −15 minutes (95% confidence interval, −18 to −11; P < .05) compared with simulated GEMS drive times. After regression, HEMS transport provides a time benefit at a driving distance greater than 119 km. ConclusionThe current study demonstrated that there was rarely a time benefit for actual primary emergency responses when HEMS was used compared with simulated driving time of GEMS transport. Using a nonsimultaneous dispatch model, a time benefit only occurs when the driving distance from the incident site to the hospital is greater than 119 km. There is an urgent need to critically evaluate HEMS utilization in the South African context.

Physical restraint use in children with mental and behavioral health emergencies in the prehospital setting.

Emergency medical services (EMS) transport for mental and behavioral health (MBH) emergencies occurs frequently in children, yet little is understood regarding prehospital physical restraint use despite the potential for serious adverse events. We aim to describe restraint use prevalence and primary impressions among children with MBH emergencies. This is a retrospective cross-sectional study of children with MBH emergencies evaluated by Alameda County (ALCO), California EMS from January 1, 2012 to December 31, 2018. Patient demographics and clinical variables were collected from the EMS records including sex, age at time of encounter, year of encounter, transport destination, medication use, and primary impression(s). The primary outcome was the use of physical restraints. Descriptive statistics were used to characterize the primary outcome and associated demographic and diagnostic features, as well as temporal use patterns. Sex and age were compared between restrained and non-restrained youth using chi-square analysis. Over the 7-year study period, ALCO EMS transported 9775 children with MBH emergencies. Of these transports, 1205 (12.3%) were physically restrained. Most children restrained had the primary impression of "behavioral/psychiatric crisis" (51.1%), "psychiatric crisis" (27.4%), and "behavioral-other" (12.4%) and the remaining children (9.1%) had a non-psychiatric/behavioral health primary impression. Over time, there was no statistically significant change in either number of children with MBH emergencies transported or physical restraint rate. More than 1 in 8 children with MBH emergencies are being physically restrained during EMS transport. Restraint rate did not substantially change over time. Further studies to understand existing restraint rates and EMS resources available to address acute agitation in children are needed to inform quality and care enhancing initiatives.