Use Of Emergency Medical Services Research Articles

Using ambulance service PCRs to understand 999 call-outs to older people with dementia

Objectives: To use local ambulance service patient care records (PCRs) at an aggregate level to study the use of emergency medical services (EMS) by older people with dementia in two English counties. To understand how and where in the PCR dementia is recorded. To measure the proportion of patients aged 75 and over who had an emergency (999) ambulance response who have dementia recorded in the PCR. To carry out a descriptive analysis of any associations with age, gender, reason for the call, time of call, residential status or call outcome. Methods: Four days of PCRs from two counties (UK) for patients aged 75 and over were reviewed and non-patient-identifiable data extracted. Data for the total number of call-outs for those days were obtained from the computer-aided dispatch (CAD) system. Results: In 4 days' records for Cambridgeshire and Hertfordshire (2 304 records), over one third of call-outs (830) were to patients aged 75 and over. Data were obtained from 358 paper records. Dementia was recorded on 14.5% of records and another 7.0% recorded details suggesting dementia or cognitive impairment. Around 15% of call-outs to ≥75-year-olds were to care homes. Ambulance crews attended higher proportions of ‘older old’ people than the local population percentages of 85 to 89-year-olds and ≥90-year-olds. The most common reason (27.5%) for a call-out was a fall. Conclusions: This is the first paper to look in detail at the numbers of older people with dementia seen by emergency ambulance crews as documented in PCRs. It gives a benchmark for others looking at ambulance service data and highlights possibilities and pitfalls of using ambulance service PCR data.

Impact of Prehospital Intervention on Delay Time to Thrombolytic Therapy in a Stroke Center with a Systemized Stroke Code Program

The use of emergency medical services (EMS) and notification to hospitals by paramedics for patients with suspected stroke are crucial determinants in reducing delay time to acute stroke treatment. The aim of this study is to investigate whether EMS use and prehospital notification (PN) can shorten the time to thrombolytic therapy in a stroke center with a systemized stroke code program. Beginning in January 2012, stroke experts in our stroke center received direct calls via mobile phone from paramedics prenotifying the transport of patients with suspected stroke. We compared baseline characteristics and prehospital/in-hospital delay time in stroke patients treated with intravenous recombinant tissue plasminogen activator for 44 months with and without EMS use and/or PN. Intravenous thrombolytic therapy was performed on 274 patients. Of those patients, 215 (78.5%) were transported to the hospital via EMS and 59 (21.5%) were admitted via private modes of transportation. The patients who used EMS had shorter median onset-to-arrival times (62 minutes versus 116 minutes, P < .001). There was no difference in in-hospital delay time between the 2 groups. In 28 cases (13%) of EMS transport, EMS personnel called the clinical staff to notify the incoming patient. Prenotification by EMS was associated with shorter median door-to-imaging time (9 minutes versus 12 minutes, P = .045) and door-to-needle time (20 minutes versus 29 minutes, P = .011). We found that EMS use reduces prehospital delay time. However, EMS use without prenotification does not shorten in-hospital processing time in a stroke center with a systemized stroke code program.

Effect of Emergency Medical Services Use on Hospital Outcomes of Acute Hemorrhagic Stroke

Background: It is unclear whether the use of emergency medical services (EMS) is associated with enhanced survival and decreased disability after hemorrhagic stroke and whether the effect size of EMS use differs according to the length of stay (LOS) in emergency department (ED). Methods: Adult patients (19 years and older) with acute hemorrhagic stroke who survived to admission at 29 hospitals between 2008 and 2011 were analyzed, excluding those who had symptom-to-ED arrival time of 3 h or greater, received thrombolysis or craniotomy before inter-hospital transfer, or had experienced cardiac arrest, had unknown information about ambulance use and outcomes. Exposure variable was EMS use. Endpoints were survival at discharge and worsened modified Rankin Scale (W-MRS) defined as 3 or greater points difference between pre- and post-event MRS. Adjusted odds ratios (AORs) with 95% confidence intervals (95% CIs) for the outcomes were calculated, including potential confounders (demographic, socioeconomic status, clinical parameter, comorbidity, behavior, and time of event) in the final model and stratifying patients by inter-hospital transfer and by time interval from symptom to ED arrival (S2D). ED LOS, classified into short (<120 min) and long (≥120 min), was added to the final model for testing of the interaction model. Results: A total of 2,095 hemorrhagic strokes were analyzed in which 75.6% were transported by EMS. For outcome measures, 17.4% and 41.4% were dead and had worsened MRS, respectively. AORs (95% CIs) of EMS were 0.67 (0.51–0.89) for death and 0.74 (0.59–0.92) for W-MRS in all patients. The effect size of EMS, however, was different according to LOS in ED. AORs (95% CIs) for death were 0.74 (0.54–1.01) in short LOS and 0.60 (0.44–0.83) in long LOS group. AORs (95% CIs) for W-MRS were 0.76 (0.60–0.97) in short LOS and 0.68 (0.52–0.88) in long LOS group. Conclusions: EMS transport was associated with lower hospital mortality and disability after acute hemorrhagic stroke. Effect size of EMS use for mortality was significant in patients with long ED LOS. Key words: emergency medical service; hemorrhagic stroke; mortality; disability

Abstract WP178: Acute Stroke Ischemic Symptom Onset-to-Arrival Time in Michigan Hospitals

Objectives: Stroke is the fifth-leading cause of death and the leading cause of disability in the United States. One of the primary goals of the American Heart Association/American Stroke Association is to increase the number of acute stroke patients arriving at emergency departments (EDs) within 1-hour of symptom onset. Earlier treatment with thrombolysis in patients with acute ischemic stroke translates into improved patient outcomes. The objective of this abstract is to examine the association between the use of emergency medical services (EMS) and symptom onset-to-arrival time in patients with ischemic stroke. Methods: A retrospective review of ischemic stroke patients (n = 8873) from 25 Michigan hospitals from January 2012-December 2014 using Get With the Guidelines databases was conducted. Symptom onset-to-ED arrival time and arrival mode were examined. Results: It was found that 17.4% of ischemic stroke patients arrived at the hospitals within 1-hour of symptom onset. EMS transported 69.1% of patients who arrived within 1-hour of symptom onset. During this 1-hour period African American patients (22%) were less likely to use EMS transportation as compared to White patients (72%). The majority of patients, 41.8%, arrived after 6-hours of symptom onset. EMS transported only 40% of patients who arrived after 6-hours of symptom onset. As before, during this 6-hour period African American patients (20%) were also less likely to use EMS transportation as compared to White patients (75%). Symptom onset-to-ED arrival time was shorter for those patients who used EMS. The median pre-hospital delay time was 2.6 hours for those who used EMS versus 6.2 hours for those who did not use EMS. Conclusions: The use of EMS is associated with a decreased pre-hospital delay, early treatment with thrombolysis and improved patient outcomes in ischemic stroke patients. Community interventions should focus on creating awareness especially in minority populations about stroke as a neurological emergency and encourage EMS use amongst stroke patients.

Patient and System-Related Delays of Emergency Medical Services Use in Acute ST-Elevation Myocardial Infarction: Results from the Third Gulf Registry of Acute Coronary Events (Gulf RACE-3Ps).

BackgroundLittle is known about Emergency Medical Services (EMS) use and pre-hospital triage of patients with acute ST-elevation myocardial infarction (STEMI) in Arabian Gulf countries.MethodsClinical arrival and acute care within 24 h of STEMI symptom onset were compared between patients transferred by EMS (Red Crescent and Inter-Hospital) and those transferred by non-EMS means. Data were retrieved from a prospective registry of 36 hospitals in 6 Arabian Gulf countries, from January 2014 to January 2015.ResultsWe enrolled 2,928 patients; mean age, 52.7 (SD ±11.8) years; 90% men; and 61.7% non-Arabian Gulf citizens. Only 753 patients (25.7%) used EMS; which was mostly via Inter-Hospital EMS (22%) rather than direct transfer from the scene to the hospital by the Red Crescent (3.7%). Compared to the non-EMS group, the EMS group was more likely to arrive initially at a primary or secondary health care facility; thus, they had longer median symptom-onset-to-emergency department arrival times (218 vs. 158 min; p˂.001); they were more likely to receive primary percutaneous coronary interventions (62% vs. 40.5%, p = 0.02); they had shorter door-to-needle times (38 vs. 42 min; p = .04); and shorter door-to-balloon times (47 vs. 83 min; p˂.001). High EMS use was independently predicted mostly by primary/secondary school educational levels and low or moderate socioeconomic status. Low EMS use was predicted by a history of angina and history of percutaneous coronary intervention. The groups had similar in-hospital deaths and outcomes.ConclusionMost acute STEMI patients in the Arabian Gulf region did not use EMS services. Improving Red Crescent infrastructure, establishing integrated STEMI networks, and launching educational public campaigns are top health care system priorities.

Effect of Emergency Medical Service Use and Inter-hospital Transfer on Time to Percutaneous Coronary Intervention in Patients with ST Elevation Myocardial Infarction: A Multicenter Observational Study

Background: The 2013 ACCF/AHA guideline for the management of ST elevation myocardial infarction (STEMI) recommends that patients be transported by emergency medical services (EMS) directly to a percutaneous coronary intervention (PCI)-capable hospital. We examined the effects of EMS use according to inter-hospital transfer on time to PCI in STEMI patients. Methods: Adult patients diagnosed with STEMI from November 2007 to December 2012 with symptom onset less than 24 hours treated with primary PCI at 29 emergency departments (ED) were included. Patients with unknown information about important time variables, inter-hospital transfer and EMS use, and patients who already received PCI at another hospital were excluded. Patients were divided into groups according to EMS use and inter-hospital transfer: Group A (direct to final ED by EMS), Group B (transferred to final ED after EMS transport), Group C (direct to final ED not by EMS), and Group D (transferred to final ED after non-EMS transport). Symptom to balloon time less than 120 minutes was considered timely PCI. Multivariable logistic regression model adjusting for potential risk factors examined the relationship between the groups and timely PCI. Interactions between EMS use and inter-hospital transfer were also tested for the outcome. Results: A total of 5826 patients were analyzed in this study, of which 28.3% called for EMS and 50% were transferred to another hospital for PCI. Median symptom to balloon time was 216 minutes. Timely PCI was achieved in 20.3% of the patients. With the Group D as the reference, the adjusted odds ratio (AOR) with 95% confidence intervals (95% CI) for timely PCI was 5.78 (4.81–6.95) for Group A, 0.80 (0.53–1.20) for Group B, and 2.87 (2.39–3.44) for Group C. In the interaction model, the AOR (95% CI) of EMS use in nontransferred groups and transferred groups was 2.01(1.71–2.38) and 0.80(0.53–1.20). Conclusions: EMS use significantly increased the odds of timely primary PCI to patients directly transported to a primary PCI center, but not in patients transferred from another hospital. EMS systems that identify STEMI patients and transport them to PCI capable hospitals, and processes to expedite the transfer of patients between non-PCI and PCI hospitals need to be developed further.

Utilizations and Perceptions of Emergency Medical Services by Patients with ST-Segments Elevation Acute Myocardial Infarction in Abu Dhabi: A Multicenter Study.

Background:Data on the use of emergency medical services (EMS) by patients with cardiac conditions in the Gulf region are scarce, and prior studies have suggested underutilization. Patient perception and knowledge of EMS care is critical to proper utilization of such services.Objectives:To estimate utilization, knowledge, and perceptions of EMS among patients with ST-elevation myocardial infarction (STEMI) in the Emirate of Abu Dhabi.Methods:We conducted a multicenter prospective study of consecutive patients admitted with STEMI in four government-operated hospitals in Abu Dhabi. Semi-structured interviews were conducted with patients to assess the rationale for choosing their prehospital mode of transport and their knowledge of EMS services.Results:Of 587 patients with STEMI (age 51 ± 11 years, male 95%), only 15% presented through EMS, and the remainder came via private transport. Over half of the participants (55%) stated that they did not know the telephone number for EMS. The most common reasons stated for not using EMS were that private transport was quicker (40%) or easier (11%). A small percentage of participants (7%) did not use EMS because they did not think their symptoms were cardiac-related or warranted an EMS call. Stated reasons for not using EMS did not significantly differ by age, gender, or primary language of the patients.Conclusions:EMS care for STEMI is grossly underutilized in Abu Dhabi. Patient knowledge and perceptions may contribute to underutilization, and public education efforts are needed to raise their perception and knowledge of EMS.

Spinal Cord Injuries and Helicopter Emergency Medical Services, 6,929 Patients: A Multicenter Analysis

ObjectiveTraumatic spinal cord injury (SCI) impacts quality of life for patients and caregivers, generating lifetime costs in the millions. Previous studies show delayed treatment of SCI patients at specialized centers is linked to complicated outcomes and extended hospitalizations. This study characterizes helicopter emergency medical service (HEMS) use in SCI and develops a methodology to study large volumes of HEMS electronic medical record data from multiple providers. MethodsThis descriptive study used deidentified data of HEMS providers that use Golden Hour Data Systems, Inc (San Diego, CA) software service from 34 states in the United States from 2004 to 2011. Demographic and logistical data underwent a deidentification protocol developed specifically for this study before analysis. ResultsSix thousand nine hundred twenty-nine SCI patients were transported. HEMS use increased but decreased relative to total transports from 2004 to 2011. The average patient was 39 ± 21 years old, male, and had a 63-minute total transport time. The largest age bracket was 15 to 25 years. ConclusionHEMS improved access for SCI patients to all localities and generally took under 2 hours. SCI patients are mostly young adult males, thus supporting the loss of years of productivity and also supporting the high lifetime cost for care for SCI. This study created a methodology for future multicenter aggregate data studies.

Elderly and Nonelderly Use of a Dedicated Ambulance Corps' Emergency Medical Services in Taiwan.

Backgrounds and Aim. Taiwan's population is gradually aging; however, there are no comparative data on emergency medical services (EMS) use between the elderly and nonelderly. Methods. We analyzed the emergency calls dealt with between January 1 and April 4, 2014, by EMS in one city in Taiwan. All calls were divided into two groups: elderly (≥65 years) and nonelderly (<65 years). Nontransport and transport calls were compared between the groups for demographic characteristics, transport time, reasons for calling EMS, vital signs, and emergency management. Results. There were 1,001 EMS calls: 226 nontransport and 775 transport calls. The elderly accounted for significantly (P < 0.05) fewer (28 (9.2%)) nontransport calls than did the nonelderly (136 (21.4%)). In the transport calls, 276 (35.6%) were the elderly. The elderly had a higher proportion of histories for cardiovascular disease, cerebrovascular disease, hypertension, diabetes, end-stage renal disease, cancer, Parkinson's disease, and Alzheimer's disease. In addition, the elderly had significantly longer total transport time, more nontrauma reasons, and poorer consciousness levels and lower oxygen saturation and needed more respiratory management and more frequent resuscitation during transport than did the nonelderly. Conclusion. The elderly have more specific needs than do the nonelderly. Adapting EMS training, operations, and government policies to aging societies is mandatory and should begin now.

The Effect of Emergency Medical Service Use and Inter-hospital Transfer on Prehospital Delay among Ischemic Stroke Patients: A Multicenter Observational Study.

The time between symptom onset and arrival at an emergency department (ED) (S2D) is a crucial time for optimal intravenous reperfusion care for ischemic stroke. We aimed to analyze the effect of emergency medical services (EMS) utilization and inter-hospital transfer on S2D in Korea. Ischemic stroke patients were prospectively enrolled from November 2007 to December 2012 in 23 tertiary and teaching hospital EDs in Korea. Of 31,443 adult ischemic stroke patients, 20,780 were categorized into 4 groups based on modes of EMS utilization and inter-hospital transfer: direct transport to destination ED by EMS (EMS direct; n=6,257, 30.1%), transfer after transport to another ED by EMS (EMS indirect; n=754, 3.6%), direct transport to the ED without using EMS (non-EMS direct; n=8,928, 43.0%), and transfer after visiting another hospital without using EMS (non-EMS indirect; n=4,841, 23.3%). Our primary outcome variable was of S2D within 2 hr (S2D ≤2 hr) and found that 30.8% of all patients and 52.3%, 16.4%, 25.9%, and 13.9% of EMS direct, EMS indirect, non-EMS direct, and non-EMS indirect, respectively, achieved S2D ≤2 hr. Adjusted odds ratio for S2D ≤2 hr were 6.56 (95% confidence interval [CI], 5.94-7.24), 2.27 (95% CI, 2.06-2.50), and 1.07 (95% CI, 0.87-1.33) for EMS direct, non-EMS direct, and EMS indirect, respectively. Patients directly transported to destination hospitals by the EMS show the highest proportion of therapeutic time window for optimal care in ischemic stroke.

Emergency medical services transport delays for suspected stroke and myocardial infarction patients.

BackgroundPrehospital delays in receiving emergency care for suspected stroke and myocardial infarction (MI) patients have significant impacts on health outcomes. Use of Emergency Medical Services (EMS) has been shown to reduce these delays. However, disparities in EMS transport delays are thought to exist. Therefore the objective of this study was to investigate and identify disparities in EMS transport times for suspected stroke and MI patients.MethodsOver 3,900 records of suspected stroke and MI patients, reported during 2006–2009, were obtained from two EMS agencies (EMS 1 & EMS 2) in Tennessee. Summary statistics of transport time intervals were computed. Multivariable logistic models were used to identify predictors of time intervals exceeding EMS guidelines.ResultsOnly 66 and 10 % of suspected stroke patients were taken to stroke centers by EMS 1 and 2, respectively. Most (80–83 %) emergency calls had response times within the recommended 10 min. However, over 1/3 of the calls had on-scene times exceeding the recommended 15 min. Predictors of time intervals exceeding EMS guidelines were EMS agency, patient age, season and whether or not patients were taken to a specialty center. The odds of total transport time exceeding EMS guidelines were significantly lower for patients not taken to specialty centers. Noteworthy was the 72 % lower odds of total time exceeding guidelines for stroke patients served by EMS 1 compared to those served by EMS 2. Additionally, for every decade increase in age of the patient, the odds of on-scene time exceeding guidelines increased by 15 and 19 % for stroke and MI patients, respectively.ConclusionIn this study, prehospital delays, as measured by total transport time exceeding guideline was influenced by season, EMS agency responsible, patient age and whether or not the patient is transported to a specialty center. The magnitude of the delays associated with some of the factors are large enough to be clinically important although others, though statistically significant, may not be large enough to be clinically important. These findings should be useful for guiding future studies and local health initiatives that seek to reduce disparities in prehospital delays so as to improve health services and outcomes for stroke and MI patients.

Characteristics of Trauma Patients With Potential Cervical Spine Injuries Underimmobilized by Prehospital Providers.

This study was a retrospective chart review to determine characteristics of patients under-immobilized by prehospital providers. Our goal was to examine the characteristics of patients who met the criteria for spinal immobilization but were inappropriately cleared. Many emergency medical services (EMS) use selective spinal immobilization (SSI) based on the NEXUS criteria. However, there is been research examining patients who are under-immobilized by EMS. This was a retrospective chart review over 18 months of a single EMS service. We reviewed all charts dispatched as "motor vehicle crash" (MVC) or "fall". We then determined, whether the patient met the criteria for SSI under Pennsylvania protocols, which mirror the NEXUS criteria. Our EMS system responded to 1151 falls and MVCs over the study period. Seventy-six patients were immobilized leaving 1075 patients who had clinical clearance of their cervical spine. Of these patients, 4/1075 (0.3%) were considered to be under-immobilized. All 4 of these patients had intoxication or altered mentation mentioned in their charts. Two of these patients had CT scans of their cervical spine, with both being negative. One patient eloped from the ED before any imaging, and 1 patient was clinically cleared. EMTs are very proficient in following the SSI guidelines with an under-immobilization rate of approximately 0.3% in our study. However, all patients who were under-immobilized were under the influence of alcohol. There were no patients who were not immobilized and had cervical spine injuries. This was a limited chart review involving only 2 dispatch categories. EMTs should be cautious while evaluating patients with possible spinal injuries who are under the influence of alcohol. 4.

Geographic Variation in the Use of Low-Acuity Pediatric Emergency Medical Services.

The aim of this study was to examine geographic variation in pediatric low-acuity emergency medical services (EMS) use in Washington, DC. This cross-sectional analysis of low-acuity EMS transports evaluated arrivals at 2 emergency departments and included 93% of pediatric transports in Washington, DC, during the study period. Low-acuity classification was defined as a triage emergency severity index of 4 or 5 not resulting in transfer, admission, or death. Logistic regression compared low-acuity visits arriving via EMS with all other low-acuity visits. Home zip code represented geographic location. Covariates included patient age, sex, race/ethnicity, hour of emergency department arrival, and insurance status. There were 45,454 low-acuity visits among children aged 0 to 17 years. Of these, 3304 (7.3%) arrived via EMS. The mean age was 5.6 (±5.0) years. Most were African American (84.3%) and had Medicaid insurance (87.3%). Geographic variation predicted EMS use. Adjusted odds ratios (ORs) of using EMS varied from 1.11 to 2.54 when compared with the lowest EMS use zip code. Odds of EMS use were higher among those with public insurance (adjusted OR [adj OR], 1.71; 95% confidence interval [CI], 1.46-2.00) and those with evening and overnight arrivals (evening arrival, adj OR of 1.65 and 95% CI of 1.47-1.86; overnight arrival, adj OR of 2.98 and 95% CI of 2.43-3.65). After adjusting for known covariates, residential zip code was associated with low-acuity EMS activation, stressing the importance of geographic variation in EMS use. Providing alternate means of transportation, or targeted education to certain residential areas, may decrease unnecessary EMS activation.

Neighborhood Influences on Emergency Medical Services Use for Acute Stroke: A Population-Based Cross-sectional Study

Delay to hospital arrival limits acute stroke treatment. Use of emergency medical services (EMS) is key in ensuring timely stroke care. We aim to identify neighborhoods with low EMS use and to evaluate whether neighborhood-level factors are associated with EMS use. We conducted a secondary analysis of data from the Brain Attack Surveillance in Corpus Christi project, a population-based stroke surveillance study of ischemic stroke and intracerebral hemorrhage cases presenting to emergency departments in Nueces County, TX. The primary outcome was arrival by EMS. The primary exposures were neighborhood resident age, poverty, and violent crime. We estimated the association of neighborhood-level factors with EMS use, using hierarchic logistic regression, controlling for individual factors (stroke severity, ethnicity, and age). During 2000 to 2009 there were 4,004 identified strokes, with EMS use data available for 3,474. Nearly half (49%) of stroke cases arrived by EMS. Adjusted stroke EMS use was lower in neighborhoods with higher family income (odds ratio [OR] 0.86; 95% confidence interval [CI] 0.75 to 0.97) and a larger percentage of older adults (OR 0.70; 95% CI 0.56 to 0.89). Individual factors associated with stroke EMS use included white race (OR 1.41; 95% CI 1.13 to 1.76) and older age (OR 1.36 per 10-year age increment; 95% CI 1.27 to 1.46). The proportion of neighborhood stroke cases arriving by EMS ranged from 17% to 71%. The fully adjusted model explained only 0.3% (95% CI 0% to 1.1%) of neighborhood EMS stroke use variance, indicating that individual factors are more strongly associated with stroke EMS use than neighborhood factors. Although some neighborhood-level factors were associated with EMS use, patient-level factors explained nearly all variability in stroke EMS use. In this community, strategies to increase EMS use should target individuals rather than specific neighborhoods.

A predictive model to identify patients with suspected acute coronary syndromes at high risk of cardiac arrest or in-hospital mortality: An IMMEDIATE Trial sub-study

BackgroundThe IMMEDIATE Trial of emergency medical service use of intravenous glucose–insulin–potassium (GIK) very early in acute coronary syndromes (ACS) showed benefit for the composite outcome of cardiac arrest or in-hospital mortality. ObjectivesThis analysis of IMMEDIATE Trial data sought to develop a predictive model to help clinicians identify patients at highest risk for this outcome and most likely to benefit from GIK. MethodsMultivariable logistic regression was used to develop a predictive model for the composite endpoint cardiac arrest or in-hospital mortality using the 460 participants in the placebo arm of the IMMEDIATE Trial. ResultsThe final model had four variables: advanced age, low systolic blood pressure, ST elevation in the presenting electrocardiogram, and duration of time since ischemic symptom onset. Predictive performance was good, with a C statistic of 0.75, as was its calibration. Stratifying patients into three risk categories based on the model's predictions, there was an absolute risk reduction of 8.6% with GIK in the high-risk tertile, corresponding to 12 patients needed to treat to prevent one bad outcome. The corresponding values for the low-risk tertile were 0.8% and 125, respectively. ConclusionsThe multivariable predictive model developed identified patients with very early ACS at high risk of cardiac arrest or death. Using this model could assist treating those with greatest potential benefit from GIK.

Alternatives to Criminalizing Public Intoxication: Case Study of a Sobering Centre in Calgary, AB

Western society has for centuries treated public intoxication as a crime, based on the idea that those found drunk in public can be harmful — to themselves, to the people around them, and to the social values of the community. To this day, public intoxication is in many places still a criminal offence, including in Canada. But what happens when, instead of approaching public drunkenness as a crime, we think of it as a symptom of larger problems? And what if, instead of routinely arresting those found drunk in public, we gave them a place to sober up, where they also have the opportunity to get help for other issues that may be contributing to the situation that put them there in the first place? As it turns out, this approach may provide a greater reduction in possible harm to the individual, others around him or her, and the broader community.In Calgary, Alpha House’s sobering centre facility takes this approach, welcoming clients who are not eligible for shelter in other, ‘dry’ facilities. Through its Downtown Outreach Addiction Partnership (DOAP), Alpha House actively works to divert publicly intoxicated people from law-enforcement responses by bringing them into the shelter, or finding other alternatives to incarceration. Once clients have been taken into Alpha House, workers are available and motivated to help clients address any addiction or mental-health issues they might be struggling with and, if appropriate, to assist them in finding secure housing.During a twelve-month assessment period, the results of Alpha House’s approach appears to be having a dramatic effect in helping those who have turned up publicly intoxicated, with apparent benefits for the community. During the period measured, there was a 50.1 per cent annualized decrease in the average number of days that clients were hospitalized, compared to the 12-month average prior to their intake into facility programs. There was a 62.6 per cent decrease in the number of times clients were hospitalized, a 50 per cent decrease in the use of emergency medical services, and a 42.4 per cent decrease in the number of times using an emergency room. Most dramatically the study observed a 92.7 percent decrease in the average number of days clients spent in jail compared to the year prior, and a 70.8 percent decrease in the number of interactions with police. The number of times clients went to jail actually increased by 26.6 percent, but that may have to do with Alpha House’s staff encouraging clients to address outstanding warrants and charges during their program participation. Calgary Police Services, meanwhile, reports notable decreases in people being processed for public intoxication in its downtown unit facilitated by partnership with community-based organizations, such as Alpha House.This is the crux of the harm-reduction approach: that holding cells should be a last resort for those publicly intoxicated people who cannot safely or effectively be helped through a sobering centre. But for those who are suitable for Alpha House’s program, the effects appear to be highly encouraging, providing an option to divert people facing the difficult personal circumstances that might cause them to be publicly intoxicated, into a program where they can access medical support, addiction and recovery programs. We may never eliminate public intoxication, but if our goal in criminalizing it has been to reduce harm to the individual and those around him or her, the sobering-centre approach appears to provide a much more effective response.Sobering centres will not and should not replace the need for medical intervention in some cases. They cannot replace the need for police custody as some clients cannot be safely assisted in such facilities. This means that the triage into sobering centres, health system and police custody will continue to be needed. Ultimately, a comprehensive approach to intoxication is necessary, one including sobering facilities along with a continuum of housing, health, and corrections responses that challenges the criminalization of addiction.

The Epidemiology of Prehospital Emergency Responses for Older Adults in a Provincial EMS System.

Societal aging is expected to impact the use of emergency medical services (EMS). Older adults are known as high users of EMS. Our primary objective was to quantify the rate of EMS use by older adults in a Canadian provincial EMS system. Our secondary objective was to compare those transported to those not transported. We analysed data from a provincial EMS database for emergency responses between January 1, 2010 and December 31, 2010 and included all older adults (≥65 years) requesting EMS for an emergency call. We described EMS use in relation to age, sex, and resources. There were 30,653 emergency responses for older adults in 2010, representing close to 50% of the emergency call volume and an overall response rate of 202.8 responses per 1,000 population 65 years and older. The mean age was 79.9±8.5 years for those 57.3% who were female. The median paramedic-determined Canadian Triage and Acuity Scale (CTAS) score was 3 and the mean on-scene time was 24.2 minutes. Non-transported calls (12.3%) for the elderly involved predominantly (54.9%) female patients of similar mean age (78.3 years) but lower acuity (CTAS 5) and longer average on-scene times (32.6 minutes). We confirmed the increasingly high rate of EMS use with age to be consistent with other industrialized populations. The low-priority and non-transport calls by older adults consumed considerable resources in this provincial system and might be the areas most malleable to meet the challenges facing EMS systems.

Ethical, legal and professional issues arising from social media coverage by UK Helicopter Emergency Medical Services

ObjectiveSocial media (SoMe) are gaining increasing acceptance among, and use by, healthcare service deliverers and workers. UK Helicopter Emergency Medical Services (HEMS) use SoMe to deliver service information and to...

Sustained impact of UK FAST-test public education on response to stroke: a population-based time-series study.

BackgroundUrgent assessment is essential after stroke. Several countries have had public education campaigns, based on the FAST (Face-Arm-Speech-Time) test to reduce delays in seeking attention. However, the impact of these campaigns on patient behavior is uncertain.MethodsWe prospectively determined patient behavior after incident major stroke (NIHSS > 3) in a UK population based study (Oxford Vascular Study) before (2002–2008) and after (2009–2013) introduction of the FAST TV-campaign and assessed any sustained impact of campaign continuation.ResultsAmong 668 consecutive patients with major stroke, medical attention was sought by a bystander in 553 (89·6%). Patients were more likely to present directly to emergency services (OR = 2·18, 95%CI:1·54–3·09, P < 0·0001) after the campaign and to arrive at hospital within 3 h (OR = 2·18, 1·55–3·06, P < 0·0001). Median [IQR] time to seeking attention fell from 53 [15–265] to 31 [7–120] minutes (P = 0·005) and median time to hospital arrival from 185 [88–885] to 119 [78–256] minutes (P < 0·0001). On time-series analysis improvements in hospital arrival within 3 h and use of emergency medical services were significantly associated to initiation of the campaign (aOR = 3·11, 1·53–6·29, P = 0·002; and 2·22, 1·05–4·67, P = 0·036, respectively), independent of trend, age, sex, ethnicity, educational level, social class, prior stroke and stroke severity, and have been sustained to 2013.ConclusionDelays to seeking and receiving medical attention after major stroke in the UK. fell strikingly in 2009, coinciding with the start of the FAST TV campaign. That medical attention was sought by a bystander in nearly 90% of cases illustrates the importance of mass-media public education rather than focused programs in high-risk groups for major stroke.

Housing First Is Associated with Reduced Use of Emergency Medical Services

Objective. Chronically homeless adults with severe alcohol problems are disproportionately burdened with health-care problems and are high utilizers of emergency medical services (EMS). Single-site Housing First (HF), which provides immediate, permanent, low-barrier, nonabstinence-based, supportive housing, has been associated with reduced publicly funded service utilization. The aims of the current study were to determine whether time spent in single-site HF predicted decreases in EMS contacts 2 years subsequent to single-site HF move-in, and to describe medical conditions and injuries associated with EMS contacts in a sample of chronically homeless individuals with severe alcohol problems. Methods. Participants were 91 chronically homeless adults with severe alcohol problems who were enrolled in a single-site HF program between December 2005 and March 2007 in Seattle, Washington. We obtained administrative data on exposure to HF and EMS utilization for the 2 years prior to and the 2 years subsequent to participants’ move-in date. EMS utilization variables included patient type (i.e., primary presenting problem), trauma/injury mechanism (i.e., EMS classification of the cause of the trauma or injury), level of care (i.e., basic life support, advanced life support), and transport destination. Results. After controlling for baseline EMS contacts, participants evinced 3% fewer EMS contacts for each additional month of single-site HF exposure. From the baseline to follow-up period, the mean number of EMS contacts declined from 15.85 (SD = 22.96) to 9.54 (SD = 15.08), representing a 54% reduction in the number of EMS contacts. Most calls were responded to by EMTs providing basic life support, and the majority resulted in transport to a local level I trauma center. The most common presenting difficulties were medical illness and trauma. Substance use and psychiatric difficulties were infrequently documented as the primary problem. Conclusions. Our findings support recent assertions that housing is health care and indicate that the amount of time spent in single-site HF is associated with significant reductions in EMS utilization for at least 2 years subsequent to move-in. These findings also underscore the high levels of medical illness and trauma exposure among chronically homeless adults with severe alcohol problems.