Emergency Medical System Research Articles

Abstract Su407: Implementing An Effective Standardized Bystander CPR Protocol For US Golf Courses

Background: A golf course is the fifth most common public place for cardiac arrest (CA). Informal interviews with golfers and golf course personnel revealed striking incomplete and variable knowledge about what to do in the event of a CA on a golf course in accordance with most current bystander resuscitation guidelines. Hypothesis: We hypothesized that the development and implementation of a standardized protocol (called “911-CPR-AED”) for the three most critical first steps to assure aperson’s survival of an on-golf course CA will improve chances of surviving if playing partners, caddies and club staff are well prepared to respond urgently and appropriately to such an emergency. Aim: To successfully implement the standardized “911-CPR-AED” protocol for 4 different golf clubs. Approach: We achieved full support and involvement of the Club Boards, professional staff, club management, grounds crew and membership as well as coordination with local Emergency Medical Systems (EMS) and communications to all golfers and caddies. We created a specific four-panel laminated infographic customized for each club and designed to fit easily into every golfer’s bag and caddy vest, assuring a readily available “911-CPR-AED” guide for lay bystanders to notify EMS and Club staff, immediately initiate chest compressions, ensure rapid delivery of an AED and BLS certified persons to the arrest site, and safely guide EMS on their arrival. We also staged live “dry run’ simulations on the golf courses with all key team members and timed each and every step of the simulation from start to finish. All aspects of this process were shared with leaders of the closest EMS and hospital emergency departments (EDs). Results: Within the past 2 years, we have successfully implemented a standardized emergency resuscitation protocol we call “911-CPR-AED” at 4 different golf clubs for immediate initiation of bystander CPR in the event of full CA on a golf course. Since implementation, we have witnessed 3 CA events and achieved successful full “on course” resuscitations that deployed this protocol for all three survivors who are now back to playing golf. We intend to share the details and many lessons learned for these ongoing efforts. Conclusion: An effective, standard bystander CPR protocol now exists for use at any US golf course. We intend to expand Implementation to 3 new golf courses and will continue to raise awareness and encourage widespread local implementation across the US.

Sex-related differences in the association of obesity described by emergency medical teams on outcomes in out-of-hospital cardiac arrest patients.

Out-of-hospital cardiac arrests (OHCA) are a major global health concern, occurring frequently worldwide. Obesity may impact outcomes in OHCA patients. This study aimed to assess the impact of obesity on the return of spontaneous circulation (ROSC) in OHCA patients, considering sex differences. A retrospective cohort study was conducted, analyzing medical records of patients assisted by the Emergency Medical System (EMS) in Poland from January 2021 to June 2022. The study included 33,636 patients with OHCA. Obesity status was determined using ICD-10 codes (E66) and descriptive diagnoses recorded by EMS teams. Univariate analysis indicated that obesity decreased the odds of ROSC by 25.47% (odds ratio (OR) = 0.75, 95% confidence interval (95% CI): 0.61-0.92) in women and by 19.76% (OR = 0.80, 95% CI: 0.66-0.97) in men. However, multivariate analysis, adjusting for confounding variables, did not confirm a statistically significant impact of obesity on ROSC outcomes. The likelihood of ROSC was significantly higher in individuals with an initial ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) rhythm compared to Asystole/pulseless electrical activity (PEA), being 4.204 times higher in women (95% CI: 3.525-5.014) and 3.655 times in men (95% CI: 3.320-4.023). Out-of-hospital cardiac arrest in a public place increased the odds of ROSC more than twofold for both sexes (women: OR = 2.20, 95% CI: 2.00-2.43; men: OR = 2.13, 95% CI: 1.98-2.29). Among women without obesity, hypertension decreased the odds of ROSC by 11.11% (OR = 0.89, 95% CI: 0.81-0.99). Our study demonstrated that obesity was not an independent predictor of ROSC in OHCA patients. Different predictors of ROSC were identified for men and women. Initial VF/pVT rhythm, location of OHCA and age were the significant factors influencing ROSC.

Awareness and preparedness of health systems and emergency medicine systems to the climate change challenges and threats: an international survey.

Climate change is widely recognised as a critical public health challenge. The objective of this study was to assess the awareness, preparedness and mitigation plans for climate change threats. A cross-sectional observational study targeting emergency medical societies in different countries was conducted between 15 February and 15 March 2024. The survey featured 16 closed questions on climate change awareness, preparedness and risks. Focus groups of 4-6 members were organised by country. Results were correlated to income levels, United Nations (UN) regional classification and the World Risk Index. The questions were ranked using a Likert-like scale from 0 to 9 (9 being the highest). Descriptive statistics used central tendency estimators, and inferential analysis used chi-square and Kruskal-Wallis tests, with the significance level set at P < 0.05. Forty-two focus groups responded, representing 36 countries: 21 (50%) high-income, seven (16.7%) low-income, five (11.9%) lower middle-income and nine (21.4%) upper middle-income countries, representing 31 of the 22 UN regions. According to the World Risk Index, the respondent countries belonged to the different categories as follows: very low risk, 6 (14%); low risk, 8 (19%); medium risk, 5 (12%); high risk, 8 (19%) and very high risk, 14 (34%). The estimated impact of climate change on national health systems had a mean score of 6.75 (SD = 2.16), while on Emergency Medical Systems was 6.96 (SD = 2.05). Overall, assessment and preparedness measures were reported by just 21.4 and 37.6% of respondents, respectively. Analysis by income did not show significant differences, with the exception of food supply. The main differences in the analysis by region were the risks of extreme weather events, vector-borne diseases and wildfires, whereas the World Risk Index was food and chain of supplies. Education and integration of health services were indicated by all as the main mitigation actions. Geographical position and country risk index influence risk perception among focus groups more than income economy, with vector-borne diseases, extreme weather events and food shortages being the threats with the most variability. The most important actions identified to mitigate Climate Change effects are educational and strategic plans.

A Randomized Trial of Drug Route in Out-of-Hospital Cardiac Arrest.

In patients with out-of-hospital cardiac arrest, the effectiveness of drugs such as epinephrine is highly time-dependent. An intraosseous route of drug administration may enable more rapid drug administration than an intravenous route; however, its effect on clinical outcomes is uncertain. We conducted a multicenter, open-label, randomized trial across 11 emergency medical systems in the United Kingdom that involved adults in cardiac arrest for whom vascular access for drug administration was needed. Patients were randomly assigned to receive treatment from paramedics by means of an intraosseous-first or intravenous-first vascular access strategy. The primary outcome was survival at 30 days. Key secondary outcomes included any return of spontaneous circulation and favorable neurologic function at hospital discharge (defined by a score of 3 or less on the modified Rankin scale, on which scores range from 0 to 6, with higher scores indicating greater disability). No adjustment for multiplicity was made. A total of 6082 patients were assigned to a trial group: 3040 to the intraosseous group and 3042 to the intravenous group. At 30 days, 137 of 3030 patients (4.5%) in the intraosseous group and 155 of 3034 (5.1%) in the intravenous group were alive (adjusted odds ratio, 0.94; 95% confidence interval [CI], 0.68 to 1.32; P = 0.74). At the time of hospital discharge, a favorable neurologic outcome was observed in 80 of 2994 patients (2.7%) in the intraosseous group and in 85 of 2986 (2.8%) in the intravenous group (adjusted odds ratio, 0.91; 95% CI, 0.57 to 1.47); a return of spontaneous circulation at any time occurred in 1092 of 3031 patients (36.0%) and in 1186 of 3035 patients (39.1%), respectively (adjusted odds ratio, 0.86; 95% CI, 0.76 to 0.97). During the trial, one adverse event, which occurred in the intraosseous group, was reported. Among adults with out-of-hospital cardiac arrest requiring drug therapy, the use of an intraosseous-first vascular access strategy did not result in higher 30-day survival than an intravenous-first strategy. (Funded by the National Institute for Health and Care Research; PARAMEDIC-3 ISRCTN Registry number, ISRCTN14223494.).

Atrial fibrillation and atrial flutter in the practice of the emergency medical team in Poland

Background: Atrial Fibrillation (AF) is one of the most common heart arrhythmias globally. It is characterized by irregular, chaotic contractions of the atrial muscle, leading to an irregular and often rapid heart rhythm. The prevalence of this arrhythmia increases with age, which is associated with both the aging population and cardiovascular risk factors such as hypertension, coronary artery disease, and diabetes. Atrial Flutter (AFL) represents a less common variant of atrial fibrillation, occurring significantly less frequently - in relation to atrial fibrillation (AF), it is estimated to account for less than one-tenth of cases. The aim of the study was to analyze emergency medical services delivered to patients diagnosed with atrial fibrillation (AF) and atrial flutter (AFL) in the Voivodeship of Warmia and Mazury (Poland). The patients were classified according to the 10th Revision of the International Classification of Diseases (ICD-10 )[1]. Methods: The study was based on a retrospective data analysis. From a total population of 400,251 subjects (n= 400,251), 4715 patients were selected for the study. The majority of the patients were women (n=2941; 62.38%), whereas men accounted for 37.62% of the examined sample (n=1774). The analysis relied on a database administered by the Governor of the Voivodeship of Warmia and Mazury in Olsztyn [2]. The analyzed data included the area of intervention, the patient's age and sex, and the diagnoses made by physicians, paramedics, and emergency nurses. Three research hypotheses postulating the presence of relationships between the patient's sex and the diagnosis (1), the patient's age and the diagnosis (2), and a life-threatening emergency and the patient's age (3) were formulated. Results: The results of the study suggest that the patient's sex affects the medical diagnosis. In particular, women were more frequently diagnosed with chest pain, whereas the probability of the remaining diagnoses was similar in both sexes. The patient's age does not significantly influence the diagnosis. The patient's sex is not a significant predictor of a life-threatening emergency. Conclusion: The conducted study on the dataset from the Warmian-Masurian Voivodeship revealed significant correlations between demographic variables and the diagnosis of atrial fibrillation (AF) and atrial flutter (AFL) in patients. Analyzing this data may have significant implications for emergency medical systems, enabling the adaptation of intervention strategies to different patient categories.

A Comparative Study of Hospitalization Mortality Rates between General and Emergency Hospitalized Patients Using Survival Analysis

Background/Objectives: In Korea’s emergency medical system, when an emergency patient arises, patients receive on-site treatment and care during transport at the pre-hospital stage, followed by inpatient treatment upon hospitalization. From the perspective of emergency patient management, it is critical to identify the high death rate of patients with certain conditions in the emergency room. Therefore, it is necessary to compare and analyze the determinants of the death rate of patients admitted via the emergency room and generally hospitalized patients. In fact, previous studies investigating determinants of survival periods or length of stay (LOS) primarily used multiple or logistic regression analyses as their main research methodology. Although medical data often exhibit censored characteristics, which are crucial for analyzing survival periods, the aforementioned methods of analysis fail to accommodate these characteristics, presenting a significant limitation. Methods:Therefore, in this study, survival analyses were performed to investigate factors affecting the dying risk of general inpatients as well as patients admitted through the emergency room. For this purpose, this study collected and analyzed the sample cohort DB for a total of four years from 2016 to 2019 provided by the Korean National Health Insurance Services (NHIS). After data preprocessing, the survival probability was estimated according to sociodemographic, patient, health checkup records, and institutional features through the Kaplan–Meier survival estimation. Then, the Cox proportional hazards models were additionally utilized for further econometric validation. Results: As a result of the analysis, in terms of the ‘city’ feature among the sociodemographic characteristics, the small and medium-sized cities exert the most influence on the death rate of general inpatients, whereas the metropolitan cities exert the most influence on the death rate of inpatients admitted through the emergency room. In terms of institution characteristics, it was found that there is a difference in determinants affecting the death rate of the two groups of study, such as the number of doctors per 100 hospital beds, the number of nurses per 100 hospital beds, the number of hospital beds, the number of surgical beds, and the number of emergency beds. Conclusions: Based on the study results, it is expected that an efficient plan for distributing limited medical resources can be established based on inpatients’ LOS.

Complicated cardiac arrest and its resuscitation characteristics in patients with intracerebral hemorrhage: Chinese Stroke Center Alliance.

Cardiac arrest (CA) is one of the most severe complications in patients with intracerebral hemorrhage (ICH), increasing the risk of death. This study explored the factors influencing CA occurrence and its resuscitation characteristics in ICH patients. Data were retrieved from the Chinese Stroke Center Alliance database. The primary outcome was CA, and the secondary outcomes were in-hospital death and survival post-CA. Absolute standardized and rate differences were utilized for intergroup comparisons, while logistic regression was employed for correlation analysis. A total of 85,105 patients were enrolled in this study. Among them, 1651 (1.9%) patients experienced CA, of whom 1032 (62.5%) died in hospital. At baseline, prehospital notification from the emergency medical service system (PRE-EMS) was a co-factor influencing CA occurrence and the presence of a death outcome (OR: 1.71, 95% CI: 1.47-1.98, p < 0.001; OR: 0.50, 95% CI: 0.41-0.62, p < 0.001). In terms of complications, post-hospital hematoma expansion and swallowing dysfunction were co-factors influencing CA occurrence and the presence of a death outcome (OR: 3.78, 95% CI: 3.20-4.47, p < 0.001, OR: 1.39, 95% CI: 1.11-1.76; p < 0.001; OR: 7.66, 95% CI:5.48-10.70, p < 0.001, OR: 1.66, 95% CI: 1.08-2.57, p < 0.001). The incidence of CA in ICH patients decreased annually from 2015 to 2019, while survival after CA increased annually (p < 0.001). PRE-EMS, posthospital hematoma expansion, and swallowing dysfunction were identified as co-factors contributing to CA occurrence and post-CA mortality following ICH. The proportion of CA patients following ICH decreased, while survival rates improved annually from 2015 to 2019.

Design of an emergency medical information system for mass gatherings

BackgroundThe frequency of mass gatherings is increasing. Such events often involve many people and carry the risk of mass casualty incidents, which require substantial medical resources from various healthcare institutions. The current medical system, while meeting daily needs, struggles to address the demand for a high volume of emergency resources and real-time data exchange. ObjectiveThe aim of this study was to develop an emergency medical information system for mass gatherings. MethodsWe developed an emergency medical information system for mass gatherings. Based on a unified prehospital and intrahospital emergency data exchange protocol, we can directly standardize medical information data and provide data support for the evacuation decision support algorithms of multiple institutions. Wearable devices, vehicle-mounted devices, video calling systems and surveillance systems are connected to capture real-time scenes. ResultsWe constructed the system via mobile applications and online platforms and deployed it in 3 hospitals, 5 ambulances and 17 on-site medical locations. We constructed a set of electronic medical records covering the whole first aid process according to the basic principles of first aid. The simulation results show that the proposed algorithm is suitable for mass gatherings. The overall survival rate of patients can be improved by 5 %, and the average evacuation efficiency of patients can be improved by 50 %. Furthermore, in a real-world environment, this method can ensure patient survival and achieve good convergence. ConclusionsOur system is capable of providing robust medical information support for emergency medical services during large-scale assembly events, ensuring a visualized full-process emergency response and decision-making for the diversion and subsequent transport of a large patient population.

Impact of an emergency department closure on out-of-hospital cardiac arrest survival and emergency medical service system in Ulsan, South Korea

IntroductionThis study evaluated the impact of an emergency department (ED) closure on out-of-hospital cardiac arrest survival outcomes and the emergency medical service system in Ulsan, South Korea. MethodsWe conducted a retrospective observational cohort study from March 2017 to February 2021 and compared survival to hospital discharge and favorable neurological outcomes. We investigated transport time intervals (TTIs) in the total study population and subgroup covered by the closed ED. The analysis methods included propensity score matching (PSM), inverse propensity weighting (IPW), and logistic regression analysis. ResultsThe study included 692 and 920 patients before and after ED closure groups, respectively. After adjusting for covariates, the adjusted odds ratios and 95 % confidence interval for survival discharge and favorable neurological outcomes were 1.040 (0.749–1.444, p = 0.814) and 2.845 (1.563–5.177, p = 0.001), respectively. PSM showed values of 1.015 (0.727–1.416, p = 0.932) for discharge survival and 1.777 (1.074–2.941, p = 0.025) for neurological outcomes. IPW showed values of 0.980 (0.762–1.261, p = 0.875) for discharge survival and 1.782 (1.196–2.656, p = 0.005) for neurological outcomes. The TTI increased from 5.8 ± 5.0 to 6.7 ± 5.5 min (p < 0.001) in the total population and from 9.2 ± 7.9 to 16.2 ± 6.5 min (p < 0.001) in the subgroup. ConclusionsThe findings suggest that while the overall system may remain stable, subgroups could be disproportionately affected by an ED closure, underscoring the importance of the ongoing monitoring of survival outcomes and transport times.

Comprehensive Risk Analysis of Emergency Medical Response Systems in Serbian Healthcare: Assessing Systemic Vulnerabilities in Disaster Preparedness and Response.

Emergency Medical Response Systems (EMRSs) play a vital role in delivering medical aid during natural and man-made disasters. This quantitative research delves into the analysis of risk and effectiveness within Serbia's Emergency Medical Services (EMS), with a special emphasis on how work organization, resource distribution, and preparedness for mass casualty events contribute to overall disaster preparedness. The study was conducted using a questionnaire consisting of 7 sections and a total of 88 variables, distributed to and collected from 172 healthcare institutions (Public Health Centers and Hospitals). Statistical methods, including Pearson's correlation, multivariate regression analysis, and chi-square tests, were rigorously applied to analyze and interpret the data. The results from the multivariate regression analysis revealed that the organization of working hours (β = 0.035) and shift work (β = 0.042) were significant predictors of EMS organization, explaining 1.9% of the variance (R2 = 0.019). Furthermore, shift work (β = -0.045) and working hours (β = -0.037) accounted for 2.0% of the variance in the number of EMS points performed (R2 = 0.020). Also, the availability of ambulance vehicles (β = 0.075) and financial resources (β = 0.033) explained 4.1% of the variance in mass casualty preparedness (R2 = 0.041). When it comes to service area coverage, the regression results suggest that none of the predictors were statistically significant. Based on Pearson's correlation results, there is a statistically significant correlation between the EMS organization and several key variables such as the number of EMS doctors (p = 0.000), emergency medicine specialists (p = 0.000), etc. Moreover, the Chi-square test results reveal statistically significant correlations between EMS organization and how EMS activities are conducted (p = 0.001), the number of activity locations (p = 0.005), and the structure of working hours (p = 0.001). Additionally, the results underscore the necessity for increased financial support, standardized protocols, and enhanced intersectoral collaboration to strengthen Serbia's EMRS and improve overall disaster response effectiveness. Based on these findings, a clear roadmap is provided for policymakers, healthcare administrators, and EMS personnel to prioritize strategic interventions and build a robust emergency medical response system.

Pre-Hospital Care and Effect of Cardiopulmonary Resuscitation (CPR) On Survival Rate of Out-Of-Hospital Cardiac Arrest (OHCA) Victims, Telangana (India)

Introduction: OHCA is among the leading causes of mortality worldwide. India lacks a comprehensive database of cardiac arrests and an efficient emergency medical system. The treatment of cardiac disease has improved, yet the outcomes of OHCA remain poor. Methods: This is an observational 1-year prospective, single center, cohort study conducted on cohorts of OHCA victims. “Utstein Resuscitation Template” was followed for gathering the information starting location of arrest till the final resuscitation outcome. The information on OHCA patient treatment and current knowledge gaps is the aim of this study. Results: The study was conducted in the Warangal region of Telangana, India. The research comprised 1167 OHCA patients with a suspected cardiac etiology who were taken to the Mahatma Gandhi Memorial Hospital between June 1, 2022, and June 30, 2023. CPR attempts were recorded. Findings suggested if an individual was aware of the risk factors for CVD, they were more likely to report symptoms before OHCA. Conclusion: OHCA survival rate can be increased if the chain of survival is maintained by offering awareness and CPR training programs to the general public or bystanders, as well as efficient emergency ambulance services with qualified emergency medical staff.

Characteristics and outcomes of emergency department patients across health care systems: an international multicenter cohort study

BackgroundA wide variation of emergency medical system configurations across countries has limited the value of comparison of quality and performance measures in the past. Furthermore, lack of quantitative data on EDs prevents definition of the problems and possibilities for data driven improvement of quality of care. Therefore, the objective is to describe and compare Emergency Department (ED) populations and characteristics, and their outcomes in the Netherlands, Denmark and Australia, using a recently developed template for uniform reporting of standardized measuring and describing of care provided in the ED (structure, staffing and governance, population, process times and outcomes).MethodsThis international multicenter cohort included all consecutive ED visits from National Quality Registries or Databases from participating sites from three countries. Patient and ED characteristics (using the template for uniform reporting) and relevant clinical outcomes were described and compared per country.ResultsWe included 212,515 ED visits in the Netherlands, 408,673 in Denmark and 556,652 in Australia. Patient characteristics differed markedly, with Australian ED patients being younger, less often triaged as “immediate”, and less often triaged with the high-risk chief complaints “feeling unwell” compared to Danish and Dutch patients. ED characteristics mainly differed with respect to the mean annual census per ED (Netherlands 26,738 (SD 2630), Denmark 36,675 (SD 12974), Australia 50,712 (4884)), median (IQR) lengths of stay of patients discharged home (Netherlands 2.1 (1.4–3.1); Denmark 2.8 (1.7–5.0); Australia 3.3 (2.0–5.0) hrs) and proportion of hospitalizations (ranging from 30.6 to 39.8%).In-hospital mortality was 4.0% in Australia, higher compared to the Netherlands and Denmark (both 1.6%). Not all indicators of the framework were available in all registries.ConclusionsPatient and ED characteristics and outcomes varied largely across countries. Meaningful interpretation of outcome differences across countries could be improved if quality registries would more consistently register the measures of the recently developed template for uniform reporting.

The Impact of Sleep and Mental Health on the Quality of Work Among Paramedics in the Kingdom of Saudi Arabia

The emergency services sector is one of the most arduous and crucial fields wherein an individual’s life lies in the hands of emergency responders such as paramedics and police. Paramedics are crucial figures in the emergency medical services system. They deliver immediate medical care to patients who suffer from critical and life-threatening conditions, serving as a gap-filler between the accident scene and health facilities. In the Kingdom of Saudi Arabia, the health authority has been constantly striving to build a credible, professional, and trustworthy EMS system while discovering challenges faced by the service in the rapidly changing health scenario of KSA. This study employed a mixed-methods approach, combining quantitative surveys and qualitative interviews to assess the relationship between sleep patterns, mental health, and work quality among paramedics in the Kingdom of Saudi Arabia. The results of this study reveal a significant correlation between sleep quality, mental health, and the overall performance of paramedics in the Kingdom of Saudi Arabia. In conclusion, the findings of this comprehensive study emphasize and highlight the critical and significant relationship that exists between sleep quality, mental health, and overall job performance among paramedics working in the Kingdom of Saudi Arabia. This highlights an urgent need for targeted and effective interventions designed specifically to enhance their well-being and support their mental health in the demanding field of emergency services.

Mobile Critical Care in Resource-Limited Settings: An Unmet Need.

Care of the critically ill in resource-limited areas, inside or outside the intensive care unit (ICU), is indispensable. Murthy and Adhikari noted that about 70% of patients in low-middle income (LMIC) areas could benefit from good critical care. Many patients in resource-limited settings still die before getting to the hospital. Investing in capacity building by strengthening and expanding ICU capability and training intensivists, critical care nurses, respiratory therapists, and other ICU staff is essential, but this process will take years. Also, having advanced healthcare facilities that are still far from remote areas will not do much to alleviate distance and mode of transportation as barriers to achieving good critical care. This paper discusses the importance of mobile critical care units (MCCUs) in supporting and enhancing existing emergency medical systems. MCCUs will be crucial in addressing critical delays in transportation and time to receive appropriate lifesaving critical care in remote areas. They are incredibly versatile and could be used to transfer severely ill patients to a higher level of care from the field, safely transfer critically ill patients between hospitals, and, sometimes, almost more importantly, provide standalone short-term critical care in regions where ICUs might be absent or immediately inaccessible. MCCUs should not be used as a substitute for primary care or to bypass readily available services at local healthcare centers. It is essential to rethink the traditional paradigm of 'prehospital care' and 'hospital care' and focus on improving the care of critically ill patients from the field to the hospital.

Use of Emergency Mental Health Dispatch Training by a 9-1-1 Medical Dispatcher Assisting a Caller Expressing Suicidal Intent: A Case Report.

A growing number of individuals with unmet mental health needs in the United States rely on emergency medical services during mental health crises, and 9-1-1 emergency medical dispatchers (EMD) are often a critical lifeline to help. Unfortunately, current industry-standard dispatching protocols and training required for EMD certification largely lack specificity for managing 9-1-1 calls related to mental health emergencies. The purpose of this report is to illustrate the value of additional targeted training for EMDs that enables them to more effectively assist callers struggling with mental illness or suicidal thoughts. We review a 9-1-1 call in which an EMD utilized specific strategies and language learned during a 3-day emergency mental health dispatch (EMHD) training course to assist a middle-aged male who was expressing suicidal intent with a firearm. Key principles and phrasing from the training were used successfully by the EMD to dissuade the caller from self-harm, and he was ultimately safely met by first responders on scene and transported for care. We also share post-call recollections and reactions from the EMD to demonstrate how in addition to reducing risks for callers and their families, EMHD training has the potential to reduce on-scene risks for field responders and may increase confidence and mitigate negative stress responses in EMDs. Emergency medical services systems in the United States should continue to explore enhanced training and protocols to improve care for 9-1-1 callers experiencing mental health crises.

A Telemedicine System Using the Remote Diagnostic Imaging App "Join" for Emergency Medicine Throughout Wakayama Prefecture in Japan.

Background Telemedicine is expected to play an increasingly important role in building universal emergency medical systems without geographical disparities in the future. To eliminate healthcare disparities between regions, Wakayama Prefecture in Japan has been promoting telemedicine for closer inter-hospital coordination with secondary and tertiary emergency medical care hospitals. The "Join" diagnostic image-sharing app has been used since November 2018 for operating a remote emergency support system that shares medical images of emergency patients between 13 secondary and tertiary emergency medical care hospitals in Wakayama Prefecture. In this study, we investigated the effects of remote emergency medicine between hospitals after the introduction of Join. Methodology Four medical specialties use the remote emergency support system, namely, cardiovascular medicine, cardiovascular surgery, neurosurgery, and emergency care medicine. We investigated the results from 497 cases for which the system was used between November 2018 and February 2023. Results Of the 497 cases, treatment for 148 (29.8%) patients was continued in the same hospital, without a transfer. Emergency medicine was the group with the largest number of uses, in 232 cases. Of the 211 patients in the neurosurgery group, 88 (41.7%) were not transferred, the statistically significantly largest number of patients among the usage group (p < 0.01). An estimated transportation cost of 6,973,900 yen was saved due to 148 patients not being transferred. Tertiary emergency medical care hospitals were most frequently consulted, but secondary emergency medical care hospitals located long distances from tertiary emergency medical care hospitals also received large numbers of consultations from neighboring rural hospitals. Conclusions The Wakayama Prefecture remote emergency support system using Join has made it possible to communicate accurate information quickly between hospitals. This has contributed to fewer non-essential transfers to tertiary medical centers, reduced medical transport costs, and more effective distribution of medical resources to secondary medical institutions because ambulance transport was not necessary.

Police Involvement in Out-of-Hospital Cardiac Arrest: A Qualitative Exploration of Law Enforcement Roles and Contributing Organizational Factors

Objectives Many American police organizations respond to out-of-hospital cardiac arrest (OHCA). This study sought to: 1) explore variation in the role of police in OHCA across emergency medical systems and 2) identify factors influencing this variation. Methods We conducted a qualitative multisite case study analysis using data collected through semi-structured key informant interviews and multidisciplinary focus groups with telecommunicators, fire, police, emergency medical services, and hospital personnel across nine Michigan emergency systems of care. Sites were sampled based on return of spontaneous circulation rates, trauma region, geography, rurality, and population density. Data were analyzed to examine police role in OHCA and the organizational factors that contribute to these roles. Transcripts and coded data were explored using iterative thematic analysis and matrices. Results Interviews included approximately 160 public safety informants of varying administrative levels (i.e., field staff, mid-level managers, and leadership). Across systems, police played four on-scene roles in OHCA response: 1) early responder, 2) resuscitation team member, 3) security, and 4) information gathering. Less consistently, police performed supplementary roles as telecommunicators and cardiac arrest educators. We found that factors including administrative structure of the police agency, resources (e.g., human and material), organizational culture, medical training, deployment and response policies, nature of response environment, and relationships with other prehospital stakeholders contributed to the degree certain roles were present. Conclusions Police serve numerous on-scene and supplementary roles in OHCA response across jurisdictions. Their roles were influenced by multiple factors at each site. Future studies may help to better understand the value of and how to optimize police engagement in OHCA response.

Diagnostic Performance of GFAP, UCH-L1, and MAP-2 Within 30 and 60 Minutes of Traumatic Brain Injury.

Data on the performance of traumatic brain injury (TBI) biomarkers within minutes of injury are lacking. To examine the performance of glial fibrillary acidic protein (GFAP), ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), and microtubule-associated protein 2 (MAP-2) within 30 and 60 minutes of TBI in identifying intracranial lesions on computed tomography (CT) scan, need for neurosurgical intervention (NSI), and clinically important early outcomes (CIEO). This cohort study is a biomarker analysis of a multicenter prehospital TBI cohort from the Prehospital Tranexamic Acid Use for TBI clinical trial conducted across 20 centers and 39 emergency medical systems in North America from May 2015 to March 2017. Prehospital hemodynamically stable adult patients with traumatic injury and suspected moderate to severe TBI were included. Blood samples were measured for GFAP, UCH-L1, and MAP-2. Data were analyzed from December 1, 2023, to March 15, 2024. The presence of CT lesions, diffuse injury severity on CT, NSI within 24 hours of injury, and CIEO (composite outcome including early death, neurosurgery, or prolonged mechanical ventilation ≥7 days) within 7 days of injury. Of 966 patients enrolled, 804 patients (mean [SD] age, 41 [19] years; 418 [74.2%] male) had blood samples, including 563 within 60 minutes and 375 within 30 minutes of injury. Among patients with blood drawn within 30 minutes of injury, 212 patients (56.5%) had CT lesions, 61 patients (16.3%) had NSI, and 112 patients (30.0%) had CIEO. Among those with blood drawn within 60 minutes, 316 patients (56.1%) had CT lesions, 95 patients (16.9%) had NSI, and 172 patients (30.6%) had CIEO. All biomarkers showed significant elevations with worsening diffuse injury on CT within 30 and 60 minutes of injury. Among blood samples taken within 30 minutes, GFAP had the highest area under the receiver operating characteristic curve (AUC) to detect CT lesions, at 0.88 (95% CI, 0.85-0.92), followed by MAP-2 (AUC, 0.78; 95% CI, 0.73-0.83) and UCH-L1 (AUC, 0.75; 95% CI, 0.70-0.80). Among blood samples taken within 60 minutes, AUCs for CT lesions were 0.89 (95% CI, 0.86-0.92) for GFAP, 0.76 (95% CI, 0.72-0.80) for MAP-2, and 0.73 (95% CI, 0.69-0.77) for UCH-L1. Among blood samples taken within 30 minutes, AUCs for NSI were 0.78 (95% CI, 0.72-0.84) for GFAP, 0.75 (95% CI, 0.68-0.81) for MAP-2, and 0.69 (95% CI, 0.63-0.75) for UCH-L1; and for CIEO, AUCs were 0.89 (95% CI, 0.85-0.93) for GFAP, 0.83 (95% CI, 0.78-0.87) for MAP-2, and 0.77 (95% CI, 0.72-0.82) for UCH-L1. Combining the biomarkers was no better than GFAP alone for all outcomes. At GFAP of 30 pg/mL within 30 minutes, sensitivity for CT lesions was 98.1% (95% CI, 94.9%-99.4%) and specificity was 34.4% (95% CI, 27.2%-42.2%). GFAP levels greater than 6200 pg/mL were associated with high risk of NSI and CIEO. In this cohort study of prehospital patients with TBI, GFAP, UCH-L1, and MAP-2 measured within 30 and 60 minutes of injury were significantly associated with traumatic intracranial lesions and diffuse injury severity on CT scan, 24-hour NSI, and 7-day CIEO. GFAP was the strongest independent marker associated with all outcomes. This study sets a precedent for the early utility of GFAP in the first 30 minutes from injury in future clinical and research endeavors.

Challenges to Integrating Portable Magnetic Resonance Imaging Systems in Emergency Medical Service Ambulances for Stroke Care

This qualitative study explores the barriers to incorporating portable MRI devices in ambulances, enabling effective patient triage and potentially reducing time to thrombolytic treatment for stroke. Using a digital twin of the patient handling process, semi-structured interviews were conducted with 11 paramedics and 7 neurologists from an emergency medical services system and a tertiary stroke care center. Thematic analysis of interview transcripts, guided by the Systems Engineering Initiative for Patient Safety framework, revealed key barriers: the need for specialized MRI operation skills, complex patient handling procedures, limited space, and the necessity for training and policy development. The study proposes solutions to address these challenges, aiming to facilitate the implementation of ambulance-based MRI systems for expedited stroke care. The findings contribute to understanding the factors influencing the adoption of advanced imaging technology in pre-hospital settings, ultimately improving patient outcomes by minimizing delays in stroke treatment.

Effect of Inter-Hospital Transfer on Mortality in Patients Admitted through the Emergency Department.

Background: Despite advancements in emergency medical systems, inter-hospital transfer (IHT) remains a critical component. Several studies have analyzed the impact of IHT on patient outcomes. Some studies have reported positive effects, indicating that transfers can improve patient prognosis. However, other studies have suggested that transfers may worsen outcomes. We investigated whether IHT is associated with in-hospital mortality. Methods: This retrospective observational study utilized data on patient outcomes from the National Emergency Department Information System (NEDIS) from 2016 to 2018, focusing on patients admitted to hospitals after visiting the emergency department (ED). The primary outcome was the in-hospital mortality rate. Results: This study included 2,955,476 adult patients admitted to emergency medical centers, with 832,598 (28.2%) undergoing IHT. The in-hospital mortality rate was significantly higher in the transfer group (6.9%) than in the non-transfer group (4.8%). Multiple logistic regression analysis revealed that IHT was an independent predictor of in-hospital mortality (adjusted odds ratio [aOR] 1.114, 95% confidence interval [CI] 1.101-1.128) after adjusting for variables. Sub-analysis indicated that higher severity scores, shorter symptom onset-to-arrival duration, and diagnoses of infectious or respiratory diseases were significantly associated with increased in-hospital mortality among transferred patients. Conclusions: This study identifies IHT as a significant factor associated with increased in-hospital mortality. Additionally, it suggested the need for policies to mitigate the risks associated with IHT, particularly in critically ill patients, those with the acute phase response, and those with infectious, genitourinary, and respiratory diseases.