EMS Run Research Articles

Acceleration of opioid-related EMS runs in the spring of 2020: The National Emergency Medical Services Information System data for 2018–2020

BackgroundState- and county-level reports suggest that the COVID-19 pandemic exacerbated the opioid crisis. We examined US national trends of nonfatal opioid overdose in 2020 in comparison to pre-COVID years 2018–2019. MethodsWe used National Emergency Medical Services Information System (NEMSIS) data to conduct a temporal analysis from 2018 to 2020. Opioid-related EMS run was defined using five scenarios of naloxone administration. To determine annual patterns and slope inflection points, we used the Prophet model of the time series analysis. Linear slopes and their 95% confidence intervals (CIs) were calculated for pre-stay-at-home (pre-SaH) and SaH periods in 2020 and compared to the slopes during the same time in 2018–2019. Three cut-points for SaH start were considered: March 19, 24, and 29. ResultsWe identified 91,065, 144,802, and 242,904 opioid-related EMS runs in 2018–2020, respectively. In 2020, opioid-related runs increased in January-June, with a pronounced acceleration in March, which coincides with the stay-at-home (SaH) orders. In both 2018 and 2019, opioid-related runs increased in January-August without the spring acceleration. In 2020, weekly increases (95% CI) during SaH for all examined cut-points were significantly greater than in pre-SaH: 18.09 (16.03–20.16) vs. 6.44 (3.42–9.47) for March 19, 17.77 (15.57–19.98) vs. 4.85 (2.07–7.64) for March 24, 18.03 (15.68–20.39) vs. 4.97(2.4–7.54) for March 29. No significant difference was found between these periods in 2018–2019. ConclusionsThe acceleration of opioid-related EMS runs during the SaH period of 2020 suggests that EMS data may serve as an early warning system for local health jurisdictions to deploy harm reduction/prevention resources.

Abstract P173: Stroke Mimics in Patients With Discordance Between VAN Determination by EMS and Experienced Stroke Teams

Background: Discordance between pre-hospital (EMS) and experienced stroke team (ED) determination of Vision-Aphasia-Neglect (VAN) assessment threatens VAN’s utility in routing patients with large vessel occlusion (LVO) to thrombectomy centers. Discordance may be due to a fluctuating exam in the setting of stroke or stroke mimics. We sought to evaluate the rate and etiology of stroke mimics in patients with discordant versus concordant VAN assessments. Methods: The EMS run reports were linked with stroke registries from three CSCs in New Orleans, Louisiana from 2/2019-7/2019. EMS-VAN was compared to that of CSCs in all patients who presented within 6 hours of last seen normal. Stroke mimics were compared in patients with concordance vs discordance between VAN determination by EMS and experienced stroke teams. Results: EMS documented VAN in 63.2% of stroke codes brought to CSCs. Concordance was 66.9%; the k, CI was 0.35, 0.20 - 0.50. The proportion of stroke mimics was largest in concordant VAN negative patients (64.4%) with seizures and altered mental status (23.7% each) the most frequent causes. The proportion of stroke mimics was smallest in concordant VAN positive patients (17.3%) with seizures as the most frequent cause (44.4%). Similar high frequency of seizure mimic was determined in VAN discordant patients; seizure accounted for 47.8% of discordant mimics and 20% of all discordant patients. Discussion: VAN assessment as performed by trained EMS providers had only fair correlation with experienced stroke team members. The rapidly evolving exam of patients with seizures may explain a significant portion of stroke mimics among patients whose exams change between EMS and ED stroke team assessments.

Abstract P503: Inter-Rater Reliability and Validity of Pre-Hospital Vision-Aphasia-Neglect Assessment for Triage of Patients With Suspected Large Vessel Occlusion: Analysis of Data From Three Comprehensive Stroke Centers in New Orleans (VAN NOLA Study)

Background: The Louisiana pre-hospital routing protocol for acute stroke patients is modeled after Mission Lifeline Stroke. The Vision-Aphasia-Neglect (VAN) assessment was adopted for large vessel occlusion (LVO) screening after education was provided to pre-hospital providers (EMS). We sought to establish the inter-rater reliability (IRR) of VAN between EMS and experienced stroke team members at comprehensive stroke centers (CSC) and assessed validity of EMS and CSC VAN. Methods: The EMS run reports were linked with stroke registries from three CSCs in New Orleans, Louisiana from 2/2019-7/2019. EMS-VAN was compared to that of CSCs in all patients who presented within 6 hours of last seen normal. Validity analyses were performed comparing EMS-VAN and CSC-VAN with radiologically confirmed (CTA) LVO as the gold standard. Kappa (k) and 95% confidence interval (CI) are reported as a measure of IRR. Likelihood of VAN non documentation by EMS and VAN discordance between EMS and CSC was determined as Odds Ratios (OR) and CI. Results: EMS documented VAN in 63.2% of stroke codes brought to CSCs. Advanced age (OR, CI: 1.02, 1.01 - 1.04) and pre-existing disability (OR, CI: 1.53, 1.32 - 1.76) increased the likelihood that VAN was not documented by EMS. Both EMS and CSC VAN assessments were documented for 166 patients Concordance was 66.9%; the k, CI was 0.35, 0.20 - 0.50. Discordance was more likely when EMS assessed a patient as positive than when assessed as negative, but no clinical predictor of discordance was identified. The accuracy of EMS-VAN was 60.2% for distinguishing LVO positive and negative patients; CSC-VAN was 65.5% accurate. Discussion: VAN assessment as performed by trained EMS providers had only fair correlation with experienced stroke team members. Further education is needed to increase the inter-rater reliability and accuracy of the VAN assessment in order to improve its utility in meeting the goal of routing patients with LVO to the thrombectomy centers.

Epidemiology and outcome of emergency medical service witnessed out-of-hospital-cardiac arrest by prodromal symptom: Nationwide observational study

BackgroundAlthough emergency medical service– (EMS-) witnessed out-of-hospital-cardiac arrest (OHCA) has a high survival rate and potential for prevention of progression to cardiac arrest, its characteristics and prodromal symptoms are not well known. The purpose of this study was to investigate the epidemiologic characteristics and outcome of EMS-witnessed OHCA by focusing on its prodromal symptoms. MethodsPopulation-based observational study was conducted for resuscitation-attempted EMS-witnessed adult OHCAs between 2012 and 2017. The prodromal symptoms were categorized according to the patients’ chief complaints, which were checked in the EMS run sheets: no prodromal, respiratory, cardiac, neurologic, gastrointestinal (GI), or other symptom. If multiple complaints were checked, the patient was assigned to multiple groups. The OHCA characteristics and time from EMS scene arrival to cardiac arrest were investigated by symptom groups and presumed etiology of OHCA. The age- and sex-standardized survival rate and good neurological outcome rate were calculated for each symptom group. ResultsOf 12,969 eligible OHCAs, 5246 (40.5%) had prodromal symptoms, 1410 (10.9%) had respiratory symptoms, 505 (3.9%) had cardiac symptoms, 1987 (15.3%) had neurologic symptoms, and 541 (4.2%) had GI symptoms. Of 9361 patients with cardiac etiology, 3522 (37.6%) had prodromal symptoms, and patients with cardiac symptoms had the best rate of survival to discharge and good neurological outcome (42.7% and 38.2%, respectively). Of 3424 patients with non-cardiac etiology, 1651 (48.2%) had prodromal symptoms, and patients with respiratory symptoms had the best survival outcomes (19.0%). The age- and sex-standardized rates of good neurological outcome were better in patients with prodromal symptoms than in patients with cardiac etiology and no prodromal symptoms (cardiac, 30.4%; neurologic, 9.8%; respiratory, 8.9%; GI 7.3%; and no prodromal symptoms, 6.8%). EMS-witnessed OHCA occurred earlier in patients with no prodromal symptoms (5–9 min from EMS arrival) than in those with prodromal symptoms (10–14 min). ConclusionAbout 40% of EMS-witnessed OHCA patients had prodromal symptom before cardiac arrest. In cardiac etiology, patients with cardiac symptoms had the best rate of survival to discharge and good neurological outcome. Promoting public awareness of prodromal symptoms is needed to earn time for preparedness and prevention of progression to cardiac arrest.

Transfer of essential AED information to treating hospital (TREAT)

BackgroundDefibrillation in out-of-hospital cardiac arrest (OHCA) is increasingly performed by using an Automated External Defibrillator (AED). Therefore presence of a shockable rhythm is recurrently only documented by the AED. However, AED-information is rarely available to the treating physician. PurposeTo determine (1) how often a shockable rhythm was recorded only in the AED; (2) if so, how often information that a shockable rhythm had been present reached the physician. MethodsData on OHCA patients with (presumed) cardiac cause with an AED connected in the years 2012–2014 (Study period 1) and 2016 (Study period 2) in the Amsterdam Resuscitation Study (ARREST) database were collected. We determined how often only the AED had defibrillated. In these patients, we retrospectively analyzed EMS run sheets and hospital discharge letters to determine if a shockable rhythm and/or AED use was correctly noted. In Study period 2, we prospectively contacted the physicians to study whether AED defibrillation was known. ResultsIn Study period 1, of 2840 OHCA CPR attempts with (presumed) cardiac cause, 1521 (54%) patients had a shockable rhythm, with 356 patients (13%) receiving AED defibrillation only. Of these patients, 11 hospital discharge letters (4%) contained no information about a shockable rhythm. In Study period 2, 125/1128 patients (11%) received AED defibrillation only; of these, in two cases the shockable rhythm was unknown by the physician. ConclusionIn 11–13% of OHCAs, a shockable rhythm is only seen on the AED-ECG. Adequate transfer to the physician of vital AED-information is essential but not always accomplished.

Abstract TP245: Variance in Ems Run Times by Receiving Hospital for Stroke Patients in San Diego County

Background: Emergency Medical Services (EMS) play an important role as initial providers after stroke. Few data are available that capture Stroke Receiving System and EMS response and transport data. We used a stroke registry from a community of 3.3 million residents, 18 stroke receiving centers, and 19 ground transporting advanced life support EMS agencies to evaluate EMS response time, scene time, and transport times. Our aim was to inform the stroke community about duration of EMS care and guide future prehospital interventions. Methods: We included all cases from the San Diego County Stroke Registry arriving by EMS with associated computer automated dispatch (CAD) record and base hospital record (BHR) from July 2017 through December 2018. Records were linked on the EMS incident number, reviewed for accuracy. We analyzed EMS response, scene, transport and total run times (enroute to arrival) by receiving hospital. Results: Between July 2017 and December 2018 2,376 EMS patients were transported to 18 hospitals. Volume per hospital ranged from 11 to 483 patients over the study period. Mean (±SD) response time was 7.0 (±3.7) minutes, range: 5.3 to 9.3 minutes between hospitals. Mean (±SD) scene time was 13.1 (±5.2) minutes, range: 10.5 to 15.0 minutes between hospitals. Transport time averaged 13.8 (±7.7) minutes, range: 8.3 to 23.8 minutes between hospitals (IQR=8.5-17.9). The mean (±SD) total EMS run time was 33.8 (±10.8) minutes, range: 26.4 to 44.9 minutes between hospitals (IQR=26.4-39.9). Conclusion: Only minor variations in EMS response and scene times were observed across the Stroke Receiving Centers. However, transport time showed greater variation and contributed to the differences in total EMS run times. Many systems had short transport times, limiting prehospital interventions. Next steps include studying factors contributing to transport time variation to inform prehospital care and triage decisions of possible stroke patients to optimize transport times.

Abstract TP256: Ems Run Times by Weekday vs. Weekend For Stroke Patients in San Diego County

Background: Emergency Medical Services (EMS) is important as the initial responder, very little data examines EMS response and transport to hospital diagnosis. Understanding differences between weekday and weekend is informative for resource and staff planning. Using a countywide registry, we evaluated differences in EMS response times on weekdays and weekends and in-hospital treatment. Methods: We included EMS San Diego County Stroke Registry cases with a computer automated dispatch (CAD) and base hospital record (BHR) from July 2017 through December 2018; linked on EMS incident number. We analyzed EMS response, scene and transport time by weekday and weekend for all cases and cases with last known normal (LKN) to EMS enroute time < 6 hours. Hospital arrival to tPA and to embolectomy therapy (EVT) time was analyzed for this subgroup. Weekend was defined as Friday 1800 through Monday 0600. Results: Of 2,376 cases, 726 (30.6%) arrived during weekends. Weekend mean (±SD) response time was 6.7 (±3.4) minutes (min); 7.1 min (±3.9) on weekdays. Mean weekend scene time was 12.8 (±5.1) min, 13.2 (±5.3) min on weekdays (p=.18). Transport time was 13.2 (±7.6) min on weekends, 14.1 (±7.8) min on weekdays (p=.01). There were 1,190 cases with LKN to EMS enroute time < 6 hours, 379 arrived on weekends (31.8%). Mean (±SD) response time was 6.6 (±3.4) min on weekends, 7.2 (±3.9) min on weekdays; weekend scene time 12.1 (±4.5) min, weekday scene time 12.2 (±4.9); weekend transport time 12.2 (±6.6) min, weekday transport time 12.7 (±7.4) min. Of this group, 378 received tPA, 126 (33.3%) on the weekend. Mean (±SD) weekend arrival to tPA was 53.6 (±22.2) min; 56.0 (±32.1) min on weekdays (p=.39). 100 cases received EVT, 39 on a weekend. Mean (±SD) weekend arrival to EVT was 2.1 (±0.6) hours; weekdays 1.9 (±0.8) hours (p=.13). Conclusion: One in three patients arrived at the hospital on weekends. EMS response time and scene time did not differ, while transport time on the weekend was shorter, although this may not be clinically significant. This may be attributed to traffic volume and patterns during these times. However, among patients with shorter LKN time and patients receiving tPA no difference in EMS times was seen. Overall acute stroke transfer times did not differ across weekends and weekdays.

An Assessment of the EMS Drug Overdose to Death Pathway from 2011 to 2017

An Assessment of the EMS Drug Overdose to Death Pathway from 2011 to 2017

Abstract 33: FAST-ED Based Pre-Hospital Stroke Triage System Improves Endovascular Treatment Times, Especially off Hours

Introduction: Acute stroke outcomes depend on timely reperfusion. In March 2017, the Fire Officers Association of Miami-Dade (FOAMD) implemented the Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale. Those with a score ≥ 4 bypass other centers for a comprehensive stroke center (CSC) and those with a score ≥ 6 also have the interventional team activated from the field. We analyzed the impact of this initiative on volume, treatment times, outcomes, and distance traveled from scene. Methods: All stroke cases brought to Baptist Hospital of Miami by FOAMD during March 2016 through February 2018 were analyzed, which included a year before and after FAST-ED implementation. Treatment times were compared on vs. off hours and to those with a FAST-ED score ≥6. We used the FAST-ED score documented on the EMS run sheet and a calculated score based on the initial NIHSS. Results: A total of 1153 patients met criteria. Of these, 761 (67%) were coded as stroke (ischemic, hemorrhagic, or TIA), and 235 (20%) underwent reperfusion treatments. Age, sex, race/ethnicity, initial NIHSS, distance traveled, length of stay, door to needle time, and 90 day mRS were comparable between periods (Table). Scale compliance was 85%. Concordance rate of ±1 point between FOAMD and calculated score was 53%. Compared to the previous year, door to groin times (DTG) improved by 17 min (p<0.01) overall, by 25 min (26%) (p<0.001) off-hours only, and by 33 min (31%) (p<0.05) off-hours and calculated FAST-ED ≥ 6. Discussion: The FAST-ED initiative led to faster DTG times. The highest impact is for off-hours with field activation. Only 1 out of 3 activations led to endovascular treatment.

Use of Intranasal Naloxone by Basic Life Support Providers

Study Objectives: Intranasal delivery of naloxone to reverse the effects of opioid overdose by Advanced Life Support (ALS) providers has been studied in several prehospital settings. In 2006, in response to the increase in opioid-related overdoses, a special waiver from the state allowed administration of intranasal naloxone by Basic Life Support (BLS) providers in our city. This study aimed to determine: 1) if patients who received a 2-mg dose of nasal naloxone administered by BLS required repeat dosing while in the emergency department (ED), and 2) the disposition of these patients. Methods: This was a retrospective review of patients transported by an inner-city municipal ambulance service to one of three academic medical centers. We included patients aged 18 and older that were transported by ambulance between 1/1/2006 and 12/12/2012 and who received intranasal naloxone by BLS providers as per a state approved protocol. Site investigators matched EMS run data to patients from each hospital's EMR and performed a chart review to confirm that the patient was correctly identified and to record the outcomes of interest. Descriptive statistics were then generated. Results: A total of 793 patients received nasal naloxone by BLS and were transported to three hospitals. ALS intervened and transported 116 (14.6%) patients, and 11 (1.4%) were intubated in the field. There were 724 (91.3%) patients successfully matched to an ED chart. Hospital A received 336 (46.4%) patients, Hospital B received 210 (29.0%) patients, and Hospital C received 178 (24.6%) patients. Mean age was 36.2 (SD 10.5) years and 522 (72.1%) were male; 702 (97.1%) were reported to have abused heroin while 21 (2.9%) used other opioids. Nasal naloxone had an effect per the prehospital record in 689 (95.2%) patients. An additional naloxone dose was given in the ED to 64 (8.8%) patients. ED dispositions were: 507 (70.0%) discharged, 105 (14.5%) admitted, and 112 (15.5%) other (e.g., left against medical advice, left without being seen, or transferred). Conclusions: Only a small percentage of patients receiving prehospital administration of nasal naloxone by BLS providers required additional doses of naloxone in the ED and the majority of patients were discharged.

LO082: EMS response to police use of force events: periods of personal and professional risk in prehospital care

Introduction: This study provides an estimate of the number of EMS calls related to police use of force events that involve struggling, intoxicated and/or emotionally distressed patients. We hypothesized there would be under-reporting of EMS risk by paramedic agencies due to lack of standardized reporting of police events by EMS services and lack of a common linked case number between prehospital agencies in Canada. Methods: Data were collected during a multi-site, prospective, consecutive cohort study of police use of force in 4 Canadian cities using standardized data forms. Use of force was defined a priori and the application of handcuffs was not considered a force modality. Inclusion criteria: all subjects ≥ 18 years of age involved in a use of force police-public encounter. We defined risk to EMS as the presence of police- and/or paramedic- assessments of violent or struggling subjects on the scene. Three separate data forms (police-report of use of force, EMS encounter, and Emergency Department (ED) visit) were linked in the study by unique ID. When police-reported EMS was activated, investigators hand searched the EMS service reports at the relevant agencies for matching call sheets. Results: From Jan 2010 to Dec 2012, we studied 3310 consecutive public-police interactions involving use of force above simple joint lock application. Subjects were male (86%) with a mean age of 33 yrs; 85% were assessed by police as emotionally disturbed, intoxicated with drugs and/or alcohol or a combination of those. 45% were violent at the scene. Police-reported EMS attendance in 24% (809/3310) of use of force events, of which only 43% (349/809) of EMS run sheets were available. In events with violent subjects, EMS transported 51% to ED compared to 35% by police transport (chi=79.7, p=0.00). Conclusion: We identified periods of professional and physical risk to paramedics attending police use of force events and found that risk significantly underrepresented in EMS data. Paramedical training would benefit from policy and procedures for response to police calls and the violent patient, the majority of whom are struggling. A common linked case number in prehospital care would enable more specific quantification of the risk for EMS providers involved in police events.

Abstract T P340: Delays in Seeking Medical Attention in Intracerebral Hemorrhage

Background: Intracerebral hemorrhage (ICH) is associated with early neurological deterioration and death. Prior studies showed that delays in seeking medical attention may occur among minorities. In this study we investigated the factors affecting time from symptom onset to ER arrival (TOA) in a race/ethnic enriched population. Methods: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) is a prospective study of spontaneous ICH. Baseline characteristics, presenting symptoms, first contact (911 vs. ER vs. primary physician), ICH volume, location and intraventricular extension, insurance status, GCS at presentation, and TOA were collected. Data was analyzed using generalized linear models and Spearman’s rank correlations. TOA was natural log transformed and a multivariate model was developed using backward elimination (P-value=0.05). Results: A total of 1158 subjects were enrolled; 28 were excluded due to lack of TOA. Of the 1,030 included 59% were men with 24% whites, 41% blacks, and 35% Hispanics. Mean age was 61±15 years, mean Glasgow Coma Scale (GCS) at presentation was 12.4±3.7 (median=15), and median TOA was 431 min (interquartile range 106-820). Location of ICH was 56% deep, 28% lobar, 8% cerebellum, and 5% brainstem. Approximately 29% of subjects had no medical insurance, 36% had medicare, 18% medicaid, 36% private insurance, and 1% VA insurance. In univariate analysis women, use of 911, EMS run, different presenting symptoms, lobar and deep location, and low GCS were associated with shorter TOA. In multivariate model only women (p=0.05), GCS (p=0.04), use of 911 (p<0.001), EMS run (p<0.001), and weakness and dysarthria as presenting symptoms remained significant. Ethnicity was not a significant predictor (p=0.79). These variables explain 23.3% of the variation in TOA. Conclusion: Ethnicity and insurance status did not affect time to presentation. Women, use of 911, EMS run, weakness and lower GCS were associated with shorter TOA in ICH. Increased education in target populations with higher incidence of ICH such as minorities on stroke signs/symptoms and use of 911 may expedite access to medical care. Further studies are needed to determine the impact of TOA on outcome.

Dispatcher-assisted bystander cardiopulmonary resuscitation in a metropolitan city: A before–after population-based study

BackgroundThe goal of this study was to determine the effects of dispatcher-assisted bystander cardiopulmonary resuscitation (DA-CPR) on outcomes of out-of-hospital cardiac arrest (OHCA). MethodsAll EMS in a metropolitan city with a population of 10 million are dispatched by a single, centralized, and physician-supervised center. Data on patients with adult OHCA with cardiac etiology were collected from the dispatch center registry and from EMS run sheets and hospital medical record review from 2009 to 2011. A standardized DA-CPR protocol (aligned with the 2010 AHA guidelines) we implemented as an intervention in January 2011. The end points were survival to discharge, good neurological outcome, and bystander CPR rate. Multivariate logistic analysis was used to compare between intervention group (2011) and historical control group (2009–2010). ResultsOf 8.144 eligible patients, bystander CPR was performed for the patients in 5.7% (148/2600) of cases in 2009, 6.7% (190/2857) in 2010, and 12.4% (334/2686) in 2011 (p<0.001). The survival to discharge rates was 7.1% (2009), 7.1% (2010), and 9.4% (2011) (p=0.001). Good neurological outcomes occurred in 2.1% (2009), 2.0% (2010), and 3.6% (2011) of cases (p<0.001). The adjusted ORs (95% CIs) for survival to discharge compared with 2009 were 1.33 (1.07–1.66) in 2011 and 1.12 (0.89–1.41) in 2010. The adjusted ORs (95% CIs) for good neurological outcomes were 1.67 (1.13–2.45) in 2011 and 1.13 (0.74–1.72) in 2010. ConclusionsAn EMS intervention using the DA-CPR protocol was associated with a significant increase in bystander CPR and an improved survival and neurologic outcome after OHCA.

Rapid epinephrine administration improves early outcomes in out-of-hospital cardiac arrest

IntroductionEarly administration of epinephrine (Epi) improves outcomes in animal models of cardiac arrest, but there is limited time-dependent clinical data regarding its benefit. ObjectiveOur objective was to assess whether timing of Epi administration was associated with improved outcomes after out of hospital cardiac arrest (OHCA). MethodsWe performed a retrospective analysis of a cardiac arrest database from a suburban EMS system from November 2005 to April 2011. Data was abstracted from EMS run sheets, including drug treatment, route and timing of drug administration, and other Utstein variables. Our primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes measured were survival to hospital admission and discharge. For analysis, data were dichotomized according to timing of Epi administration: early Epi group (defined as 911 call to Epi administration of ≤10min) and late Epi group (>10min). Further, exploratory analyses were conducted looking at subgroups sorted by initial rhythm and whether the arrest was witnessed. Wilcoxon rank sum tests, chi-square tests, 95% confidence intervals, and multi-variable regression were used for statistical analysis. ResultsWe reviewed 809 patients from study communities: 123 patients were excluded, leaving a sample size of 686 for study analysis. The mean time from 911-Epi was 14.3±5.5min, with 155 (22.6%) receiving early Epi. Key arrest and treatment characteristics were similar between groups. Patients who received early Epi were more likely to have ROSC (32.9% vs. 23.4%, OR 1.59 (1.07, 2.38)), however, no significant increase in survival to admission or discharge was observed. Patients with an initial rhythm of PEA had an increased rate of ROSC (48.6% vs. 21.5%, OR 3.45 (1.56, 7.62)) but not survival to discharge (5.9% vs. 2.6%), OR 2.35 (0.38, 14.7) with early Epi. In a multivariable analysis of bystander witnessed arrests, early Epi was associated with a higher rate of ROSC (OR 3.20 (1.75, 5.88) but not survival to discharge (OR 1.48 (0.50, 4.36)). No improvement in ROSC or secondary outcomes was noted in patients with other arrest rhythms or un-witnessed arrest with Early Epi. ConclusionsWithin the limitations of our study, this data suggests improved rates of ROSC with early Epi administration during OHCA resuscitation, but this study lacks adequate sample size to demonstrate impact on survival to discharge. Large prospective trials are needed to further delineate the benefit of early Epi administration in OHCA.

Abstract 230: Epidemiology and Outcomes of Emergency Medical Services-Assessed Out-of-Hospital Cardiac Arrest in Korea: A Nationwide Observational Study from 2006 to 2010

Background The goal of this study is to better understand the epidemiologic features and the patient-community-emergency medical service (EMS)-hospital factors affecting outcomes of out-of-hospital cardiac arrest (OHCA). Methods and Results This study was performed in an EMS system with a single-tiered basic-to-intermediate service level and approximately 900 destination hospitals for eligible OHCA cases. A nationwide OHCA database including demographic, Utstein, EMS, and hospital factors and outcomes was constructed using EMS run sheets of eligible cases transported by 119 EMS ambulances and followed by medical record review for 2006 to 2010. Cases with unknown outcome were excluded. The primary end points were survival to discharge. The epidemiologic characteristics of OHCA were described and adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated for main outcome, adjusting for potential predictors. There were 97,291 EMS-assessed OHCAs excluding 14,798 cases because the medical records were not available (N=10,626) and the survival outcomes were unknown (N=4,172). Of these, 73,826 (75.9%) OHCAs were resuscitation attempted by EMS. The survival to discharge was 3.0% for EMS-assessed (3.3% for cardiac origin vs. 2.3% for non-cardiac origin), 3.6% for EMS-treated (4.0% for cardiac vs. 2.7% for non-cardiac), and 20.9% for cardiac origin with shockable rhythm. The drowning, intoxication, and asphyxia induced OHCAs had statistically better survival rates than cardiac origin. The odds for survival to discharge are significantly lower for elderly, asystole as primary ECG, OHCA with cardiac origin occurred in winter or 6PM to midnight, un-witnessed, no bystander cardiopulmonary resuscitation, OHCA with longer EMS response, and being transported to lower level of ED. Conclusions In this nationwide cohort study from 2006 to 2010, the standardized incidence rate increased 46.3 in 2006 to 52.0 per 100,000 person-years for EMS-assessed OHCA and overall survival rate was 3.0%. Potential factors for poor outcome were systemically identified in individual, community, EMS, and hospital chain.

Language Barriers as a Reported Cause of Prehospital Care Delay in Minnesota

Objective. Although anecdotal reports exist, the frequency of language barriers encountered between EMS providers andpatients/families in the prehospital environment remains unknown. The purpose of this study was to determine the frequency of EMS provider-reported perceived delays in care due to language barrier andto characterize the nature of calls involved.Methods. Retrospective analysis of the Minnesota State Ambulance Reporting system (MNSTAR) database, a mandated statewide EMS data collection tool. All EMS run reports submitted between January 1, 2004, andJune 30, 2005, were reviewed to identify instances of reported treatment delay secondary to a language barrier.Results. During the 18-month study period, 629,738 patient encounter reports were submitted to MNSTAR, of which 2,052 identified treatment delays secondary to language. The rate of language barrier care delays in the state of Minnesota is 3.3 per 1,000 prehospital patient encounters.Conclusion. EMS responses troubled by delays in care secondary to language barriers represent a small percentage of total runs in Minnesota. However, approximately 1,370 cases per year occur.

A Paramedic Peer-Review Quality Assurance Audit

AbstractIntroduction:A daily EMS audit was performed to assess whether a paramedic peer review audit would improve the quality of documentation and radio communications in cases transported to a single receiving facility.Methods:Prehospital EMS run sheets and run tapes were reviewed for adherence to standards developed for the county EMS system. Items evaluated were run sheet documentation of care and paramedic radio presentation. Checklists were used and multiple parameters evaluated for each case. Two periods, 1987–88 and 1989 were compared to evaluate the effectiveness of this system. Care rendered by a total of 106 paramedics was evaluated. Confidence intervals of 0.95 were calculated on the differences between groups. Practicing paramedics audited 63% of the days in 1987–88 and 80% in 1989. Data from each case were tabulated and a profile, average deficiencies per run calculated for each paramedic.Results:A total of 4175 run sheets and tapes were audited for the period 1987–88 with an average of deficiencies/run of 0.27, and for 1989 a total of 1872 run sheets and tapes were reviewed with a deficiency/run rate of 0.21, indicating a statistically significant improvement (0.95 CI= 0.02, 0.08). Twelve paramedics were not auditors in 1987–88, but audited in 1989. Their deficiencies/run decreased from 0.13 to 0.08Conclusion:A peer review audit in this system appears to be effective in improving documentation and radio performance. Performance also improved when paramedics served as auditors.

Motor vehicle damage documentation: Failure of EMS run reports compared to photographs using a vehicle damage score : Hunt, RC, Brown, RL, Cline, KA, Krohmer, JR, McCabe, JB, Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, North Carolina, USA

Motor vehicle damage documentation: Failure of EMS run reports compared to photographs using a vehicle damage score : Hunt, RC, Brown, RL, Cline, KA, Krohmer, JR, McCabe, JB, Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, North Carolina, USA