Large Emergency Medical Services Research Articles

Identifying patients at imminent risk of out-of-hospital cardiac arrest during the Emergency Medical call: The views of call-takers

IntroductionThere is little research on the triage of patients who are not yet in cardiac arrest when the emergency call is initiated, but who deteriorate and suffer a cardiac arrest during the prehospital phase of care. The aim of this study was to investigate Emergency Operation Centre staff views on ways to improve the early identification of patients who are at imminent risk of cardiac arrest, and the barriers to achieving this. MethodsA qualitative interview and focus group study was conducted in two large Emergency Medical Services in England, United Kingdom. Twelve semi-structured interviews and one focus group were completed with Emergency Operations Centre staff. Data were analysed using reflexive thematic analysis. ResultsThree main themes were identified: The dispatch protocol and call-taker audit; Identifying and responding to deteriorating patients; Education, knowledge and skills. Barriers to recognising patients at imminent risk of cardiac arrest include a restrictive dispatch protocol, limited opportunity to monitor a patient, compliance auditing and inadequate education. Clinician support is not always optimal, and a lack of patient outcome feedback restricts dispatcher learning and development. Suggested remedies include improvements in training and education (call-takers and the public), software, clinical support and patient outcome feedback. ConclusionsEmergency Operation Centre staff identified a multitude of ways to improve the identification of patients who are at imminent risk of out-of-hospital cardiac arrest during the Emergency Medical Service call. Suggested areas for improvement include education, triage software, clinical support redesign and patient outcome feedback.

A Standardized Formulary to Reduce Pediatric Medication Dosing Errors: A Mixed Methods Study

Objective: We hypothesized that implementation of a Medical Control Guideline (MCG) with a standardized formulary (fixed medication concentrations) and pre-calculated medication dosages in a large emergency medical services (EMS) system would reduce pediatric dosing errors. To assess the effectiveness of the standardized formulary to reduce errors, we chose to evaluate midazolam administration for seizures, because it is the most frequently dosed medication by EMS for children, and seizures are a time-sensitive condition. The objective of this study was to compare: 1) frequency of midazolam dosing errors during the field treatment of pediatric seizures and 2) paramedic anxiety and confidence in dosing midazolam for pediatric seizures, before and after implementation of the MCG. Methods: In this mixed-methods study, we utilized the Los Angeles County EMS data registry to identify pediatric patients ≤14 years-old treated with midazolam for seizure. We defined a dosing error as outside the dose directed by the color code on the length-based resuscitation tape, or ±20% the weight-based midazolam dose when color code was absent. We compared dosing errors during a two-year period before and after implementation of the MCG with the standardized formulary in February 2017. We surveyed paramedics to assess their level of anxiety and confidence in dosing midazolam and conducted semi-structured interviews with 20 respondents to further explore its impact on paramedic practice. Results: There were 80 dosing errors in 569 patients treated post-formulary (14.1%) compared with 92 dosing errors in 497 patients treated pre-formulary (18.5%), risk difference −4.5% (95% CI −8.9 to 0.0), p = 0.049. Among 304 paramedic survey respondents who had experience with the formulary, anxiety decreased (p < 0.001) and confidence increased (p < 0.001) post-formulary. Paramedics expressed the challenges of pediatric calls, the benefits of the MCG with the standardized formulary, and the ongoing challenges of pediatric medication dosing. Benefits included simplifying paramedic tasks, increasing paramedic self-efficacy, facilitating provider communication, and improving patient care. Conclusion: Implementation of a MCG with standardized formulary and pre-calculated medication dosing by weight reduced pediatric medication dosing errors and increased paramedic confidence in pediatric medication dosing. It may have the potential to facilitate patient care through improved communications and task simplification.

Prehospital management of pediatric asthma patients in a large emergency medical services system.

Asthma is a common pediatric diagnosis for emergency medical services (EMS) transports, however there is a paucity of data on prehospital asthma management. The purpose of this study was to describe prehospital management of pediatric patients with suspected asthma exacerbation. We conducted a retrospective review of electronic medical records from 24 ground EMS agencies in Southwestern Pennsylvania between 1 January 2014 to 31 December 2017. We identified patients 2 to 17 years with documented wheezing, excluding those with suspected anaphylaxis. Patients with documented respiratory distress were classified as severe asthma. We report descriptive statistics of demographics, vital signs, and management including administration of medications and performance of procedures. Of 19 246 pediatric transports, 1078 (5.6%) patients had wheezing. Of these, 532 (49%) met criteria for severe asthma. Patients with severe asthma were more likely to be adolescents compared to those with nonsevere asthma (49.6% vs 6%; P < .001). While rates of intravenous methylprednisolone administration were higher in patients with severe asthma (68/532, 12.8%) compared to those with nonsevere asthma (13/546, 2.4%; P < .001), overall use of steroids was low (7.5%). Other therapies provided included albuterol (n = 699, 64.8%), ipratropium bromide (n = 271, 25.1%), and oxygen (n = 280, 26.0%). One hundred eighty patients (16.7%) received a peripheral IV line. Two patients (0.4%) were given continuous positive airway pressure. Approximately 6% of pediatric EMS transports are for asthma. Steroid usage was low in even those with severe asthma, representing an area of process improvement. These data provide a baseline to future research to identify interventions that may improve outcomes.

Association Between Early Intravenous Fluids Provided by Paramedics and Subsequent In-Hospital Mortality Among Patients With Sepsis

ImportanceEarly administration of intravenous fluids is recommended for all patients with sepsis, but the association of this treatment with mortality may depend on the patient’s initial blood pressure.ObjectiveTo test the association between early administration of intravenous fluids by paramedics and in-hospital mortality among patients with sepsis, accounting for patients’ initial blood pressure.Design, Setting, and ParticipantsCohort study in which multiple analyses were conducted using a 1-year (from April 1, 2015, to March 31, 2016) cohort of 1871 patients with sepsis who were transported to the hospital by paramedics from a large emergency medical services system in Alberta, Canada. Multivariable logistic regression and a propensity-matched analysis adjusting for baseline patient characteristics were used to minimize confounding by indication and test the association between early administration of intravenous fluids by paramedics and in-hospital mortality. Nonparametric additive regression was used to assess the association of early administration of intravenous fluids with prehospital and in-hospital treatment times.ExposuresIntravenous fluids administered by paramedics at the point of first contact and during transportation to the hospital.Main Outcomes and MeasuresThe primary outcome was in-hospital mortality. Secondary outcomes included prehospital and emergency department treatment times.ResultsA total of 1871 patients with sepsis were identified (955 women and 916 men; median age, 77 years [interquartile range, 64-85 years]), with an overall in-hospital mortality of 28.2% (n = 528). More than half of patients (1015 [54.2%]) received intravenous fluids from paramedics; the median volume provided was 400 mL (interquartile range, 250-500 mL). The association of intravenous fluids with mortality depended on the patient’s initial systolic blood pressure (range, 42-222 mm Hg; P < .001 for interaction). For example, in a typical patient with an initial systolic blood pressure of 100 mm Hg, intravenous fluids were associated with decreased mortality (odds ratio, 0.73; 95% CI, 0.56-0.95), but for a typical patient with the median initial systolic blood pressure of 125 mm Hg, intravenous fluids were not associated with in-hospital mortality (odds ratio, 1.41; 95% CI, 0.81-2.44). Similar results were obtained in the propensity-matched analysis. The administration of intravenous fluids was associated with increased prehospital time compared with patients who did not receive intravenous fluids (median difference, 3.2 minutes; 95% CI, 1.7-4.7 minutes) but was not associated with time to assessment in the emergency department (median difference, 2.4 minutes; 95% CI, –2.4 to 7.3 minutes).Conclusions and RelevanceIntravenous fluids provided by paramedics were associated with reduced in-hospital mortality for patients with sepsis and hypotension but not for those with a higher initial systolic blood pressure.

Procedure rates performed by emergency medicine residents: a retrospective review

BackgroundThe purpose of our study is to investigate rates of individual procedures performed by residents in our emergency medicine (EM) residency program. Different programs expose residents to different training environments. Our hypothesis is that ultrasound examinations are the most commonly performed procedure in our residency.MethodsThe study took place in an academic level I trauma center with multiple residency and fellowship programs including surgery, surgical critical care, trauma, medicine, pulmonary/critical care, anesthesiology and others. Also, the hospital provides a large emergency medical services program providing basic and advanced life support and critical care transport, which is capable of performing rapid sequence intubation. Each EM residency class, except for the first 2 months of the inaugural class, used New Innovations to log procedures. New Innovations is an online database for tracking residency requirements, such as procedures and hours. For the first 3 months, procedures were logged by hand on a log sheet. In addition, our department has a wireless electronic system (Qpath) for recording and logging ultrasound images. These logs were reviewed retrospectively without any patient identifiers.Actual procedures and simulation procedures were combined for analysis as they were only logged separately halfway through the study period. Procedures were summed and the average procedure rate per resident per year was calculated.ResultsIn total, 66 full resident years were analyzed. Overall, ultrasound was the most commonly performed procedure, with each resident performing 125 ultrasounds per year. Removing “resuscitations,” the second most common was endotracheal intubation, performed 28.91 times per year, and third most was laceration repair, which was performed 17.39 times per year.Our lowest performed procedure was thoracentesis, which was performed on average 0.11 times per resident per year.ConclusionsResidents performed a variety of procedures each year. Ultrasound examinations were the most frequent procedure performed. The number of ultrasound procedures performed may reflect the changing training landscape and influence future Accreditation Council of Graduate Medical Education requirements.

Dynamic ambulance dispatching: is the closest-idle policy always optimal?

We address the problem of ambulance dispatching, in which we must decide which ambulance to send to an incident in real time. In practice, it is commonly believed that the 'closest idle ambulance' rule is near-optimal and it is used throughout most literature. In this paper, we present alternatives to the classical closest idle ambulance rule. Most ambulance providers as well as researchers focus on minimizing the fraction of arrivals later than a certain threshold time, and we show that significant improvements can be obtained by our alternative policies. The first alternative is based on a Markov decision problem (MDP), that models more than just the number of idle vehicles, while remaining computationally tractable for reasonably-sized ambulance fleets. Second, we propose a heuristic for ambulance dispatching that can handle regions with large numbers of ambulances. Our main focus is on minimizing the fraction of arrivals later than a certain threshold time, but we show that with a small adaptation our MDP can also be used to minimize the average response time. We evaluate our policies by simulating a large emergency medical services region in the Netherlands. For this region, we show that our heuristic reduces the fraction of late arrivals by 18 % compared to the 'closest idle' benchmark policy. A drawback is that this heuristic increases the average response time (for this problem instance with 37 %). Therefore, we do not claim that our heuristic is practically preferable over the closest-idle method. However, our result sheds new light on the popular belief that the closest idle dispatch policy is near-optimal when minimizing the fraction of late arrivals.

Pediatric Intubation by Paramedics in a Large Emergency Medical Services System: Process, Challenges, and Outcomes

Pediatric intubation is a core paramedic skill in some emergency medical services (EMS) systems. The literature lacks a detailed examination of the challenges and subsequent adjustments made by paramedics when intubating children in the out-of-hospital setting. We undertake a descriptive evaluation of the process of out-of-hospital pediatric intubation, focusing on challenges, adjustments, and outcomes. We performed a retrospective analysis of EMS responses between 2006 and 2012 that involved attempted intubation of children younger than 13 years by paramedics in a large, metropolitan EMS system. We calculated the incidence rate of attempted pediatric intubation with EMS and county census data. To summarize the intubation process, we linked a detailed out-of-hospital airway registry with clinical records from EMS, hospital, or autopsy encounters for each child. The main outcome measures were procedural challenges, procedural success, complications, and patient disposition. Paramedics attempted intubation in 299 cases during 6.3 years, with an incidence of 1 pediatric intubation per 2,198 EMS responses. Less than half of intubations (44%) were for patients in cardiac arrest. Two thirds of patients were intubated on the first attempt (66%), and overall success was 97%. The most prevalent challenge was body fluids obscuring the laryngeal view (33%). After a failed first intubation attempt, corrective actions taken by paramedics included changing equipment (33%), suctioning (32%), and repositioning the patient (27%). Six patients (2%) experienced peri-intubation cardiac arrest and 1 patient had an iatrogenic tracheal injury. No esophageal intubations were observed. Of patients transported to the hospital, 86% were admitted to intensive care and hospital mortality was 27%. Pediatric intubation by paramedics was performed infrequently in this EMS system. Although overall intubation success was high, a detailed evaluation of the process of intubation revealed specific challenges and adjustments that can be anticipated by paramedics to improve first-pass success, potentially reduce complications, and ultimately improve clinical outcomes.

The Methodology of the Australian Prehospital Outcomes Study of Longitudinal Epidemiology (APOStLE) Project

This paper describes the methodology of a large emergency medical services (EMS) data linkage research project currently under way in the statewide EMS system of New South Wales, Australia. The paper is intended to provide the reader with an understanding of how linkage techniques can be used to facilitate EMS research. This project, the Australian Prehospital Outcomes Study of Longitudinal Epidemiology (APOStLE) Project, links data from six statewide sources (computer-assisted dispatch, EMS patient health care reports, emergency department data, inpatient data, and two death registries) to enable researchers to examine the patient's entire journey through the health care system, from the emergency 0-0-0 call to the emergency department and inpatient setting, through to discharge or death, for approximately 2.6 million patients transported by the Ambulance Service of New South Wales to emergency departments between June 2006 and July 2009. Manual, deterministic, and probabilistic data linkages are described, and potential applications of linked data in EMS research are outlined.

Abstract P321: Hospital Angioplasty Volumes and ST-Elevation Myocardial Infarction Patient Admission Patterns: Improvement in Florida from 2001-2007

Background: The ACC/AHA guidelines recommend percutaneous coronary intervention (PCI) at high-volume centers with at least 400 procedures per year for ST-elevation myocardial infarction (STEMI), but fewer than 25% of acute care hospitals in the US are PCI capable. In Florida, a statewide system for regional STEMI patient care does not yet exist, but some local STEMI care coalitions have formed. We examined trends over time in the percent of STEMI patients admitted to hospitals categorized by PCI volume. Methods: Using comprehensive statewide hospital discharge data, we classified 191 acute care hospitals according to annual PCI volume: no PCI capability (n=90), low-volume (1-199 PCIs; n=33) medium volume (200-399 PCIs; n=4) and high-volume (400+ PCIs; n=64). Hospital classifications were specific for a 3-month time window; therefore a single hospital's category could vary over time. We determined the percent of STEMI patients treated at each type of hospital for the first and second half of each year from 2001-2007. Results: From early 2001 to late 2007, the percent of STEMI patients treated at non-PCI capable hospitals declined from 31.0 to 7.9%, while the proportion at high-volume PCI centers rose from 58.3 to 72.3%. Low- and medium-volume hospitals typically accounted for &lt;15% of total patient volume but realized slight increases from 2001 to 2007. The percentage of STEMI patients seen at low-volume PCI hospitals rose from 6.6 to 8.7% from 2001-2007, and from 4.2% to 11.1% at medium-volume hospitals. No differences in the hospital admission trends were observed by race/ethnicity or gender. Conclusions: The pattern of STEMI care has changed substantially from 2001-2007 in Florida, with a greater proportion of patients seen at high-volume PCI hospitals and fewer than 10% admitted to non-PCI hospitals by 2007. These trends are likely due to implementation of STEMI protocols by many large emergency medical services (EMS) providers across the state and the positive impact of local STEMI care coalitions in some metropolitan areas. Further research is needed to determine if there has been increased STEMI patient awareness of the value of undergoing PCI at high-volume centers. A positive trend toward regionalized STEMI care appears to be in progress in Florida.

Prehospital Use of Continuous Positive Airway Pressure for Acute Severe Congestive Heart Failure

BackgroundThe utility of continuous positive airway pressure (CPAP) in the in-hospital treatment of congestive heart failure (CHF) is well established. Its exact role is less clear in the prehospital arena. ObjectiveTo describe the prehospital use of CPAP for patients presenting with acute severe heart failure in a large Emergency Medical Services system in New Jersey. MethodsRetrospective review of prehospital charts from January 1, 2005 to December 31, 2006 of patients treated for acute CHF. Inclusion criteria for eligibility for CPAP mask use were: respiratory rate > 25 breaths/min, labored and shallow breathing, bilateral rales, history of CHF, intact mental status, and prehospital clinical diagnosis of CHF. Data collected included demographics, vital signs, oxygen saturation (SaO2), need for endotracheal intubation (ETI), and complications. ResultsThere were 1306 charts reviewed; 387 patients met inclusion criteria. Of the 387, 149 patients had placement of CPAP (38.5%). The prehospital treatment times were (CPAP = 30 min; non-CPAP = 31 min; p < 0.01). The increase in SaO2 for the CPAP group (9%) vs. the non-CPAP group (5%) was statistically significant (p < 0.01). Systolic blood pressure (BP) reduction (CPAP [27.1 mm Hg], non-CPAP [19.9 mm Hg], p < 0.01), diastolic BP reduction (CPAP [14.1 mm Hg], non-CPAP [7.4 mm Hg], p < 0.01), heart rate reduction (CPAP [17.2 beats/min], non-CPAP [9.6 beats/min], p < 0.01), respiratory rate reduction (CPAP [5.63], non-CPAP [4.09], p < 0.01), and ETI reduction (CPAP [2.6%], non-CPAP [5.46%], p < 0.01), all were statistically significant. Adjunctive CHF treatments were similar between the groups. ConclusionThe use of CPAP for eligible patients with acute severe CHF seems to be feasible and beneficial. Large-scale randomized prospective prehospital studies are needed to validate these results.

Pre-hospital Use of Continuous Positive Airway Pressure (CPAP) for Acute Severe Congestive Heart Failure (CHF)

Objective: To describe the pre-hospital use of continuous positive airway pressure (CPAP) for patients presenting with acute severe congestive heart failure (CHF) in a large Emergency Medical Services (EMS) system. Methods: This study utilized a retrospective design of pre-hospital charts of patients treated by paramedics in the Monmouth and Ocean County EMS system for acute CHF. Inclusion criteria were placement of CPAP therapy by Mobile Intensive Care Unit protocol, respiratory rate (RR) > 25 breaths/min, labored and shallow breathing, bilateral rales, history of CHF, intact mental status, and pre-hospital diagnosis of CHF. Data collected included patient demographics, vital signs, oxygen saturation by pulse oximetry (SaO2), need for endotracheal intubation, and complications. All patients meeting inclusion criteria from January 1, 2005 to December 31, 2006 were included in this study. Results: A total of 1306 charts were reviewed; 387 patients met inclusion criteria. Of the 387, 149 patients had placement of CPAP (38.5%). When comparing patients that received CPAP to ones that did not, the out-of-hospital treatment times did not differ (CPAP = 30 min; non-CPAP = 31 min; p < 0.01); Adjunctive CHF treatment such as use of nitrates, diuretics, or morphine were similar between the two groups. The increase in post-treatment SaO2 was statistically significant (CPAP group 9% vs. non-CPAP 5%, p < 0.01). This was also true for systolic blood pressure (BP) reduction (CPAP 27.1 mm Hg, non-CPAP 19.9 mm Hg, p < 0.01), Diastolic BP reduction (CPAP 14.1 mm Hg, non-CPAP 7.4 mm Hg, p < 0.01), heart rate (HR) reduction (CPAP 17.2 beats/min, non-CPAP 9.6 beats/min, p < 0.01), as well as RR reduction (CPAP 5.63, non-CPAP 4.09, p < 0.01). Rate of pre-hospital intubation was higher in the non-CPAP group vs. the CPAP group (CPAP 2.6%, non-CPAP 5.46%, p < 0.01). Conclusion: The use of CPAP for eligible patients with acute severe CHF seems to be feasible and beneficial. Its use seems to result in improvement in oxygen saturation, improvement of vital signs, and decreased rates of pre-hospital intubation. Randomized prospective pre-hospital studies are needed to validate these results.

The experience of linking Victorian emergency medical service trauma data

BackgroundThe linking of a large Emergency Medical Service (EMS) dataset with the Victorian Department of Human Services (DHS) hospital datasets and Victorian State Trauma Outcome Registry and Monitoring (VSTORM) dataset to determine patient outcomes has not previously been undertaken in Victoria. The objective of this study was to identify the linkage rate of a large EMS trauma dataset with the Department of Human Services hospital datasets and VSTORM dataset.MethodsThe linking of an EMS trauma dataset to the hospital datasets utilised deterministic and probabilistic matching. The linking of three EMS trauma datasets to the VSTORM dataset utilised deterministic, probabilistic and manual matching.ResultsThere were 66.7% of patients from the EMS dataset located in the VEMD. There were 96% of patients located in the VAED who were defined in the VEMD as being admitted to hospital. 3.7% of patients located in the VAED could not be found in the VEMD due to hospitals not reporting to the VEMD. For the EMS datasets, there was a 146% increase in successful links with the trauma profile dataset, a 221% increase in successful links with the mechanism of injury only dataset, and a 46% increase with sudden deterioration dataset, to VSTORM when using manual compared to deterministic matching.ConclusionThis study has demonstrated that EMS data can be successfully linked to other health related datasets using deterministic and probabilistic matching with varying levels of success. The quality of EMS data needs to be improved to ensure better linkage success rates with other health related datasets.

Use of an impedance threshold device improves short-term outcomes following out-of-hospital cardiac arrest

Introduction: An impedance threshold device (ITD) has been developed for the treatment of cardiac arrest to augment circulation to the heart and brain during cardiopulmonary resuscitation (CPR). The ITD has ventilation timing lights that flash at 12 min −1 to discourage excessive ventilation rates. Hypothesis: Implementation of the ITD during conventional manual CPR in a large emergency medical services (EMS) system (Staffordshire, UK) is safe, feasible and will improve short-term survival. Methods: ITD use was implemented by the Staffordshire Ambulance Trust, which treats 1600 cardiac arrests per year with 90 advanced life support (ALS) units and an average response time of 6.3 min. During training, rescuers learned to use the ventilation timing lights to discourage hyperventilation. Rescuers applied the device after tracheal intubation. They were trained to allow the chest to recoil fully after each compression. Prospective ITD use in adults receiving conventional manual CPR for non-traumatic cardiac arrest was compared to matched historical controls receiving conventional manual CPR without inspiratory impedance. All received similar ALS care. The primary endpoint was admission to the emergency department (ED) alive following cardiac arrest. Chi-square, Fisher's exact and Kolmogorov–Smirnov tests were used for statistical analyses. Results: Survival (alive upon ED admission) in all patients receiving an ITD (61/181 [34%]) improved by 50% compared to historical controls (180/808 [22%]) ( P < 0.01). Survival in patients presenting in asystole tripled in the group receiving an ITD (26/76 [34%]) compared with historical controls (39/351 [11%]) ( P = 0.001). There were no significant adverse events. Conclusions: The ITD was used safely and effectively in a large, diverse EMS system and markedly improved short-term survival for adult patients in non-traumatic cardiac arrest.

Derivation of a Termination-of-resuscitation Guideline for Emergency Medical Technicians Using Automated External Defibrillators

To determine the association between characteristics of cardiac arrest and survival to hospital discharge following failed resuscitation by defibrillation-trained emergency medical technicians (EMT-Ds), and to propose an out-of-hospital termination-of-resuscitation (TOR) guideline for EMT-Ds. A 22-month retrospective review of 700 out-of-hospital primary cardiac arrest patients in a large emergency medical services (EMS) system who received exclusively EMT-D care. Seven hundred primary cardiac arrest patients were identified. Follow-up was obtained in 662 cases (94.6%). Of these, 36 (5.4%) achieved a return of spontaneous circulation (ROSC) prior to transport. Among the 626 patients who failed to achieve ROSC at any time, two (0.3%) survived to discharge. Multivariate analysis showed that ROSC at any time had the strongest association with survival [odds ratio (OR) 45.5; 95% confidence interval (95% CI) = 8.5 to 243.7]. A shock prior to transport (OR 6.9; 95% CI = 1.2 to 40.3) and cardiac arrest witnessed by EMS personnel (OR 4.4; 95% CI = 1.0 to 18.5) were also independently associated with survival. These variables were incorporated into a TOR guideline. The guideline was 100% sensitive (95% CI = 99.1 to 100) in identifying survivors and had 100% negative predictive value (95% CI = 75.3 to 100) for identifying nonsurvivors of out-of-hospital cardiac arrest in the study population. In this EMS system, cardiac arrest patients may be considered for out-of-hospital TOR following EMT-D resuscitation attempts when there has been no ROSC, no shock has been given, and the arrest was not witnessed by EMS personnel. These guidelines require prospective validation.

Prehospital evaluation of non-transported pediatric patients by a large emergency medical services system

1) To determine whether demographic characteristics of prehospital pediatric patients evaluated, but not transported, by emergency medical services (EMS) personnel were different than those of transported patients in a large metropolitan area, 2) to determine whether chart documentation for non-transported (NT) patients by EMS personnel varied among paramedic and ambulance units, and 3) to describe the most common complaints of pediatric non-transported patients. We conducted a cross-sectional study of children 12 years of age and less who were evaluated, but not transported, by EMS personnel over a 1-year period. We incorporated a nested case control study, comparing the demographic and presenting characteristics of the NT and transported children (eg, age, gender, ethnicity, and time of day). Among NT patients, significant elements of chart documentation as completed by personnel on paramedic versus ambulance units were compared. Chief complaints of the NT children were described. During the study period, 3057 patients met inclusion criteria for cases, and 12,302 met the criteria for controls. Non-transport was less common in the first two years of life, among Hispanic patients, and during the hours of midnight to 6 am. Among NT patients, personnel of paramedic units had significantly better documentation of contact with on-line medical command (OLMC) (52% vs. 33%) than did personnel of ambulance units. Injuries (27.7%), motor vehicle accidents (20.4%), and choking episodes (10.2%) were the most common complaints among NT patients. In this large metropolitan population, non-transport was less common in children under 2 years of age and during the early morning hours. Hispanic children were more likely to be transported. Ambulance units were significantly less likely than paramedic units to document contact with OLMC. Injuries were the most common complaints of pediatric NT patients.