Medical Services Agencies Research Articles

Abstract WP46: Patterns Of Emergency Medical Transport For Suspected Acute Stroke, Acute Myocardial Infarction, And Other Diagnoses During The Covid-19 Pandemic: A Retrospective Analysis Of A Large Hospital-based Emergency Medical Services (EMS) Agency

Introduction: During the initial peak of the COVID-19 pandemic, many centers globally reported a significant decrease in volumes of emergencies including acute stroke (AS) and acute myocardial infarction (AMI). While the reason for this remains unknown, pandemic-driven anxiety among patients may have resulted in unwarranted refusals to transport when deemed necessary by EMS (Emergency Medical Services) providers. We sought to study the impact of COVID-19 pandemic on the patterns of Emergency Medical transport (EMTr) and patient refusals to transport when serious medical conditions were suspected by EMS personnel. Methods: In this retrospective, observational study of Grady Health System’s EMS, we compared the rates of EMTr and refusals for adult patients with suspected diagnoses of AS, AMI, and other medical conditions in the first year of the pandemic (Y1, Mar 2020-Feb 2021) with the corresponding period in the year prior (Y0). We also compared the temporal trends for these variables across the different pandemic waves (1 st , Mar-May 2020; 2 nd , Jun-Aug 2020; 3 rd , Sep 2020-Feb 2021) with the corresponding periods in the year before. Results: Grady EMS responded to 207,888 calls in Y1 compared to 201,968 in Y0. The overall rate of refusals for all diagnoses was 15.5% in Y1 vs 14.1% in Y0, that for AS was 2.25% in Y1 vs 1.77% in Y0 and 7.5% in Y1 vs 5.67% in Y0 for AMI (Figure). Conclusion: There were more refusals in the first two waves of the pandemic. While refusals were higher for AS and AMI, this was not statistically significant. Our study provides valuable insight into the behavioral patterns of patients seeking emergency care during the pandemic and emphasizes a need for public education and more research.

Critical Factors in Planning a Pediatric Prehospital Airway Trial

Objective: The objective of this study was to assess factors influencing the design of a pediatric prehospital airway management trial, including minimum clinically significant differences for three clinical subgroups. Methods: We conducted a virtual consensus-conference among U.S. emergency medical services (EMS) agency medical directors and researchers in the Fall of 2020. This included (1) a preconference survey, (2) an interactive live videoconference, and (3) a postconference survey. Participants were identified through co-investigator relationships and by surveying “The Eagles,” a consortium of medical directors from large urban EMS systems and, subsequently, through follow up email contact based on survey responses. Results: Twenty-seven of the 34 (80%) EMS agencies we invited responded to the prewebinar survey. Of the 27 agencies, 27 (100%) use BMV, 19 (70%) use endotracheal intubation (ETI), 21 (78%) use supraglottic airways (SGA). SGA use included 14 (52%) who use the iGel, 8 (30%) who use the King laryngeal tube (LT), and 2 (7%) who use a laryngeal mask airway (LMA). Three agencies use more than one of the available SGAs. Twenty (74%) of the EMS agencies indicated they had access to an SGA suitable for pediatric patients, and 9 (33%) agencies have access to pediatric video laryngoscopy. The majority of agencies indicated that the minimum clinically significant difference for survival to change practice was 1% for cardiac arrest patients with a baseline survival assumption of 7%, 4% for respiratory failure with a baseline survival assumption of 73%, and 3% for trauma with a baseline survival assumption of 42%. Overall, these agencies responded that BVM vs. SGA is the most important comparison that would change their practice. Conclusions: This virtual consensus conference provided a new perspective on current airway management practice and identified specific factors likely to drive change in pediatric prehospital airway management. This information will be leveraged in future trial design to ensure impactful clinical trials.

Evaluation of Care Quality Related to Dietary Intake and Swallowing Functions of Residents at Long-Term Facilities in Japan

This study aimed to evaluate the quality of healthcare services pertaining to the dietary intake and swallowing functions of residents, nutrition management practices, and performance of residents at long-term care facilities. We investigated outcome indicators, such as changes in dietary intake and swallowing function levels of residents, and clarified which structural and process indicators were associated with the outcome indicators. This was a retrospective study, analyzing information on healthcare services from 1067 long-term care facilities during the fiscal year 2012, sampled from among those registered with the Welfare, Health and Medical Care Information Network of the Welfare and Medical Service Agency in Japan. Five outcome indicators were identified. Next, we examined the relationships between the outcome indicators and structural or process indicators using a multivariate linear regression model, adjusting for facility type. The findings showed how the five outcome indicators were used in long-term care facilities over a period of one year and determined the independent predictors of these outcome indicators. The amplification of dietary function 1 was associated with “assessment of oral functions using a feeding and swallowing assessment checklist every three months”, “holding care conferences related to ingestion and swallowing every three months”, and “maintaining a 1:2 ratio for meal-time assistants to residents”. To improve the quality of care, it is necessary to increase the number of staff (e.g., to provide meal assistance to residents) and to understand changes in the residents’ status through accurate assessment and monitoring.

Abstract 367: Factors That Influence Emergency Responder Treatment Versus Transport Decisions for Out-of-hospital Cardiac Arrest

Introduction: Emergency medical system factors that improve out-of-hospital cardiac arrest (OHCA) survival have not been well elucidated. This study explores factors important to decisions to transport patients before obtaining sustained return of spontaneous circulation (ROSC) in the field throughout the OHCA system of care. Choosing to treat versus transport is a complex decision and reflects various aspects of EMS care that may differ across agencies at different levels of performance. Methods: This sequential mixed-methods study used data from the Michigan Cardiac Arrest Registry to Enhance Survival (MI-CARES) for the years 2014—2017 to identify variation in OHCA outcomes across emergency medical services (EMS) agencies. We then sampled emergency medical stakeholders—dispatch, fire, police, EMS, and receiving emergency departments (EDs)—across nine EMS system sites of varied urbanicity: four high-survival, two intermediate-survival, and three low-survival based on a primary outcome of sustained ROSC with pulse upon ED arrival. To qualitatively explore variations in OHCA survival, we conducted key informant and focus group interviews at each site. Qualitative data were analyzed through combined rapid and rigorous analysis, with a focus on treat versus transport decisions in the Advanced Care link of the “chain of survival” within a broader system of care framework. Results: Key factors that weighed into OHCA treatment versus transport decisions pre-ROSC across all sites included: clearly defined roles and protocols, on-scene decision-making authority, distance to the hospital, level of training and expertise, resource availability with regard to personnel and equipment, and payment and reimbursement models. Conclusions: Recognizing the critical role of each link in the “chain of survival,” this study identified key factors that impact treat versus transport decisions from the perspective of EMS stakeholders. The next phase of this work will include validating the importance of the identified factors to OHCA survival through a statewide survey of EMS agencies in Michigan. The final product will be a toolkit of best practices to improve survival across U.S. communities.

A video session of produced by the Welfare And Medical Service Agency (WAM) Grant –

This video session demonstrates the practical method, which joint seminar presentations showed in maintaining physical function and overcoming disability. It is hoped that the simple implementation of the Takizawa method of rehabilitation will improve medical care, which has often been shown to be inefficient. First, we will describe the inefficiencies in the United States, Japan and our research showed. Next, I will show the present situation of effective rehabilitation, the rehabilitation of 30% of the bedridden elderly who regained their gait, and the scene of exercises performed.

Cleaner Production Quality Regulation Strategy of Pharmaceutical with Collusive Behavior and Patient Feedback

The quality of pharmaceuticals has always been a hot issue in the world, and it involves public health, economic development of countries, social stability, and national security. Cleaner production is a prerequisite for ensuring the quality of medicines. However, the various types of counterfeit pharmaceuticals and fake vaccines exposed in the recent years have revealed many problems, such as lacking government regulation, loose quality management of companies, illegal profit of medical service agencies, and failure of patient complaints. This paper’s two innovations are as follows: first, it not only considers the collusion between pharmaceutical companies and medical service agencies, but also introduces patient feedback to study drug quality regulation strategies from a microperspective; second, this paper constructs a tripartite evolutionary game model involving cleaner production pharmaceutical companies, medical service agencies, and the governments to analyze the evolutionary stability using the Lyapunov first rule. The results of the research show that, first, improvement of patient complaint rates can effectively curb collusive behavior and promote the stable improvement of cleaner production drug quality; second, the governments must impose sufficient fines on pharmaceutical companies to avoid a stable strategic combination of collusion; third, enhancing patient feedback can speed up the evolution of the stable choice of legitimate strategies by pharmaceutical companies and the medical service agencies; finally, the government reducing the strict regulation costs can increase the strict regulation rate employed in the evolution process and slow down the pace of evolution to loose regulation. In addition, the simulation analysis was carried out using Matlab 2017b, which verified the validity of the model and proved the practical meaning of countermeasures and suggestions for improving government quality regulation.

Safety and Quality of Care Evaluation in Japanese Long-Term Facilities Focused on the Activity Condition and Cognitive Function of Residents

Objective: Currently, standards for evaluating long-term care facilities do not exist in Japan. This study aimed to evaluate the quality of healthcare services in Japan’s long-term care facilities and identify the structural and process indicators associated with the facilities’ outcome indicators. Methods: This retrospective study assessed changes in residents’ abilities to participate in physical activities, their cognitive function, and their vulnerability to injuries. From 2012 to 2013, we collected information on the healthcare services at 1067 long-term care facilities registered with Japan’s Welfare, Health and Medical Care Information Network in the Welfare and Medical Service Agency. We examined 12 structural indicators, 26 process indicators, and 7 outcome indicators. We used multivariate linear regression models adjusted to analyze relationships between outcome indicators and structural or process indicators. Results: Residents’ activity and cognitive function indicators either improved by 80% - 90% or were maintained for one year. The Geriatric Functional Independence Measures, the Barthel Index, and holding conferences related to care were all considered activities of daily living. Three adverse events—tumbles and falls, behavioral problems, and aimless wandering or leaving the facility without permission—were factors that restricted residents’ behavior and number of residents per care staff member. Conclusions: Maintaining or improving levels of independence and cognition in daily living requires a care process system that enables ongoing monitoring of residents’ activities of daily living and cognitive functioning. Ensuring the safety of residents and improving the quality of care in long-term care facilities without securing adequate care staff are not possible.

Abstract 296: Quality Analysis of Cardiopulmonary Resuscitation From Two Emergency Medical Service Systems Using a Feedback Device

Background: High quality cardiopulmonary resuscitation (CPR) plays a critical role in the success of out-of-hospital resuscitation from sudden cardiac arrest (SCA). AHA guidelines provide protocol to achieve recommended targets for CPR quality metrics including chest compression fraction (CCF), percentage of chest compressions (CCs) with full chest recoil, CC rate and CC depth. Our objective was to report the CPR quality of two emergency medical services (EMS) agencies with different basic life support (BLS) CPR protocols. Methods: Data from 673 patients, 2015 to 2017, suffering out-of-hospital SCA were obtained from Philips FR3 AEDs. The Philips Q-CPR tool was used for real-time CPR feedback, and CC waveforms were recorded for retrospective CPR analysis using Philips Event Review Pro 5.0 and custom software. The two EMS systems had BLS protocol differences: Site 1(King County, WA, n = 93) applied a compression - ventilation ratio of 30:2, while Site 2 (Mecklenburg County, NC, n = 580) applied 200 compressions in each CPR interval and ventilations were performed during CCs. Analyses were performed comparing CPR metrics between sites and to AHA targets. Results: There were 3,460 minutes of resuscitation data analyzed, representing the initial phase of resuscitation prior to ALS. The proportion of cases with shocks was 21.5% (20 of 93) for site 1 and 16.9% (98 of 580) for site 2 (p = 0.3). Both sites achieved guideline metrics though there were statistical differences (Table 1). Compared to site 1, site 2 was associated with a higher CCF, faster CC rate, but less CC depth on average (p < 0.001). Conclusions: High quality CPR defined by AHA guidelines was achieved with both sites during the early phase of AED resuscitation though some differences were observed. Additional investigation should identify equipment, or rescuer characteristics that are important to consistently achieve high quality CPR and how the combination might be tailored to optimize individual patient outcome.

Racial and Ethnic Disparities in Emergency Medical Services Transport to EDs

The American College of Emergency Physicians states that emergency medical services (EMS) agencies should transport patients to the nearest emergency

An Overview of Chicago (Illinois USA) Marathon Prehospital Care Demographics, Patient Care Operations, and Injury Patterns.

Large-scale mass-sporting events are increasingly requiring greater prehospital event planning and preparation to address inherent event-associated medical conditions in addition to incidents that may be unexpected. The Bank of America Chicago Marathon (Chicago, Illinois USA) is one of the largest marathons in the world, and with the improvement of technology, the use of historical patient and event data, in conjunction with environmental conditions, can provide organizers and public safety officials a way to plan based on injury patterns and patient demands for care by predicting the placement and timing of needed medical support and resources. During large-scale events, disaster planning and preparedness between event organizers, Emergency Medical Services (EMS), and local, state, and federal agencies is critical to ensure participant and public safety. This study looked at the Bank of America Chicago Marathon, a significant endurance event, and took a unique approach of reviewing digital runner data retrospectively over a five-year period to establish patterns of medical demand geographically, temporally, and by the presenting diagnoses. Most medical complaints were musculoskeletal in nature; however, there were life-threatening conditions such as hyperthermia and cardiac incidents that highlight the need for detailed planning, coordination, and communication to ensure a safe and secure event. The Chicago Marathon is one of the largest marathons in the world, and this study identified an equal number of participants requiring care on-course and at the finish line. Most medical complaints were musculoskeletal in nature; however, there were life-threatening conditions such as hyperthermia and cardiac incidents that highlight the need for detailed planning, multi-disciplined coordination, and communication to ensure a safe and secure event. As technology has evolved, the use, analysis, and implementation of historical digital data with various environmental conditions can provide organizers and public safety officials a map to plan injury patterns and patient demands by predicting the placement and timing of needed medical support, personnel, and resources.

Injured Older Adults Transported by Emergency Medical Services: One Year Outcomes by POLST Status

Background: Advance care planning documents, including Physician Orders for Life-Sustaining Treatment (POLST), are intended to guide care near end of life, particularly in emergency situations. Yet, research on POLST during emergency care is sparse. Methods: A total of 7,055 injured patients age ≥ 65 years were transported by 8 emergency medical services (EMS) agencies to 23 hospitals in Oregon. We linked multiple data sources to EMS records, including: the Oregon POLST Registry, Medicare claims data, Oregon Trauma Registry, Oregon statewide inpatient data, and Oregon vital statistics records. We describe patient and event characteristics by POLST status at time of 9-1-1 contact, subsequent changes in POLST forms, and mortality to 12 months. Results: Of 7,055 injured older adults, 1,412 (20.0%) had a registered POLST form at the time of 911 contact. Among the 1,412 POLST forms, 390 (27.6%) specified full orders, 585 (41.4%) limited interventions, and 437 (30.9%) comfort measures only. By one year, 2,471 (35%) patients had completed POLST forms. Among the 4 groups (no POLST, POLST-full orders, POLST-limited intervention, POLST-comfort measures), Injury Severity Scores were similar. Mortality differences were present by 30 days (5.0%, 4.6%, 8.0%, and 13.3%, p < 0.01) and were greater by one year (19.5%, 23.9%, 35.4%, and 46.2%, p < 0.01). Conclusions: Among injured older adults transported by ambulance in Oregon, one in 5 had an active POLST form at the time of 9-1-1 contact, the prevalence of which increased over the following year. Mortality differences by POLST status were evident at 30 days and large by one year. This information could help emergency, trauma, surgical, inpatient, and outpatient clinicians understand how to guide patients through acute injury episodes of care and post-injury follow up.

Abstract 118: The Epidemiology of Airway Management Following Pediatric Out-of-Hospital Cardiac Arrest in the United States

Introduction: Bag mask ventilation (BMV) has been associated with improved survival following out of hospital cardiac arrest (OHCA), however advanced airway placement remains part of pre-hospital protocols for many emergency medical services (EMS) agencies. Hypothesis: To characterize airway management for pediatric OHCA and assess whether BMV alone vs. BMV plus advanced airway (supraglottic airway or tracheal intubation) is associated with neurologically favorable survival. Methods: Analysis of the Cardiac Arrest Registry to Enhance Survival database. Inclusion criteria were age ≤ 18 years, non-traumatic OHCA from 2013 through 2017, resuscitated by EMS. To adjust for covariate imbalance, propensity score matching and entropy balancing were utilized; variables included age category, sex, bystander CPR, and shockable rhythm. The primary outcome was favorable neurologically favorable survival defined as a cerebral performance category scale of 1 or 2. Results: Of 5241 cardiac arrests, 2588 (49.3%) had BVM and 2653 (50.6%) had advanced airway placement. The majority 5118 (97.7%) were resuscitated by agencies using both BMV and advanced airways. Advanced airway placement was more common in older children compared to infants, arrests with bystander CPR, in white and Hispanic children, witnessed arrests, arrests with a shockable rhythm, and AED use (Table). Neurologically favorable survival was significantly higher with BMV compared to advanced airways in bivariate analysis (11.4% vs. 5.7%, p&lt;0.001). In multivariable analysis, advanced airway placement was associated with lower neurologically favorable survival (adjusted proportion 4.9% vs. 13.5% BVM, OR 0.21, 95% CI 0.17, 0.28). These results were robust on propensity analysis 3.0% advanced airway vs.11.9% BMV (OR 0.18, 95% CI 0.14, 0.25), and entropy balance 5.9% advanced airway, 15.0% for BMV (OR 0.28, 95% CI 0.22). Conclusion: In pediatric OHCA, advanced airways are placed in half of cardiac arrests where resuscitation is attempted. Advanced airway, compared to BMV alone management, is associated with lower neurologically favorable survival.

Challenges in Statewide Implementation of a Prehospital Evidence-Based Guideline: An Assessment of Barriers and Enablers in Five States

Background: Individual states, regions, and local emergency medical service (EMS) agencies are responsible for the development and implementation of prehospital patient care protocols. Many states lack model prehospital guidelines for managing common conditions. Recently developed national evidence-based guidelines (EBGs) may address this gap. Barriers to statewide dissemination and implementation of model guidelines have not been studied. The objective of this study was to examine barriers and enablers to dissemination and implementation of an evidence-based guideline for traumatic pain management across 5 states. Methods: This study used mixed methods to evaluate the statewide dissemination and implementation of a prehospital EBG. The guideline provided pain assessment tools, recommended opiate medication dosing, and indications and contraindications for analgesia. Participating states were provided an implementation toolkit, standardized training materials, and a state-specific implementation plan. Outcomes were assessed via an electronic self-assessment tool in which states reported barriers and enablers to dissemination and implementation and information about changes in pain management practices in their states after implementation of the EBG. Results: Of the 5 participating states, 3 reported dissemination of the guideline, one through a state model guideline process and 2 through regional EMS systems. Two states did not disseminate or implement the guideline. Of these, one state chose to utilize a locally developed guideline, and the other state did not perform guideline dissemination at the state level. Barriers to state implementation were the lack of authority at the state level to mandate protocols, technical challenges with learning management systems, and inability to track and monitor training and implementation at the agency level. Enablers included having a state/regional EMS office champion and the availability of an implementation toolkit. No participating states demonstrated an increase in opioid delivery to patients during the study period. Conclusion: Statewide dissemination and implementation of an EBG is complex with many challenges. Future efforts should consider the advantages of having statewide model or mandatory guidelines and the value of local champions and be aware of the challenges of a statewide learning management system and of tracking the success of implementation efforts.

Out-of-Hospital Research in the Era of Electronic Health Records

Conducting out-of-hospital research is unique and challenging and requires tracking patients across multiple phases of care, using multiple sources of patient records and multiple hospitals. The logistics and strategies used for out-of-hospital research are distinct from other forms of clinical research. The increasing use of electronic health records (EHRs) by hospitals and emergency medical services (EMS) agencies presents a large opportunity for accelerating out-of-hospital research, as well as particular challenges. In this study, we describe seven key aspects of designing and implementing out-of-hospital research in the era of EHRs: (1) selection of research sites, (2) defining the patient population, (3) patient sampling and sample size calculations, (4) EMS data, (5) hospital selection, (6) handling missing data, and (7) statistical analysis. We use examples from a recent prospective out-of-hospital cohort study to illustrate these topics, including lessons learned.

Compulsory Use of the Backboard is Associated with Increased Frequency of Thoracolumbar Imaging

Background: Backboards have been shown to cause pain in uninjured patients. This may alter physical exam findings, leading emergency department (ED) providers to suspect a spinal injury when none exists resulting in additional imaging of the thoracolumbar spine. New York had previously employed a “Spinal Immobilization” protocol that included compulsory backboard application for all patients with suspected spinal injuries. In 2015, New York instituted a new “Spinal Motion Restriction” protocol that made backboard use optional for these patients. The objective of this study was to determine if this protocol change was associated with decreased backboard utilization and ED thoracolumbar spine imaging. Methods: This was a retrospective before-and-after chart review of subjects transported by a single emergency medical services (EMS) agency to one of four EDs for emergency calls dispatched as motor vehicle collisions (MVC). EMS and ED data were included for all calls within a 6-month interval before and after the protocol change. The protocol change was implemented in the second half of 2015. Subject demographics, backboard use, and spine imaging were reviewed for the intervals January–June 2015 and January–June 2016. Results: There were 818 subjects in the before period and 796 subjects in the after period. Subjects were similar in terms of gender, age and type of MVC in both periods. A backboard was utilized for 440 (54%) subjects in the before period and 92 (12%) subjects in the after period (p < 0.001). ED thoracic spine imaging was performed on 285 (35%) subjects in the before period, and 235 (30%) subjects in the after period (p = 0.02). ED lumbar spine imaging was performed for 335 (41%) subjects in the before period, and 281 (35%) subjects in the after period (p = 0.02). Conclusion: A shift from a spinal immobilization protocol to a spinal motion restriction protocol was associated with a decrease in backboard utilization by EMS providers and a decrease in thoracolumbar spine imaging by ED providers.

9-1-1 Triage of Non-Traumatic Chest Pain: Association with Hospital Diagnosis

Objective: Chest pain is one of the most common reasons people seek emergency care—and one of the most critical. In the United States, chest pain is the second most common reason for emergency department (ED) visits. A patient's primary complaint of “chest pain” may reflect a broad range of underlying causes; therefore, it is important that emergency medical service (EMS) agencies gain a thorough understanding of these cases, beginning with the initial management of chest pain in the 9-1-1 center. The primary objective of this study was to compare hospital-confirmed patient discharge diagnoses to all calls handled by emergency medical dispatchers (EMDs) using the Chest Pain/Chest Discomfort (Non-Traumatic) Chief Complaint Protocol. Methods: The retrospective descriptive study utilized emergency medical dispatch, EMS, and hospital datasets, collected at two emergency communication centers in North America, from January 1, 2013 to December 31, 2014. Patients who were dispatched using the Chest Pain/Chest Discomfort Chief Complaint Protocol and matched to hospital datasets were included. The primary outcome was the number and percentage of cases classified as ischemic heart disease (IHD), other cardiac-related conditions, or non-cardiac-related conditions associated with chest pain. We also evaluated the distribution of causes of chest pain across demographic indicators and dispatch determinants. Results: 3,007 cases were identified as “chest pain” at dispatch for which corresponding hospital records were identified. Cases in the study were obtained by linking EMS/Hospital and Emergency Medical Dispatch datasets. Of these cases, 47.1% (n = 1,417) were due to cardiac-related causes of chest pain, 61.5% of which were Ischemic Heart Disease (IHD), while the rest had other cardiac-related causes. Of the IHDs, 32.1% were Acute Myocardial Infarction (AMI). Conclusions: Underlying causes of non-traumatic chest pain reported to 9-1-1 demonstrate a wide range of etiologies, with a mix similar to that of chest pain patients in several other healthcare settings, including hospital emergency departments. Most IHD events are triaged by EMDs to the (highest) DELTA priority level, while the CHARLIE level captures nearly all of the remaining IHD cases.

An evaluation of pre-hospital emergency medical systems for suspected ST-elevation myocardial infarction in Colorado

ABSTRACTObjectives: Patients presenting with ST-elevation myocardial infarction (STEMI) benefit from rapid cardiac reperfusion therapy. Emergency medical service (EMS) agencies can improve patient outcomes by calling STEMI alerts to the receiving facility. The aim of this study was to evaluate the use of pre-hospital activation systems for suspected ST-elevation myocardial infarctions (STEMI) throughout Colorado.Methods: A cross sectional, survey design was utilized to collect all data from EMS agencies in Colorado. A univariable logistic regression model was used to identify factors predictive of an agency reporting that they utilize a STEMI activation protocol.Results: 84.5% [95% CI: 78.3 to 90.7%] of agencies included indicate that they utilize a STEMI activation protocol. Based on the logistic regression analysis, the number of EMT employees was significantly associated with whether or not an agency indicates that they utilize a STEMI activation protocol. For every 10% increase in the number of EMTs employed by an EMS agency, there was a 3.0 [95% CI: 1.5 to 6.0, p = 0.0012] fold increase in the odds of the agency indicating they utilize a STEMI activation protocol.Conclusions: Our study provides evidence that larger agencies are more likely to utilize a STEMI activation protocol. In areas without a STEMI system of care, improvements in smaller agencies that cover more ground (with longer transport times) should be the focus for protocol implementation. Based on the current prevalence of such training, competency based training in reading ST-elevations on ECG should be considered by EMS agencies.

Impact of System-Wide King LT Airway Implementation on Orotracheal Intubation

Objectives: Orotracheal intubation is a key component of prehospital airway management and success rates are dependent on procedural experience. Supraglottic airway devices are increasingly being used in the prehospital setting. As a result, paramedics may have fewer opportunities for performing intubation, limiting their proficiency in the procedure. We aimed to determine the trends in intubation versus supraglottic airway use over an 8 year period. We also aimed to determine the association between system-wide introduction of King LT guidelines and ETI success rates. Methods: We performed a retrospective observational study of 37 Emergency Medical Services (EMS) agencies in a 10 county region of Southwestern Pennsylvania. Cases between January 1, 2005 and December 31, 2012 were included if an advanced airway procedure was performed. We determined trends in advanced airway placement and compared the proportion of cases with first pass intubation success before and after the King LT was introduced and promoted by statewide protocol starting in 2007. Use of airway devices before and after King LT implementation were presented using descriptive statistics and compared using Pearson's Chi-square or Fishers Exact test as appropriate. We compared first pass success rate of orotracheal intubation between study periods using multivariable logistic regression, controlling for other factors that may impact success of orotracheal intubation (year, EMS agency, age category, traumatic injury, and cardiac arrest). Results: There were 712 cases of orotracheal intubation before and 2,835 cases after introduction of the King LT. The proportion of cases ultimately managed with orotracheal intubation before and after 2007 decreased from 72.3% (95% CI 68.9-75.6%) to 67.1% (95% CI 65.3-68.8%) (p = 0.007). In the multivariable analysis, success of orotracheal intubation was not associated with implementation of the King LT airway (OR 1.02, 95% CI 0.74-1.41). Conclusion: Fewer patients with advanced airway management received orotracheal intubation since introduction of the King LT. In spite of this modest change in airway management, there has not been a change in orotracheal intubation success rate since introduction of this supraglottic device as a primary or rescue airway in this regional EMS setting.

Abstract 235: Prehospital STEMI Protocol Administering Aspirin, Ticagrelor, and Heparin Reduces Reperfusion Times

Background: Emergency Medical Service (EMS) agencies serving large rural areas have not traditionally administered Ticagrelor or Heparin IV in the pre-hospital setting for STEMI patients who are ultimately transferred for Primary PCI. A recent international study demonstrated the safety of administering Ticagrelor by EMS. We hypothesized that allowing EMS to administer medications normally given in the hospital setting could be beneficial. A protocol was implemented with the goal being that if the ECG is Positive, give Aspirin, Ticagrelor, and Heparin, also known as (EPATH). Methods: Data was collected on 31 consecutive STEMI activations from a large rural area, from both the regional hospital and by the local EMS agency, prior to implementation of the EPATH Protocol, and 31 consecutive STEMI activations after implementing the EPATH Protocol. Data was stored on a Microsoft Excel spreadsheet, and analyzed using the calculation functions available within the database. Findings: Multiple STEMI performance Metrics improved, including the following: The median first EMS contact to Percutaneous Coronary Intervention (PCI) time was reduced by 28 minutes. The median 911 call to PCI time was reduced by 21 minutes. The rural referral hospital median door to PCI time was reduced by 22 minutes. Conclusion: After implementing the EPATH protocol in a large rural area, which allowed EMS to administer Prehospital Aspirin, Ticagrelor, and Heparin for STEMI, we observed an improvement in multiple STEMI performance metrics, including a 28 minute median reduction in first EMS contact to PCI time. Further research is warranted.

Practice of Outpatient Rehabilitation of the Takizawa Method and Motivative Exercise

We studied the new Rehabilitation intervention technique (Takizawa method), which realized re-acquirement of walking from bedridden of 30% or more of the bedr1) idden elderly by the grant of Japanese National Foundation, Association for Technical Aids in 2000 . An increase in the elderly population, including the disabled, demands the expansion of social security-related expenditures, which confers an unbearable burden to the following generation. These “Aging Crises” would give rise to the collapse of the social system. The social security-related expenditures are enabled to reduce by getting knowledge of the way for disabled persons to live independently from to live with depending on caregivers. That elderly people live independently means the reduction of social security costs. It leads to preventing the collapse of the social system. Then, we studied “the formulation study of the community rehabilitation network by the advanced age disabled person oneself”. by the grant of the Incorporated Administrative Agency(IAA), Welfare And Medical Service Agency（WAM）. The purpose for us was to make everyday life of as much as disabled elderly become independent possible but care reliance2) . We clarified the significant difference on improvement in a degree of independent living degree . At this time, my facility was only one which has already introduced the Takizawa method from starting time but the facility in Fujisawa. Therefore, we made a video of our reality of rehabilitation enforcement and contributed it to the test implementation facility. We used it simultaneously as a report to the WAM of the research grant offer IAA. This video is created with two of information. One shows the everyday training situation of this institution and the other does it at home. All of the people who appears in the video are users of members in this facility and one is a patient of the Fujisawa one. All of them agreed with photography and televising. Please look at the video as an example of Takizawa method rehabilitation enforcement.