Regional Emergency Medical Services System Research Articles

The Correlation between COVID-19 Hospitalizations and Emergency Medical Services Responses for Time-Sensitive Emergencies during the COVID-19 Pandemic

Objective COVID-19 has had significant secondary effects on health care systems, including effects on emergency medical services (EMS) responses for time-sensitive emergencies. We evaluated the correlation between COVID-19 hospitalizations and EMS responses for time-sensitive emergencies in a large EMS system. Methods This was a retrospective study using data from the Los Angeles County EMS Agency. We abstracted data on EMS encounters for stroke, ST-elevation myocardial infarction (STEMI), out-of-hospital cardiac arrest (OHCA), and trauma from April 5, 2020 to March 6, 2021 and for the same time period in the preceding year. We also abstracted daily hospital admissions and censuses (total and intensive care unit [ICU]) for COVID-19 patients. We designated November 29, 2020 to February 27, 2021 as the period of surge. We calculated Spearman’s correlations between the weekly averages of daily hospital admissions and census and EMS responses overall and for stroke, STEMI, OHCA, and trauma. Results During the study period, there were 70,616 patients admitted for confirmed COVID-19, including 12,467 (17.7%) patients admitted to the ICU. EMS responded to 899,794 calls, including 9,944 (1.1%) responses for stroke, 3,325 (0.4%) for STEMI, 11,207 (1.2%) for OHCA, and 114,846 (12.8%) for trauma. There was a significant correlation between total hospital COVID-19 positive patient admissions and EMS responses for all time-sensitive emergencies, including a positive correlation with stroke (0.41), STEMI (0.37), OHCA (0.78), and overall EMS responses (0.37); and a negative correlation with EMS responses for trauma (-0.48). ICU COVID-19 positive patient admissions also correlated with increases in EMS responses for stroke (0.39), STEMI (0.39), and OHCA (0.81); and decreased for trauma (-0.53). Similar though slightly weaker correlations were found when evaluating inpatient census. During the period of surge, the correlation with overall EMS responses increased substantially (0.88) and was very strong with OHCA (0.95). Conclusion We found significant correlation between COVID-19 hospitalizations and the frequency of EMS responses for time-sensitive emergencies in this regional EMS system. EMS systems should consider the potential effects of this and future pandemics on EMS responses and prepare to meet non-pandemic resource needs during periods of surge, particularly for time-sensitive conditions.

Impact of temporary closures of emergency departments during the COVID-19 outbreak on clinical outcomes for emergency patients in a metropolitan area.

BackgroundDuring the early phase of the coronavirus disease 2019 (COVID-19) outbreak, many emergency departments (EDs) were exposed to COVID-19 and were temporarily closed according to national protocol of Korea. We aimed to evaluate the effect of concurrent and recurrent temporary closures of EDs on the clinical outcomes of patients who visited EDs during the COVID-19 outbreak.MethodsThis cross-sectional study used a nationwide emergency patient database. Patients who visited one of the 46 EDs in Daegu and Gyeongbuk between January 21 and April 14, 2020 were included. The main exposure variable was the first medical contact (ED visit or 119 call to emergency medical services (EMS)) during closure of at least one ED. There were 25 temporary closures of six Level-1 and Level-2 EDs between February 18 and March 17, 2020. We constructed a dataset by performing bidirectional crossover matching and conducted a conditional logistic regression analysis where the primary outcome was in-hospital mortality.ResultsOf the 94,360 eligible study participants, 36,327 were classified into the non-EMS-use group and 10,116 were classified into the EMS-use group. In-hospital mortality rates were 2.0% and 1.6% for the temporary-closure and no-closure groups in the non-EMS-use group (p-value, 0.03) and 8.7% and 7.4% in the EMS-use group (p-value, 0.02), respectively. In the conditional logistic analysis for in-hospital mortality, the odds ratios (95% confidence intervals) of the temporary-closure group compared the no-closure group were 1.22 (1.03–1.44) among the non-EMS-use group and 1.23 (1.04–1.46) among the EMS-use group.ConclusionThe temporary closures of EDs due to the unpredicted COVID-19 exposure resulted in an increase in emergency patients' in-hospital mortality rates irrespective of whether they used EMS. Preparing regional EMS systems to cope with new outbreaks is essential to protect the safety of all citizens.

Utility of Glucose Testing and Treatment of Hypoglycemia in Patients with Out-of-Hospital Cardiac Arrest

Objective: Many emergency medical services (EMS) protocols for out-of-hospital cardiac arrests (OHCA) include point-of-care (POC) glucose measurement and administration of dextrose, despite limited knowledge of benefit. The objective of this study was to describe the incidence of hypoglycemia and dextrose administration by EMS in OHCA and subsequent patient outcomes. Methods: This was a retrospective analysis of OHCA in a large, regional EMS system from 2011 to 2017. Patients ≥18 years old with non-traumatic OHCA and attempted field resuscitation by paramedics were included. The primary outcomes were frequency of POC glucose measurement, hypoglycemia (glucose <60 mg/dl), and dextrose/glucagon administration (treatment group). The secondary outcomes included field return of spontaneous circulation (ROSC), survival to hospital discharge (SHD), and survival with good neurologic outcome. Results: There were 46,211 OHCAs during the study period of which 33,851 (73%) had a POC glucose test performed. Glucose levels were documented in 32,780 (97%), of whom 2,335 (7%) were hypoglycemic. Among hypoglycemic patients, 41% (959) received dextrose and/or glucagon. Field ROSC was achieved in 30% (286) of hypoglycemic patients who received treatment. Final outcome was determined for 1,714 (73%) of the hypoglycemic cases, of whom 120 (7%) had SHD and 66 (55%) had a good neurologic outcome. Of the 32,780 patients with a documented POC glucose result who were identified as hypoglycemic, only 27 (0.08%) received field treatment, and survived to discharge with good neurologic outcome. 48 (6%) of patients in the treatment group had SHD vs. 72 (8%) without treatment, risk difference −2.0% (95%CI −4.4%, 0.4%), p = 0.1. Conclusion: In this EMS system, POC glucose testing was common in adult OHCA, yet survival to hospital discharge with good neurologic outcome did not differ between patients treated and untreated for hypoglycemia. These results question the common practice of measuring and treating hypoglycemia in OHCA patients.

Weather and temporal models for emergency medical services: An assessment of generalizability

Emergency medical services (EMS) response volume has been linked to weather and temporal factors in a regional EMS system. We aimed to identify if models of EMS utilization incorporating these data are generalizable through geographically disparate areas in the United States. We performed a retrospective analysis of EMS dispatch data from four regions: New York City, San Francisco, Cincinnati, and Marin County for years 2016-2019. For each model, we used local weather data summarized from the prior 6 h into hourly bins. Our outcome for each model was EMS dispatches as count data. We fit and optimized a negative binomial regression model for each region, to estimate incidence rate ratios. We compared findings to a prior study performed in Western Pennsylvania. We included 5,940,637 EMS dispatches from New York City, 809,405 from San Francisco, 260,412 from Cincinnati, and 77,461 from Marin County. Models demonstrated consistency with the Western Pennsylvania model with respect to temperature, season, wind speed, dew point, and time of day; both in terms of direction and effect size when expressed as incidence rate ratios. Precipitation was associated with increasing dispatches in the New York City, Cincinnati, and Marin County models, but not the San Francisco model. With minor differences, regional models demonstrated consistent associations between dispatches and time and weather variables. Findings demonstrate the generalizability of associations between these variables with respect to EMS use. Weather and temporal factors should be considered in predictive modeling to optimize EMS staffing and resource allocation.

A Tribute to N. Genell Lee

A Tribute to N. Genell Lee

Temporal Trends and Future Predictions of Regional EMS System Utilization Using Statistical Modeling.

Trends in utilization of Emergency Medical Services (EMS) systems can be used to extrapolate future use of an EMS system, which will be valuable for the budgeting and planning of finances and resources. The best model for incorporation of seasonal and regional fluctuations in utilization to predict future utilization is unknown. Authors aimed to trend patterns of utilization in a regional EMS system to identify the needs of a growing population and to allow for a better understanding of how the EMS system is used on a basis of call volume and frequency of EMS transportation. The authors then used a best-fitting prediction model approach to show how the studied EMS system will be used in future years. Systems data were retrospectively extracted by using the electronic medical records of the studied EMS system and its computer-assisted dispatch (CAD) database from 2010 through 2017. All EMS dispatches entering the system's 9-1-1 public service access point were captured. Annual utilization data were available from 2010 through 2017, while quarterly data were available only from 2013 through 2017. The 9-1-1 utilization per capita, Advanced Life Support (ALS) utilization per capita, and ALS cancel rates were calculated and trended over the study period. The methods of prediction were assessed through a best-fitting model approach, which statistically suggested that Additive Winter's approach (SAS) was the best fit to determine future utilization and ALS cancel rates. Total 9-1-1 call volume per capita increased by 32.46% between 2010 and 2017, with an average quarterly increase of 0.78% between 2013 and 2017. Total ALS call volume per capita increased by 1.93% between 2010 and 2017. Percent ALS cancellations (cancelled en route to scene) increased by eight percent between 2010 and 2017, with an average quarterly increase of 0.42% (2013-2017). Predictions to end of 2019 using Additive Winter's approach demonstrated increasing trends in 9-1-1 call volume per capita (R2=0.47), increasing trends of ALS utilization per capita (R2=0.71), and increasing percent ALS cancellation (R2=0.93). Each prediction showed increasing future trends with a 95% confidence interval. The authors demonstrate paramount per capita increases of 9-1-1 call volume in the studied ALS system. There are concomitant increases of ALS cancellations prior to arrival, which suggests a potential burden on this regional ALS response system.

Critical Medication Shortages: Effective Strategies to Maintain Continuous Medication Availability for Emergency Medical Services

Objective: Critical shortages of generic injectable medications are an ongoing challenge for Emergency Medical Services (EMS) systems. Mitigation strategies have been proposed to address the issue, but a limited amount of data exists quantifying the scope of the problem or describing strategies being used to ensure access to essential medications for prehospital care. In this study, we sought to quantify specific medication shortages and to determine the most frequently employed mitigation strategies to maintain medication availability in a large, regional EMS system. Methods: A survey was distributed to the 30 public advanced life support (ALS) provider agencies in Los Angeles County (LAC) to assess the prevalence of specific medication shortages and types of shortage mitigation strategies implemented. Survey responses were reviewed and presented using descriptive statistics. Results: Survey responses were received from 29 of 30 (97%) provider agencies. All but one of the responding agencies reported being impacted by medication shortages. Strategies to maintain the supply of medications included use of alternative vendors 20/28 (71%), rotating medications from low to high volume units (54%), utilizing expired medication FDA-approved extensions (50%), substituting medications (43%), borrowing medications from the LAC EMS Agency (39%) or other EMS provider agencies (32%), utilizing expired medications with medical director approval (29%), diluting medications to obtain desired concentration (18%), reducing minimum periodic automatic replacement (PAR) levels (14%), and using alternate medication concentrations/formulations (14%). The medications most frequently reported to have shortages included epinephrine (0.1 mg/mL), morphine, dextrose 10%, and normal saline. None of the provider agencies self-reported adverse events due to the shortages. Conclusions: Critical medication shortages remain a problem for many EMS systems. EMS medical directors need to implement multiple mitigation strategies to maintain supply of critical medications for prehospital patient care.

Abstract WP298: Communication Center Guided Prehospital Stroke Assessment Scoring has High Inter-rater Agreement

Introduction: We are prospectively validating a model of communication center guided prehospital identification of stroke patients with large vessel occlusion (LVO). Goal: Assess the inter-rater agreement between a Vascular Neurologist and Alabama Trauma Communication Center (ATCC) personnel in diagnostic classification of stroke patients. Methods: The ATCC is staffed by paramedic-trained dispatchers who field calls from Emergency Medical Service (EMS) responders and maintain up-to-the-minute status of hospitals and resources 24/7. We trained ATCC personnel in stroke pathology, pathophysiology, appropriate patient selection for thrombolytic and endovascular therapies; and the previously derived 6 point Emergency Medical Stroke Assessment (EMSA). ATCC personnel guided EMS responders in the Birmingham Regional Emergency Medical Services System (BREMSS), and paged-out a hospital stroke prenotification that included specific EMSA scale items (gaze, facial droop, arm drift, leg drift, naming, and repetition). All interactions between the ATCC and EMS responders were recorded, allowing review of audio files and ongoing quality improvement. ATCC personnel and a vascular neurologist separately reviewed recordings and assigned scores to each patient according to the deficit stated by the EMS. To determine inter-rater reliability we utilized the Kappa statistic with a significance level of 0.05, and 95% confidence intervals (CI). Results: We sampled a total of 146 patients. We observed statistically significant agreement between the raters for all EMSA components, with 71% (CI=45-97%, p&lt;0.0001) agreement in rating the gaze component, 54% (CI=26-82%, p=0.002) for the face, 57% (CI=29-85%, p=0.001) for the arm, 60% (CI=33-86%, p&lt;0.0006) for the leg, 56% (CI=30-81%, p&lt;0.001) for naming, and 34% (CI=6-61%, p&lt;0.04) for repetition. Conclusion: We conclude that there is moderate to substantial agreement in most stroke assessment items by a paramedic staffed communication center and a vascular neurologist. There was only fair inter-rater agreement for repetition. Paramedic-trained dispatchers can reliably guide EMS responders and score the Emergency Medical Stroke Assessment.

Abstract TP313: Communication Center Guided Prehospital Stroke Assessment Has Sustained Ability to Identify Patients With Large Vessel Occlusion

Introduction: There is need for sustainable models of effective prehospital stroke triage. Goal: Prospectively validate communication center guided prehospital identification of stroke patients with large vessel occlusion (LVO). Methods: We trained Alabama Trauma Communication Center (ATCC) paramedics in the previously derived 6 point Emergency Medical Stroke Assessment (EMSA). ATCC staff guided Emergency Medical Service (EMS) responders in the Birmingham Regional Emergency Medical Services System (BREMSS), and paged-out a hospital prenotification that included specific EMSA items (gaze, facial droop, arm drift, leg drift, naming, and repetition). Ongoing quality improvement was designed to enable the ATCC staff to effectively guide EMS responders. We derived the sensitivity, specificity, negative likelihood ratio (LR-), positive likelihood ratio (LR+), and receiver operator characteristics area under the curve (AUC) and 95% confidence intervals (CI) of ATCC guided EMSA for predicting a discharge diagnosis of LVO for patients transported to the University of Alabama at Birmingham. Results: We enrolled 521 patients from September 2016 through February 2018. Patients who only responded to pain (n=29, 5.6%) or who were unresponsive (n=21, 4%) were excluded. Of 471 patients analyzed, 247(52%) had a discharge diagnosis of stroke, including 182 (74%) acute ischemic stroke, 36 (14%) intracerebral hemorrhage, and 29 (11%) transient ischemic attack. There were 45 (18%) stroke patients with proximal LVO, including 31 middle cerebral artery stem, 12 internal carotid artery, and 2 basilar artery. Overall, an EMSA score ≥ 4 had sensitivity = 75.6%, specificity = 62.2%, LR- = 0.39, and LR+ = 2.00 for proximal LVO. During the first 9 months of the study, the EMSA AUC = 0.61 (CI = 0.45 – 0.77) compared to an AUC = 0.74 (CI = 0.64 – 0.84) during the second 9 month period of the study. Conclusions: EMS stroke medical control based on communication center guided prehospital stroke assessment and ongoing quality improvement is feasible and results in sustained ability to identify patients with LVO. Further studies are needed to evaluate the impact of guided prehospital triage of patients with suspected LVO on health outcomes.

Differences in Prehospital Patient Assessments for Pediatric Versus Adult Patients

To evaluate whether completion of vital signs assessments in pediatric transports by emergency medical services (EMS) differs by patient age. We reviewed records by 20 agencies in a regional EMS system in Southwestern Pennsylvania between April 1, 2013 and December 31, 2016. We abstracted demographics, vital signs (systolic blood pressure, heart rate, respiratory rate), clinical, and transport characteristics. We categorized age as neonates (≤30 days), infants (1 month to <1 year), toddler (1 to <2 years), early childhood (2 to <6 years), middle childhood (6 to <12 years), adolescent (12 to <18 years), and adult (≥18 years). We used unadjusted and adjusted logistic regression to test if age group was associated with vital signs documentation, reporting of Glasgow Coma Scale and pain scale after trauma, and recording of oxygen saturation and breath sounds in respiratory complaints, using adults as the reference group. In total, 371 746 cases (21 883 pediatric, 5.9%) were included. In adjusted analysis, most pediatric categories had reduced odds of complete vitals documentation (percent, OR, 95% CI): neonates (49.6%, 0.02, 0.02-0.03), infants (68.2%, 0.04, 0.03-0.04), toddlers (78.1%, 0.07, 0.06-0.07), early childhood (87.4%, 0.13, 0.12-0.15), and middle childhood (95.3%, 0.54, 0.46-0.63). Pain score documentation was lower in children after trauma (OR 0.80, 95%CI 0.76-0.85), and oxygen saturation documentation was lower in children with respiratory complaints (OR 0.20, 95%CI 0.18-0.25). Pediatric patients were at increased risk of lacking vital signs documentation during prehospital care. This represents a critical area for education and quality improvement.

The impact of a freestanding ED on a regional emergency medical services system

ObjectiveThe objective of the study is to examine the effect of the opening of a freestanding emergency department (FED) on the surrounding emergency medical services (EMS) system through an examination of EMS system metrics such as ambulance call volume, ambulance response times, and turnaround times. MethodsThis study is based on data from the county's computer-aided dispatch center, the FED, and the Maryland Health Services Cost Review Commission. The analysis involved a pre/post design, with a 6-month washout period. The preintervention period was April to October 2010, and the postintervention period was April to October 2011. Data were analyzed using standard t tests. ResultsThe average daily number of EMS-related calls received in the computer-aided dispatch center was lower after the FED opened (16.3 [95% confidence interval {CI}, 15.7-16.9] vs 15.8 [95% CI, 14.9-16.9]). One-fourth of all patients were transported by ambulance to the FED after it opened. Use of the FED and adjacent hospitals increased by 8647 visits (15.8%) during the study period. Turnaround time for the county's ALS units decreased from 26.8 (95% CI, 26.2-27.5) to 25.1 (95% CI, 24.3-25.8) minutes. The ambulance out-of-service interval decreased from 87.3 (95% CI, 86.0-88.5) to 81.1 (95% CI, 79.7-82.4) minutes. Based on change in out-of-service this study had a small effect size (Cohen's d = 0.33). ConclusionsThe opening of an FED was associated with a modest improvement in time-specific EMS system metrics: a decrease in ambulance turnaround time and shorter out-of-service intervals.

Improving use of targeted temperature management after out-of-hospital cardiac arrest: a stepped wedge cluster randomized controlled trial.

International guidelines recommend use of targeted temperature management following resuscitation from out-of-hospital cardiac arrest. This treatment, however, is often neglected or delayed. To determine whether multifaceted quality improvement interventions would increase the proportion of eligible patients receiving successful targeted temperature management. A network of 6 regional emergency medical services systems and 32 academic and community hospitals serving a population of 8.8 million people providing post arrest care to out-of-hospital cardiac arrest. Comparing interventions improve the implementation of targeted temperature management post out-of-hospital cardiac arrest through passive (education, generic protocol, order set, local champions) versus additional active quality improvement interventions (nurse specialist providing site-specific interventions, monthly audit-feedback, network educational events, internet blog) versus no intervention (baseline standard of care). The primary process outcome was proportion of eligible patients receiving successful targeted temperature management, defined as a target temperature of 32-34ºC within 6 hours of emergency department arrival. Secondary clinical outcomes included survival and neurological outcome at hospital discharge. Four thousand three hundred seventeen out-of-hospital cardiac arrests were transported to hospital; 1,737 (40%) achieved spontaneous circulation, and 934 (22%) were eligible for targeted temperature management. After accounting for secular trends, patients admitted during the passive quality improvement phase were more likely to achieve successful targeted temperature management compared with those admitted during the baseline period (25.7% passive vs 9.0% baseline; odds ratio, 2.76; 95% CI, 1.76-4.32; p < 0.001). Active quality improvement interventions conferred no additional improvements in rates of successful targeted temperature management (26.9% active vs 25.7% passive; odds ratio, 0.96; 95% CI, 0.63-1.45; p = 0.84). Despite a significant increase in rates of successful targeted temperature management, survival to hospital discharge was unchanged. Simple quality improvement interventions significantly increased the rates of achieving successful targeted temperature management following out-of-hospital cardiac arrest in a large network of hospitals but did not improve clinical outcomes.

An Emergency Department Paramedic Staffing Model Significantly Improves EMS Transport Unit Offload Time – A Novel Approach to an ED Crowding Challenge

Objective: We assessed the impact of emergency department (ED) paramedic staffing on emergency medical services (EMS) unit offload time, an intervention designed to assist with EMS unit patient offload when the ED is at full bed capacity. Methods: This prospective pre/post intervention study assessed patients offloaded via the regional EMS system at an urban tertiary care teaching hospital. Three groups were compared: 1) a pre-paramedic group with data obtained prior to any paramedics staffing the ED; 2) a transition (control) group with data obtained during paramedic orientation; and 3) a post-paramedic group with data measured after paramedics were staffing the ED. Research assistants stationed in the ambulance bay of the ED enrolled a convenience sample of patients for seven consecutive days and recorded offload time as patients were brought in by EMS. The primary outcome measure was offload time (the interval between patient arrival via EMS and transfer of patient care to an ED stretcher). Results: A total of 519 offloaded patients were assessed: 207 in the pre-paramedic period, 93 in the transition (control) period and 219 in the post-paramedic period. Overall median offload times (in minutes) in the preparamedic and post-paramedic groups were 10 [IQR 4-32] versus 4 [IQR 1-16] respectively (p<0.001). In those who were triaged directly to an ED bed the median offload times were 14 [IQR 3-40] and 4 [IQR 1-16] respectively (p<0.001). The proportion of patients offloaded within 5 minutes went from 29% before the paramedic intervention to 53% after (p<0.001). The proportion of patients offloaded within 30 minutes went from 66% before paramedics to 83% (p<0.001) after and those offloaded within 60 minutes went from 87% to almost 100% (p<0.001). Conclusion: An ED paramedic-staffing model focused on receiving EMS-arrived patients at times when the ED is at full bed capacity significantly reduced the offload time for EMS units.

Evaluating the Performance of the Emergency Medical Services Index

Background: In 2006 Emergency Medical Services Index (EMSI), which summarizes the performance of regional emergency medical services system, was developed. This study assesses the performance of the EMSI to help determine whether EMSI can be used as evaluation tool. Methods: To build a composite score of the EMSI from predefined 24 indicators, 3 normalized values were calculated for each indicator, the normalized values of each indicator were weighted using 4 weighting methods, and the weighted values were aggregated into the final composite score using 2 aggregation schemes. The performance of EMSI was evaluated using 3 criteria: discrimination, construct validity, and sensitivity. Discrimination was the proportion of regions that did not include the overall median rank in the 5th to 95th percentiles rank interval, which was calculated from Monte Carlo simulation. Construct validity was a correlation among the alternative EMSIs. Sensitivity of EMSIs was evaluated by total shift of quartile membership and changes of 5th to 95th percentile intervals. Results: The total discrimination performance of the EMSI was 50.0%. Correlation coefficients between EMSIs using standardized values and those using rescaled values ranged from 0.621 to 0.997. Variation of the quartile membership of regions ranged from 0.0% to 75.0%. The total change in the 5th to 95th percentile intervals ranged from -19 to +17 places. Conclusion: The results suggested that the EMSI could be used as a tool for evaluating quality of regional EMS system and for identifying the areas for quality improvement.

(A47) Pediatric Mass-Casualty Triage: The New York City Approach

IntroductionA Mass-Casualty Event (MCE) involving pediatric victims could overwhelm existing pediatric resources. Therefore, early recognition of critically ill infants and children is essential for proper distribution among pediatric capable hospitals. However, emergency medical services (EMS) personnel have limited experience with pediatric assessments, and less with pediatric mass-casualty triage (MCT). To address these gaps, the New York City (NYC) Pediatric Disaster Coalition (PDC) in collaboration with the Fire Department (FDNY) and Office of Emergency Management, made simple alterations to the START-based NYC-MCT Algorithm that can be rapidly and accurately applied by EMS personnel in the field with minimal additional education and preparation, obviating the requirement for extensive and expensive retraining.MethodsThe PDC includes experts in pediatric emergency preparedness, emergency medicine, critical care, and trauma surgery in NYC, as well as DOHMH, FDNY-OMA, and OEM. Its Triage Subcommittee determined the minimum essential pediatric alterations to the Algorithm, which then was tested by FDNY-EMS.ResultsAfter focused literature review and multiple draft revisions aimed to maximize pediatric benefit yet minimize unnecessary complexity, the Algorithm was modified to ensure that: (1) five rescue breaths will be provided to infants or children prior to being categorized as Dead or Expectant; (2) infants under 12 months old will be categorized as Critical and receive priority transport, and (3) children initially categorized as Delayed or Minor will be uptriaged to a new Urgent (Orange) category to receive such care in a rapid manner. To date, &gt; 3,000 FDNY personnel have been trained in its use, and tested its accuracy using tabletop scenarios. Mean accuracy is 80–90%.ConclusionsThe model is an effective, multidisciplinary approach to planning. Minimum alterations to the Algorithm were adopted by the regional EMS system. The Modified Algorithm improves identification of critically ill infants and children. This approach could be adopted by other large urban centers.

Regional Impact of Cardiac Arrest Center Criteria on Out-of-Hospital Transportation Practices

Background. Cardiac arrest center (CAC) criteria are not well defined, nor is their potential impact on current emergency medical services (EMS) transportation practices for post–cardiac arrest (PCA) patients. In addition to the availability of emergent cardiac catheterization (CATH) and therapeutic hypothermia (TH), high-volume centers and those with PCA protocols have been associated with improved outcomes. Objectives. This study aimed 1) to identify the PCA treatment capabilities of receiving hospitals in a 10-county regional EMS system without official CAC designation and 2) to determine the proportion of PCA patients who are transported to hospitals meeting three proposed CAC definitions. We hypothesized that a majority of patients are already transported to hospitals that meet proposed CAC criteria. Methods. We distributed a survey to 34 receiving hospitals to determine availability and volume of CATH, TH, a PCA protocol, and a 24-hour intensivist. We conducted a retrospective study of adult, nontrauma cardiac arrest patients transported with a pulse from 2006 to 2008 for 16 EMS agencies. The proportions of patients transported to hospitals meeting three CAC criteria were compared: criteria A (availability of CATH and TH), criteria B (criteria A, >200 CATHs per year, and a PCA protocol), and criteria C (criteria B and a 24-hour intensivist). Results: Data were obtained from 31 of 34 hospitals (91.1%), of which 10 (32.3%) met criteria A, seven (22.6%) met criteria B, and six (19.4%) met criteria C. Of 1,193 cardiac arrest patients, 46 (3.9%) were excluded because of transport to a pediatric, closed, or out-of-region hospital. There were 335 patients (81.1%) with return of spontaneous circulation and a pulse present upon arrival at the destination facility transported to hospitals meeting criteria A, 304 patients (73.6%) transported to hospitals meeting criteria B, and 273 patients (66.1%) transported to hospitals meeting criteria C. Conclusions. In a region without official CAC designation, only one-third of hospitals meet basic CAC criteria (CATH and TH), but those facilities receive 81% of PCA patients. Fewer patients (66%) are transported to hospitals meeting more stringent CAC criteria. These data describe the potential impact of developing a CAC policy based on current transportation practices.

Teaching Emergency Medical Services Management Skills Using a Computer Simulation Exercise

Simulation exercises have long been used to teach management skills in business schools. However, this pedagogical approach has not been reported in emergency medical services (EMS) management education. We sought to develop, deploy, and evaluate a computerized simulation exercise for teaching EMS management skills. Using historical data, a computer simulation model of a regional EMS system was developed. After validation, the simulation was used in an EMS management course. Using historical operational and financial data of the EMS system under study, students designed an EMS system and prepared a budget based on their design. The design of each group was entered into the model that simulated the performance of the EMS system. Students were evaluated on operational and financial performance of their system design and budget accuracy and then surveyed about their experiences with the exercise. The model accurately simulated the performance of the real-world EMS system on which it was based. The exercise helped students identify operational inefficiencies in their system designs and highlighted budget inaccuracies. Most students rated the exercise as moderately or very realistic in ambulance deployment scheduling, budgeting, personnel cost calculations, demand forecasting, system design, and revenue projections. All students indicated the exercise was helpful in gaining a top management perspective, and 89% stated the exercise was helpful in bridging the gap between theory and reality. Preliminary experience with a computer simulator to teach EMS management skills was well received by students in a baccalaureate paramedic program and seems to be a valuable teaching tool.

Early Cardiac Catheterization Laboratory Activation by Paramedics for Patients with ST-segment Elevation Myocardial Infarction on Prehospital 12-Lead Electrocardiograms

Background. Prompt reperfusion in ST-segment elevation myocardial infarction (STEMI) saves lives. Although studies have shown that paramedics can reliably interpret STEMI on prehospital 12-lead electrocardiograms (p12ECGs), prehospital activation of the cardiac catheterization laboratory by emergency medical services (EMS) has not yet gained widespread acceptance. Objective. To quantify the potential reduction in time to percutaneous coronary intervention (PCI) by early prehospital activation of the cardiac catheterization laboratory in STEMI. Methods. This prospective, observational study enrolled all patients diagnosed with STEMI by paramedics in a mid-sized regional EMS system. Patients were enrolled if: 1) the paramedic interpreted STEMI on the p12ECG, 2) the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) score was 75%% or greater, and 3) the patient was transported to either of two area PCI centers. Data recorded included the time of initial EMS “STEMI alert” from the scene, time of arrival at the emergency department (ED), and time of actual catheterization laboratory activation by the ED physician, all using synchronized clocks. The primary outcome measure was the time difference between the STEMI alert and the actual activation (i.e., potential time savings). The false-positive rate (patients incorrectly diagnosed with STEMI by paramedics) was also calculated and compared with a locally accepted false-positive rate of 10%%. Results. Twelve patients were enrolled prior to early termination of the study. The mean and median potential time reductions were 15 and 11 minutes, respectively (range 7–29 minutes). There was one false STEMI alert (8.3%% false-positive rate) for a patient with a right bundle branch block who subsequently had a non–ST-segment elevation myocardial infarction. The study was terminated when our cardiologists adopted a prehospital catheterization laboratory activation protocol based on our initial data. Conclusion. Important reductions in time to reperfusion seem possible by activation of the catheterization laboratory by EMS from the scene, with an acceptably low false-positive rate in this small sample. This type of clinical research can inform multidisciplinary policies and bring about meaningful clinical practice changes.

Federal Policy Leading the Way in Emergency Medical Services

he most influential piece of federal legislation during my 30-year tenure with the North Carolina Office of Emergency Medical Services (NC OEMS), the last 15 as the state Emergency Medical Services (EMS) director, was creation of the EMS program at the National Highway Traffic Safety Administration (NHTSA). Since then, federal EMS legislation, programs, and agencies have profoundly impacted the evolution of EMS throughout our nation and my personal career in North Carolina. Federal EMS legislation permitted NHTSA to 1) assist states and local communities with the purchase of ambulances; 2) fund for automobile extrication courses; 3) provide national-level guidance and support to evolving EMS systems; and 4) standardize emergency medical technician (EMT) training across the nation. The NHTSA also made the term EMT a household word and created a universally recognized symbol for EMS, the blue “Star of Life.” The 1973 National EMS Systems Act helped shaped state legislation including that of North Carolina. The NHTSA state EMS assessments and reassessments program, a program supporting expert team evaluations of state EMS systems, continues to help guide the development of state EMS systems. NHTSA publications, such as the EMS Agenda for the Future and its various spin-off documents including the EMS Education Agenda for the Future: A Systems Approach, the EMS Research Agenda for the Future, and others, encouraged the nation to adopt a collaborative, consensus-based, and forward-thinking approach to EMS issues. The passage of the Emergency Medical Services Systems (EMSS) Act of 1973 brought positive changes to EMS. Health care provided in the hospital could now be extended into the community 1 and mechanisms were now available for funding the development of regional EMS systems. 2 The EMSS Act brought much needed recognition to emergency medicine as a field of medicine. 3 It also placed substantial obligations on hospitals

The Effectiveness of Out-of-Hospital Use of Continuous End-Tidal Carbon Dioxide Monitoring on the Rate of Unrecognized Misplaced Intubation Within a Regional Emergency Medical Services System

We evaluate the association between out-of-hospital use of continuous end-tidal carbon dioxide (ETCO2) monitoring and unrecognized misplaced intubations within a regional emergency medical services (EMS) system. This was a prospective, observational study, conducted during a 10-month period, on all patients arriving at a regional Level I trauma center emergency department who underwent out-of-hospital endotracheal intubation. The regional EMS system that serves the trauma service area is composed of multiple countywide systems containing numerous EMS agencies. Some of the EMS agencies had independently implemented continuous ETCO2 monitoring before the start of the study. The main outcome measure was the unrecognized misplaced intubation rate with and without use of continuous ETCO2 monitoring. Two hundred forty-eight patients received out-of-hospital airway management, of whom 153 received intubation. Of the 153 patients, 93 (61%) had continuous ETCO2 monitoring, and 60 (39%) did not. Forty-nine (32%) were medical patients, 104 (68%) were trauma patients, and 51 (33%) were in cardiac arrest. The overall incidence of unrecognized misplaced intubations was 9%. The rate of unrecognized misplaced intubations in the group for whom continuous ETCO2 monitoring was used was zero, and the rate in the group for whom continuous ETCO2 monitoring was not used was 23.3% (95% confidence interval 13.4% to 36.0%). No unrecognized misplaced intubations were found in patients for whom paramedics used continuous ETCO2 monitoring. Failure to use continuous ETCO2 monitoring was associated with a 23% unrecognized misplaced intubation rate.