Single Emergency Medical Services Agency Research Articles

Use of Stroke Alert Sticker in the Field Decreases Time to Acute Interventions for Ischemic Stroke Patients.

BACKGROUND: Stroke is a medical emergency requiring timely intervention to optimize patient outcomes. The only treatments currently Food and Drug Administration approved for acute stroke are intravenous (IV) thrombolytics, which require obtaining specific medical history to be administered safely. This medical history may be overlooked in the prehospital setting or lost during patient handoff between emergency medical services (EMS) personnel and hospital staff, delaying treatment. We evaluated whether utilization of a "stroke alert sticker" by EMS to capture key information in the field would decrease door-to-needle (DTN) time. METHODS: Bright-orange "stroke alert stickers" were disseminated to our local EMS agency to be placed on all suspected stroke patients in the field prompting documentation of key elements needed for timely treatment decisions. The "stroke alert sticker" included time last known well, contact information, presenting symptoms, and relevant medications. We evaluated the impact of the "stroke alert sticker" on acute stroke metrics, including DTN time. RESULTS: The project included 220 consecutive stroke alert patients brought to our comprehensive stroke center by a single EMS agency from May 2021 through February 2022. Twenty-one patients were treated with an IV thrombolytic. Overall "stroke alert sticker" use compliance was 40%; for the subgroup of patients who were given an IV thrombolytic, the "stroke alert sticker" was used 60% of the time. In patients who received an IV thrombolytic, prehospital EMS notification was 100% with "stroke alert sticker" use, compared with 75% without (P = .13). In addition, with "stroke alert sticker" utilization, DTN time was reduced by 20 minutes (31 [11] minutes with sticker vs 51 [21] minutes without, P = .04). CONCLUSION: Utilization of the "stroke alert sticker" significantly improved DTN times compared with patients without the sticker. This evidence supports continued use of the "stroke alert sticker" to improve DTN times and patient outcomes.

An Incomplete Medical Record: Transfer of Care From Emergency Medical Services to the Emergency Department

Background: Transition of care from Emergency Medical Services (EMS) to the Emergency Department (ED) represents an intersection at high risk for error. Minimal research has quantitatively examined data transfer at this point. In Pennsylvania, this handoff consists of a transfer-of-care form (TOC) provided by EMS to ED in addition to a verbal report. A prehospital patient care report (PCR) is later filed by EMS up to 72 hours after concluding care.Objective: To evaluate the congruence between prehospital records provided at handoff and the final PCR found in the patient’s medical record. Our hypothesis was that there would be discrepancies between the TOC and final PCR.Methods: A retrospective chart review was conducted comparing the TOC from a single EMS agency to the final PCR found in the electronic medical record. A convenience sample of 200 patients who received advanced life support transport over a one-month period were included. Metrics to assess the discrepancy between the reports included chief complaint, allergies, medications, systolic and diastolic blood pressure (SBP and DBP), pulse, respiratory rate (RR), Glasgow Coma Score (GCS), and prehospital treatment provided. The level of agreement between the two sources was compared using kappa statistics and concordance correlation coefficients (CCC) with 95% confidence intervals.Results: Of the 200 encounters that met inclusion criteria, 72% had matching chief complaints between the TOC and PCR. Medications matched in 66% and allergies matched in 82%. Up to three BP, pulse, and RR readings were collected; only 30% of the third BP readings were available from the TOC, while 68% were available from the PCR. Comparing the three SBP values on the TOC to respective counterparts on the PCR showed a substantial correlation (all CCC >0.95). Pulse and DBP values had moderate-to-substantial correlation (CCC: 0.93, 0.94, 0.96 and 0.77, 0.92, 0.94 respectively). RR showed inconsistent correlation (CCC: 0.37, 0.84, 0.94). GCS showed a moderate correlation between the two forms (CCC: 0.81).Conclusion: There were significant differences between the information transferred to the ED through the TOC compared to what was recorded in the PCR. Further evaluation of the TOC process is needed to improve accuracy.

Non-transport after Prehospital Naloxone Administration Is Associated with Higher Risk of Subsequent Non-fatal Overdose

Objective: U.S. opioid overdoses increased nearly sixfold from 1999 to 2018, and greater than 1% of all emergency medical services (EMS) encounters now involve naloxone administration. While “treat and release” protocols may have low short-term mortality, the risk of subsequent non-fatal overdoses is not known. This study compares the risk of repeat overdose encounters between patients transported to an emergency department (ED) and those who refused transport after prehospital naloxone administration. Methods: All EMS charts within a large single-tier fire-based urban EMS system between January 1 and August 31, 2018 were reviewed if either naloxone administration or a clinical impression related to opioid overdose was documented. Charts were excluded if there was no documented evidence of an opioid toxidrome (respiratory depression or altered mental status), if there was another clear explanation for the symptoms (e.g., hypoglycemia), or if naloxone was not administered. Ten percent of charts were reviewed by a second author to assess reliability. Cox regression (survival analysis) was used to estimate the risk of a subsequent EMS encounter with naloxone administration following an index encounter with naloxone administration. Results: Of the 2143 charts reviewed, 1311 unique patients with 1600 overdose encounters involving naloxone administration were identified. Inter-rater reliability for chart inclusion was strong [κ = 0.83 (95% CI: 0.72–0.90)]. Police/bystanders administered naloxone in 208/1600 (13.0%) encounters. A substantial proportion of encounters resulted in transport refusal (674/1600, 42.1%). The final Cox model included only refusal vs. acceptance of transport to an ED during the index EMS encounter. Patient age, gender, and naloxone administration prior to EMS arrival were not statistically significant in univariate or multivariable analyses, nor were they significant confounders. Refusal of transport was associated with a hazard ratio of 1.66 (95% CI: 1.23–2.23) for subsequent EMS encounters with naloxone administration. Conclusions: Non-transport after prehospital naloxone administration is associated with an increased risk of subsequent non-fatal overdose requiring EMS intervention. Limitations include the use of a single EMS agency as patients may have had uncaptured overdose encounters in neighboring municipalities.

A Descriptive Analysis of Pediatric Prehospital Refusal of Medical Assistance Within a Single Service Provider System.

Pediatric refusal of medical assistance (RMA) is a potentially high-risk event with implications for both individual patient outcomes and greater emergency medical services system efficiency. The purpose of this study was to describe characteristics of pediatric RMA calls and outcomes. Single emergency medical services agency retrospective study of calls between January 1, 2011, and December 31, 2015, for pediatric patients resulting in RMA was performed. Dispatch complaint-matched case-control group was generated from transported patients. The percentage of pediatric calls that resulted in RMA was 12.7%, compared with 5% adult calls (P < 0.0001). The 3 most common RMA dispatch complaints were seizures, difficulty breathing, and traffic accidents. Furthermore, 65.1% pediatric RMA calls were emergently dispatched, compared with 56.4% of transported pediatric patients (P = 0.01). Medical control was contacted for 4.6% RMA calls. The average ± SD word count for RMA patient care narratives was 179 ± 99 words, compared with 164 ± 139 words for controls (P = 0.11). Documentation of risk-benefit discussion occurred in 28.6% RMA narratives. Outcome data were available for 83.8% RMA patients. The percentage of RMA patients with documented alternative plans who completed the alternative plan was 61.6%. Within 72 hours of RMA, 5.0% of calls with known outcome resulted in unexpected emergency department visit. No unexpected emergency department visits resulted in admission. Five percent of RMA patients were admitted; 1 patient was admitted to the intensive care unit. No emergent surgeries or deaths occurred during the study period. Pediatric RMA is common within our study population, and two thirds involve emergent dispatch. Although outcomes are generally good, refusal documentation is sparse and medical control is seldom contacted. Multiple opportunities for systems improvement exist.

Abstract 238: Automating Medical Record Matching: A Key Component of an Automated Cardiac Arrest Registry

Introduction: An automated registry for out-of-hospital cardiac arrest can facilitate cardiac arrest research and emergency medical services (EMS) and community health quality improvement programs. A key element of a cardiac arrest registry is outcome, especially survival to hospital discharge, which is usually obtained from the hospital medical record. A crucial step in capturing survival data automatically is being able to reliably match EMS patient care reports with hospital medical records. Objective: To determine the accuracy of a probabilistic record-linkage approach to match EMS and hospital encounters and identify barriers of automation. Methods: This is a prospective feasibility study from the Dallas Fort-Worth Center for Resuscitation Research. Our cardiac arrest registry was part of the Resuscitation Outcomes Consortium (ROC) Epistry from 2006 to 2016. Since 2016, we maintained it separately from the ROC and have since enrolled over 20,000 cases. Record linkage was performed using demographic data of encounters from a single EMS agency within the registry and a community hospital in Dallas where these were transported from January 2017 to May 2018. An expectation maximization algorithm to aid in discerning matches and nonmatches was performed using the R package RecordLinkage identifying record pairs as a match, non-match, or possible match based on a pre-determined threshold. Match and Possible Match pairs were manually reviewed to assess the algorithm’s accuracy. Results: The EMS and hospital data sets had 67 and 6,050 unique encounters, respectively. The record linkage algorithm identified 40 EMS encounters as having a match (60%), 12 with a possible match (18%), and 15 with no identified match (22%). After manual review, the algorithm had a positive predictive value (PPV) of 100% (40/40) for the match group with a sensitivity of 60%. Conclusions: Applying probabilistic linkage to aid in automating a cardiac arrest registry was successful in linking over half of the EMS encounters with a PPV of 100%. When reviewing the unmatched encounters, many were adjacent to each other when sorted by time suggesting the poor sensitivity is more likely a reflection of the hospital’s data collection method as opposed to the linkage methodology.

Effect of Intravenous Versus Intraosseous Access in Prehospital Cardiac Arrest

ObjectiveThe prevailing standard of care in prehospital emergency medical services (EMS) is that either intravenous (IV) or intraosseous (IO) access is an acceptable route for obtaining vascular access and delivery of resuscitation medications and volume expanders in cardiac arrest patients. The aim of this study was to evaluate the effectiveness of IV access versus IO access in terms of return of spontaneous circulation (ROSC) for patients suffering from cardiac arrest. MethodsA retrospective chart review examining cardiac arrest data with a single advanced life support EMS agency over a 4-year period was performed. Cardiac arrest patients were identified from a quality assurance database. Exclusion criteria included trauma arrest, pediatrics, pregnancy, and obvious signs of death. ResultsA total of 795 patients remained after applying the exclusion criteria. A total of 183 (45.1%) out of 406 cardiac arrest patients achieved ROSC who had an IV placed. A total of 389 cardiac arrest patients had an IO placed with ROSC in 100 (25.7%). ConclusionsHigher ROSC rates were achieved with IV access versus IO access. Limitations include the small sample size, a single EMS agency, and the retrospective nature of the study. Future studies should further evaluate the effectiveness of IO versus IV access in cardiac arrest and other low perfusion states.

Factors associated with advanced cardiac care in prehospital chest pain patients

IntroductionMany patients transported by emergency medical services (EMS) may require advanced cardiac care but do not have ST-segment elevation (STEMI) on the initial prehospital EKG. We sought to identify factors associated with the need for advanced cardiac care in undifferentiated EMS patients reporting chest pain in the absence of STEMI on EKG. MethodsWe performed a retrospective analysis of all adult patients, reporting atraumatic chest pain from a single EMS agency, presenting to a single, urban hospital over a 10-year period. Patients with STEMI on prehospital electrocardiogram were excluded. Patient demographics, chest pain characteristics and prehospital factors were abstracted for all patients. We identified those patients that required advanced cardiac care and performed regression analysis to determine associated factors. ResultsA total of 956 charts were analyzed. Of this total, 193 patients (20.2%) met the primary composite outcome. Of the outcome group, 185 patients (95.9%) had coronary artery disease documented on cardiac catheterization, 22 patients (11.4%) underwent CABG, and seven patients (3.6%) died in the hospital. Most significant variables (multivariable IRR) included age (1.02), male gender (1.65), history of MI (1.47), PCI (1.66), hyperlipidemia (1.40), diaphoresis (1.51), home aspirin (1.53), and improvement with EMS treatment (1.60). ConclusionWe have identified several factors that could be considered when risk stratifying prehospital patients reporting chest pain. While potentially predictive, the factors are broad and support the need for other objective factors that could augment prediction of patients who may benefit from early advanced cardiac care.

Morbidity and Mortality Associated with Prehospital “Lift-assist” Calls

Introduction: When an individual requires assistance with mobilization, emergency medical services (EMS) may be called. If a patient does not receive treatment on scene and is not transported to hospital, these are referred to as “Lift Assist” (LA) calls. It is possible this need for assistance represents a subtle onset of a disease process or decline in function. Without recognition or treatment, the patient may be at risk for recurrent falls, repeat EMS visits or worsening illness. Objective: To examine the 14-day morbidity and mortality associated with LA calls and determine factors that are associated with increased risk of these outcomes. Methods: All LA calls from a single EMS agency were collected over a one year study period (January–December 2013). Calls were linked with hospital records to determine if LA patients had a subsequent visit to the emergency department (ED), admission, or death within 14 days of the LA call. Logistic regression analyses were completed to determine factors predicting ED visit or hospital admission within 14 days of the LA call. Results: Of 42,055 EMS calls, 804 (1.9%) were LAs. These calls were for 414 individuals; 298 (72%) patients had 1 LA, and 116 (28%) patients had >1 LA call. There were 169 (21%) ED visits, 93 (11.6%) hospital admissions and 9 (1.1%) deaths within 14 days of a LA call. Patient age (p = 0.025) significantly predicted ED visit. Patient age (p = 0.006) and an Ambulance Call Record missing at least 1 vital sign (p = 0.038) significantly predicted hospital admission. Conclusions: LA calls are associated with short-term morbidity and mortality. Patient age was found to be associated with these outcomes. These calls may be early indicators of problems requiring comprehensive medical evaluation and thus further factors associated with poor outcomes should be determined.

Receiving Hospital Characteristics Associated With Survival in Patients Transported by Emergency Medical Services After Out-of-hospital Cardiac Arrest.

To test whether primary emergency medical services (EMS) transport to hospitals with certain characteristics (24/7 percutaneous coronary intervention [PCI] availability, trauma center status, large [>24 bed] intensive care unit [ICU]) versus hospitals without those characteristics is associated with improved hospital survival after out-of-hospital cardiac arrest (OHCA). This is an analysis of a prospectively collected EMS database, which archives patients with OHCA treated by a single large metropolitan EMS system. The database contains Utstein data, EMS transport data, and survival to hospital discharge. EMS providers uniformly apply advanced cardiac life support protocols to OHCA patients in the field. Patients with return of spontaneous circulation (ROSC) are transported to one of 10 hospitals in the area. If ROSC is not achieved within 30 minutes, efforts are terminated and the patient is not transported. We used multivariate logistic regression to test if receiving hospital characteristics were independently associated with survival among those transported after ROSC. We excluded patients not transported to a hospital and patients with incomplete outcome data. Between January 2011 and December 2014, a total of 1,188 OHCA patients were resuscitated in the field and transported to an area hospital. After patients with missing data were excluded, 1,024 patients were included in the analysis. The mean (±SD) age was 61.1 (±17.0) years, and 57.7% were male. Of transported patients, 76% were taken to 24/7 PCI centers, 46% were taken to trauma centers, and 37% were taken to hospitals with large ICUs. There was considerable overlap in these hospital characteristics. A multivariate logistic regression model including age, sex, shockable rhythm, EMS time to scene, and dispatch complaint of cardiac arrest found that none of the hospital characteristics were independently associated with increased survival to discharge. The odds ratios (95% confidence intervals) for survival were as follows: PCI center, 1.28 (0.80 to 2.04); trauma center, 1.44 (0.73 to 2.85); and large ICU, 1.39 (0.69 to 2.80). After adjusting for patient demographic data, we found no significant independent association between receiving hospital characteristics and survival to discharge among OHCA patients transported after ROSC by a single EMS agency.

P079: Comparison of vital sign documentation for pre-hospital “lift-assist” calls and non “lift-assist” calls

Introduction: When an individual requires assistance with mobilization, emergency medical services (EMS) may be called. If treatment is not administered and the patient is not transported to hospital, it is referred to as a “Lift Assist” (LA) call. We have previously shown that LA are associated with morbidity and mortality. Subtle pathology may exist in those who require LAs and they may benefit from being transported to the Emergency Department for medical evaluation. Given that the majority of LA calls result in no-transport, there may be a bias towards not upholding the same standards of care as patients who are transported to hospital. Objective: To determine if there is a difference in Ambulance Call Record (ACR) documentation of vitals signs between LA calls and non-LA calls. Methods: All LA calls from a single EMS agency were collected over a one-year period (Jan - Dec 2013). A control group of randomly selected calls of low acuity (Canadian Triage Acuity Scale 3,4,5) from the same time period was collected for comparison. ACRs from these calls were reviewed for missing vital sign documentation. Results: Of 42, 055 EMS calls, 808 (1.9%) were LA calls. A comparison of 784 randomly-selected non-LA control calls were reviewed. There were significantly more missing vitals (12.08% vs 6.64% p &lt; 0.001) and refused vitals (1.87% vs 0.51% p = 0.013). Conclusion: There is a significant discrepancy in the complete documentation of vital signs in LA calls vs non-LA calls. There were also significantly more patient refusals for obtaining vitals compared to transported patients. Abnormal vital signs may be a clue to a subtle disease process that has resulted in a LA call, thus care should be taken to ensure that these patients are treated with the same standards of care and documentation as those patients calling EMS for overt medical reasons.

P080: Factors predicting morbidity and mortality associated with pre-hospital “lift assist” calls

Introduction: When an individual requires assistance with mobilization, emergency medical services (EMS) may be called. If treatment is not administered and the patient is not transported to hospital, it is referred to as a “Lift Assist” (LA) call. We have previously shown that LA are associated with morbidity and mortality. What places patients at an increased risk for morbidity and mortality is not yet known. Objective: To determine factors that are associated with increased risk of 14 day morbidity, determined by an ED visit or hospital admission, and mortality in LA calls. Methods: All LA calls from a single EMS agency were collected over a one-year period (Jan - Dec 2013). These calls were linked with hospital records to determine if LA patients had a subsequent visit to the emergency department (ED), admission, or death within 14 days. Logistic regression analyses were run to predict ED visit or hospital admission within 14 days of the LA call from patients’ age, gender, co-morbidities and vital signs at the initial LA call. Results: Of 42,055 EMS calls, 808 (1.9%) were LA calls. There were 169 (20.9%) ED visits, 93 (11.5%) hospital admissions and 9 (1.1%) deaths within 14 days of a LA. Patient age &gt; 61 (p &lt; 0.001) and history of cardiac disease (p = 0.006) significantly predicted ED visit, while patient age &gt;61 (p = 0.001) and an Ambulance Call Record (ACR) missing at least 1 vital sign (p = 0.017) significantly predicted hospital admission. There was a 10% increase in risk of ED visit and hospital admission for every 10 year increase of age after the age of 61. Of the 96 patients with at least 1 missing vital sign, 14 (14.5%) were coded as patient refusals. The sample size was too small to determine predictors for mortality. Conclusion: Patients at risk for morbidity are older than 61 years of age and have co-existing cardiac disease. Patients who are greater than 61 years of age and had at least one missing vital sign on the ACR were more at risk for hospital admission.

Cardiac arrest with initial arrest rhythm of pulseless electrical activity: do rhythm characteristics correlate with outcome?

ObjectivesCardiac arrest is a leading cause of death in the United States, with pulseless electrical activity (PEA) as a common initial arrest rhythm. We sought to determine if rate of electrical activity and QRS width correlate with survival in patients who present with PEA out-of-hospital cardiac arrest. Methods and resultsThis is a retrospective review of patients with PEA out-of-hospital cardiac arrest with first documented cardiac rhythm of PEA from January 2010 to September 2013. Demographic, arrest and initial rhythm characteristics, and patient outcome were abstracted via systematic chart review. The initial 20 seconds of each rhythm strip were used to ascertain electrical rate and QRS width. Primary outcome was survival to hospital discharge. Four hundred fourteen patients were eligible for the study. One hundred fifty-two patients did not have sufficient data for analysis. Two hundred sixty-two patients were included in the final analysis with mean age, 66 years. There were 23 (8.8%) survivors and 17 (6.5%) neurologically intact survivors. Mean heart rate was 58 (confidence interval, 54-63) beats per minute, and mean QRS interval was 100 (confidence interval, 95-106) milliseconds. Twenty-nine point seven percent of patients had wide QRS complexes, and 70.3% were narrow. There was no difference in survival in patients based on heart rate (13.1% vs 7.4%, P = .16) or QRS interval (8.7% vs 7.7%, P = .79). ConclusionsIn this single emergency medical services agency study, neither PEA electrical rate nor QRS width correlated with survival or neurologic outcome.

Abstract 164: Treatment Differences in Acute Stroke By Mode of Transport

Background: EMS (Emergency Medical Services) is an important component of the stroke chain of survival. While in hospital stroke time targets have shown to be better when prehospital providers provide advance notification, population-wide studies on thrombolysis rates (IV t-PA) for those who arrive by EMS is sparse. Objective: To examine differences in treatment rates for acute stroke by mode of transport. Methods: This is a cross-sectional study of all patients who were transported to hospitals in two Northern California counties by providers of a single EMS agency during a three year period. Patient demographic data, prehospital provider clinical assessment was obtained from the computerized prehospital transport records and patient location, hospital demographics, physician diagnosis and treatment rates were obtained from statewide administrative patient discharge data. The data sources were linked using probabilistic linkage methodology. Patients ≥18 years of age with validated ICD- 9 code for stroke were included. We excluded inter-facility transports and direct admissions. Results: Of 10,456 patients who had a hospital based discharge diagnosis of stroke, 3787 (36%) were transported by EMS. Mean age at the time of admission was 75 years (+/- 14); 55% (2093) were females, 65% (2471) were whites and 86% (3247) were Hispanics. Most of the patients had Medicare (72%, 2737) and 92% (3471) were transported from home. Majority of the patients were treated at stroke centers [n=3014, (80%)]) and at community hospitals [n=3664, (97%)]. Of 3757 patients with a primary diagnosis of stroke, 4% (150) were treated with IV t-PA. After controlling for covariates, patients transported by EMS had higher odds of treatment with IV t-PA (OR 2.6, 95 CI 1.9-3.3). Treatment at stroke centers (OR 1.5, 95 CI 1-2.2) and academic centers were independently associated with treatment rates (OR 2.4, 95 CI 1.6-3.6). Conclusions: Arrival by EMS to emergency department is associated with higher treatment rates with thrombolytics for acute stroke patients and efforts should be targeted to improve use of EMS for stroke.