Standard Emergency Medical Services Research Articles

Abstract 228: Comparative Analysis of Mobile Stroke Treatment Unit (MSTU) and Emergency Department (ED) Patients with Large Vessel Occlusion (LVO) in Need of Endovascular Thrombectomy

Introduction Large vessel occlusion (LVO) strokes represent a critical medical emergency requiring prompt intervention to minimize neurological damage and improve patient outcomes. Traditionally, patients with LVO are taken to the Emergency Department (ED) via standard Emergency Medical Services (EMS) before undergoing endovascular mechanical thrombectomy (MT). However, some Mobile Stroke Treatment Units (MSTUs) are introducing an alternative pathway for rapid, pre‐hospital care by taking the LVO patient directly to the Operating Room (OR), bypassing the ED all together. This study compares the outcomes of patients with LVOs admitted directly to the OR from the MSTU versus those arrived by EMS and admitted through the ED. The findings from this project will aim to inform best practice for managing LVO cases, improve patient care protocols, as well as further investigate the value of a MSTU. Methods This quality improvement project is a retrospective cohort analysis comparing LVO patients directly admitted to the OR from the MSTU versus the standard process of EMS‐to‐ED, excluding hospital‐to‐hospital transfers and arrival by personal vehicle. “Door” for MSTU patients is measured as the time the patient crosses the threshold of the unit. Time measurements for MSTU LVO patients include transport time to the hospital. We reviewed the records of patients with LVO treated with mechanical thrombectomy at the University of Florida between 7/25/23 and 6/30/24. Demographics, endovascular thrombectomy stroke metrics, functional outcomes, and mortality data were compared using univariate and multivariate logistic regression analyses. Results A total of 71 patients (mean age 72.2, 47.8% female) were included in the final analyses. 20 patients in the MSTU cohort and 51 patients in the ED cohort were evaluated. The MSTU patient cohort had a faster mean door‐to‐puncture time of 40.9 minutes compared to 65.2 minutes for the ED cohort (OR 1.10 (95%CI 1.04‐1.17), p=0.001). Similarly, the MSTU cohort also had a faster mean door‐to‐recanalization time of 62.9 minutes versus 86.4 minutes in the ED cohort (OR 1.06 (96%CI 1.02‐1.11), p=0.003). These findings remained statistically significant despite adjusting for age and sex. Patients treated on the MSTU with direct to OR also had higher odds of being discharged with favorable functional outcomes defined as mRS of 0‐2 compared to patient arriving via EMS‐to‐ED (OR 9.61 (95%C.I. 1.64‐56.4), p=0.012, adjusted for age and sex). While not statistically significant, we also found a trend towards decreased mortality with patients treated on the MSTU (p=0.09). Conclusion Our study demonstrates improved quality measures and outcomes for LVO stroke patients treated on a MSTU. The MSTU brings expert stroke care to the patient and allows for improved early diagnosis and intervention. With direct admission to the OR, door‐to‐puncture and door‐to‐recanalization times were significantly decreased and functional outcomes were improved as compared to those admitted through the ED via traditional EMS arrival. MSTUs are well‐positioned to enhance the efficiency and effectiveness of LVO stroke pathways by providing more timely treatment, and improving stroke systems of care and patient outcomes.

Mobile Stroke Unit Management in Patients With Acute Ischemic Stroke Eligible for Intravenous Thrombolysis

Clinical trials have suggested that prehospital management in a mobile stroke unit (MSU) improves functional outcomes in patients with acute ischemic stroke who are potentially eligible for intravenous thrombolysis, but there is a paucity of real-world evidence from routine clinical practice on this topic. To determine the association between prehospital management in an MSU vs standard emergency medical services (EMS) management and the level of global disability at hospital discharge. This was a retrospective, observational, cohort study that included consecutive patients with a final diagnosis of ischemic stroke who received either prehospital management in an MSU or standard EMS management between August 1, 2018, and January 31, 2023. Follow-up ended at hospital discharge. The primary analytic cohort included those who were potentially eligible for IV thrombolysis. A separate, overlapping cohort including all patients regardless of diagnosis was also analyzed. Patient data were obtained from the American Heart Association's Get With The Guidelines-Stroke (GWTG-Stroke) Program, a nationwide, multicenter quality assurance registry. This analysis was completed in May 2024. Prehospital management in an MSU (vs standard EMS management). The primary efficacy end point was the utility-weighted modified Rankin Scale (UW-mRS) score. The secondary efficacy end point was independent ambulation status. The coprimary safety end points were symptomatic intracranial hemorrhage (sICH) and in-hospital mortality. Of 19 433 patients (median [IQR] age, 73 [62-83] years; 9867 female [50.8%]) treated at 106 hospitals, 1237 (6.4%) received prehospital management in an MSU. Prehospital management in an MSU was associated with a better score on the UW-mRS at discharge (adjusted mean difference, 0.03; 95% CI, 0.01-0.05) and a higher likelihood of independent ambulation at discharge (53.3% [468 of 878 patients] vs 48.3% [5868 of 12 148 patients]; adjusted risk ratio [aRR], 1.08; 95% CI, 1.03-1.13). There was no statistically significant difference in sICH (5.2% [57 of 1094] vs 4.2% [545 of 13 014]; aRR, 1.30; 95% CI, 0.94-1.75]) or in-hospital mortality (5.7% [70 of 1237] vs 6.2% [1121 of 18 196]; aRR, 1.03; 95% CI, 0.78-1.27) between the 2 groups. Among patients with acute ischemic stroke potentially eligible for intravenous thrombolysis, prehospital management in an MSU compared with standard EMS management was associated with a significantly lower level of global disability at hospital discharge. These findings support policy efforts to expand access to prehospital MSU management.

Impact of Mobile Stroke Units on Patients With Large Vessel Occlusion Acute Ischemic Stroke: A Prespecified BEST‐MSU Substudy

BackgroundThe impact of mobile stroke units (MSUs) on outcomes in patients with large vessel occlusions eligible for endovascular thrombectomy (EVT) has yet to be characterized.MethodsWe completed a prespecified substudy of patients with EVT‐eligible stroke with anterior and posterior circulation large vessel occlusions on computed tomography and/or computed tomography angiography who were enrolled in BEST‐MSU (Benefits of Stroke Treatment using a Mobile Stroke Unit). Primary outcome was 90‐day utility‐weighted modified Rankin scale. Groups were compared using chi‐square or Fisher's exact tests for categorical variables, and 2‐samplet‐tests for continuous variables. Multiple logistic regression was used to assess the effect of MSU on binary outcomes after adjusting for other baseline factors.ResultsOf 1515 trial patients, 293 had large vessel occlusions eligible for EVT: 168 in the MSU group and 125 in the emergency medical services group. Baseline characteristics were comparable, with the exception of baseline National Institutes of Health Stroke Scale score (MSU median 19 [interquartile range 13, 23] versus emergency medical services 16 [11, 20],P= 0.002) and study site. The mean (±SD) score on the utility‐weighted modified Rankin scale at 90 days was 0.63±0.39 in MSU group and 0.51±0.41 in emergency medical services group (mean difference 0.13, 95% CI [0.03–0.22]). After adjustment, MSU had significantly higher odds of functional independence (odds ratio 2.60 [95% CI, 1.45–4.77],P= 0.002). Secondary outcomes also favored MSU: early neurologic recovery (30% improvement in National Institutes of Health Stroke Scale score at 24 hours) 68% versus 52%; adjusted odds ratio 1.98 [95% CI, 1.19–3.33]; time of tissue plasminogen activator bolus from symptom onset 65.0 minutes [50.5–92.0] versus 96.0 [79.3–130.0],P≤0.001. The groups had similar onset to arterial puncture (169.0 minutes [133.5, 210.0] versus 162.0 [135.0–207.0],P= 0.83).ConclusionsIn patients with EVT‐eligible large vessel occlusion stroke, MSU management was associated with better clinical outcomes compared with standard emergency medical services management. MSU management sped thrombolysis but did not expedite EVT treatment times. Future MSU processes should include efforts to capitalize on the potential of MSUs to provide earlier EVT.

Golden Hour Treatment With tPA (Tissue-Type Plasminogen Activator) in the BEST-MSU Study.

Treatment of patients with acute ischemic stroke on mobile stroke units (MSUs) improves outcomes compared with management by standard emergency medical services ambulances and is associated with more patients treated with intravenous tPA (tissue-type plasminogen activator) in the first golden hour after last known normal. We explored the predictors and outcomes of first-hour treatment (FHT) compared with later treatment in an alternating-week cluster-controlled trial of MSUs. We analyzed all patients treated with intravenous tPA in the BEST-MSU Study (Benefits of Stroke Treatment Delivered by a Mobile Stroke Unit Compared to Standard Management by Emergency Medical Services). After stratifying by treatment timeframe, we identified factors associated with FHT. We performed adjusted analyses of the association between FHT and clinical outcome and modeled the shape of the relationship between last known normal-to-treatment time and excellent outcome. Among 941 tPA-treated patients, 206 (21.8%) had lytic started within 60 minutes. Treatment on the MSU, older age, male sex, alert by 911, faster arrival on-scene and imaging, more severe stroke, atrial fibrillation, and absence of heart failure and pretreatment antihypertensive treatment were associated with FHT. Compared with later treatment, FHT was associated with higher adjusted odds ratio for 90-day modified Rankin Scale score of 0 to 1 (odds ratio, 1.87 [95% CI, 1.25-2.84]; P=0.003). Among FHT patients, 68% achieved a 90-day modified Rankin Scale of 0 or 1 or returned to their baseline status. FHT was not associated with higher risk of hemorrhage and was associated with reduced risk of treating neurovascular mimics. FHT almost doubles the odds of excellent clinical outcome without increased risk compared with later treatment, which supports the use of MSUs.

Abstract 24: Mobile Stroke Units Associated With Favorable Clinical Outcome In Large Vessel Occlusion Stroke Patients: BEST-MSU Substudy

Introduction: Mobile Stroke Units (MSUs) improve clinical outcome in patients treated with tPA compared to standard management by Emergency Medical Services (EMS), but the impact of MSUs on outcomes in patients with large vessel occlusions (LVOs) having endovascular thrombectomy (EVT) has yet to be determined. Methods: A pre-specified substudy of tPA-eligible stroke patients with LVOs on CT and/or CTA who were enrolled in the Benefits of Stroke Treatment Using a Mobile Stroke Unit (BEST-MSU), a prospective multicenter controlled trial comparing MSU with standard EMS management, was conducted. The primary outcome was the score on the 90-day utility-weighted modified Rankin Scale (uw-mRS). Secondary outcomes were rate of early neurologic recovery (30% improvement in NIHSS score) at 24 hours and functional independence (mRS 0-1) at 90 days. Results: A total of 295 patients were included, 169 in the MSU group and 126 in the EMS group. Baseline characteristics were comparable between the groups, with the exception of baseline NIHSS (MSU median 19.0 [IQR 13.0, 23.0] vs EMS 16.0 [11.0, 20.0], p=0.003). 92% MSU vs 87% EMS LVO patients received tPA, and 78% vs 85% went on to have EVT. MSU LVO patients had faster tPA bolus from symptom onset (65.0 min [50.5, 92.0] vs 96.0 [79.3, 130.0], p<0.001), however the two groups had similar onset to groin puncture (169.0 min [133.8, 212.3] vs 162.0 [135.3, 207.0], p=0.77). The mean (±SD) score on the uw-mRS at 90 days was 0.64±0.39 in the MSU group and 0.50±0.40 in the EMS group (mean difference 0.16, 95% CI [0.07, 0.25] after adjustment for age, baseline NIHSS, premorbid functional status, prior stroke/TIA and site; p<0.001). Early neurologic recovery (68% vs 52%; adjusted OR 1.89 95% CI [1.14,3.17]) and functional independence (Figure 1, 42% vs 29%; 2.48 [1.38,4.55]) also favored the MSU group. Conclusions: In tPA-eligible LVO stroke patients, MSU management was associated with better clinical outcomes compared with standard EMS management.

Abstract 1122‐000126: Mobile Stroke Unit Process Metrics in Large Vessel Occlusion Stroke Patients: BEST‐MSU Substudy

Introduction : Mobile Stroke Units (MSUs) speed thrombolytic treatment for acute ischemic stroke and improve clinical outcomes compared to standard management by Emergency Medical Services (EMS). However, MSU process metrics in the subset of patients with large vessel occlusions (LVOs) having endovascular thrombectomy (EVT) have yet to be optimized. Methods : A pre‐specified Benefits of Stroke Treatment Using a Mobile Stroke Unit (BEST‐MSU) substudy of tPA‐eligible stroke patients with imaging evident LVOs was conducted. The primary outcome was process metrics related to treatment times from stroke onset and first medical alert. Safety outcomes included rates of symptomatic intracerebral hemorrhage and procedural complications. Groups were compared using Chi‐square or Fisher’s exact tests for categorical variables, and Wilcoxon rank‐sum tests for continuous variables. Results : A total of 295 patients were included, 169 in the MSU group and 126 in the EMS group. Baseline characteristics were comparable between the groups, with the exception of baseline NIHSS (MSU mean 19.0 [IQR 13.0,23.0] vs EMS 16.0 [11.0, 20.0], p = 0.003). 92% of MSU and 87% of EMS LVO patients received tPA, and 78% and 85% went on to have EVT. Process metrics are detailed in Table 1. MSU LVO patients had faster tPA bolus from 911‐alert (MSU 45.0 minutes [40.0, 53.5] vs EMS 76.0 [64.0, 87.8], p<0.001), however the two groups had similar alert to groin puncture (MSU 142.5 [116.8, 171.0] versus EMS 131.5 [114.0, 159.8], p = 0.15). MSU patients spent more time on‐scene, (EMS arrival to ED arrival, 53.0 [45.0, 62.0] vs 27.0 [22.0, 33.0], p<0.001) however less time prior to EVT (door to groin puncture, 76.5 [54.8, 108.5] vs 94.0 [72.0, 123.0], p<0.001) with variable use of field CTAs and direct cath lab admission with ED bypass, yielding a net neutral result. The variability among site protocols is reflected in the range of median alert to groin puncture times (minimum 107.0 minutes, maximum 152.0). In the 222 patients undergoing EVT, median alert to recanalization time was 181.5 minutes [146.8, 225.5] in the MSU group and 190.5 [157.5, 227.5] in the EMS group (p = 0.47). Recanalization (Thrombolysis In Cerebral Infarction [TICI] 2b/3) was achieved in 76% of MSU and 70% of EMS (p = 0.32) with comparable rates of EVT complications (including hemorrhage, perforation, dissection, hematoma). 54% MSU and 44% of EMS LVO patients achieved good functional outcome (modified Rankin Scale [mRS] ≤ 2) at 90 days (p = 0.11). Conclusions : In tPA‐eligible LVO stroke patients, MSU management did not increase or expedite EVT treatment times as compared to standard EMS management. Future MSU processes should include field CTA with direct admission to cath labs to maximize the early treatment advantage this technology provides.

Optimized Benzodiazepine Treatment of Pediatric Status Epilepticus Through a Standardized Emergency Medical Services Resuscitation Tool

BackgroundOptimized benzodiazepine (BZD) dosing decreases morbidity and mortality in children with status epilepticus (SE), but previous studies have documented widespread underdosing. Prior interventions have focused on in-hospital SE treatment, although more than 75% of pediatric patients with SE are initially treated by emergency medical services (EMS). Our goal was to assess whether an EMS-focused, collaboratively developed dosing resuscitation aid (Medic One Pediatric [MOPed] cards) and training could improve BZD dosing and pediatric SE outcomes. MethodsWe conducted a retrospective review of patients aged 12 years and younger treated by EMS for SE and transferred to Seattle Children's Hospital during the 1 year before and immediately after MOPed card training. The primary outcome was the percentage of patients receiving underdosed BZD treatment. Secondary outcomes included time to second-line antiseizure medication (ASM), intubation, and intensive care unit (ICU) admission. ResultsThe 44 children before and 33 after MOPed implementation were similar with respect to age, gender, and pre-existing epilepsy diagnosis. The percentage of children receiving underdosed BZDs fell from 52% to 6% after MOPed implementation (P < 0.001). There was no significant decrease in requirement for intubation and ICU admission. The interval to treatment with a second-line ASM remained prolonged. ConclusionsEMS-focused training significantly increased the percentage of outpatient pediatric patients with SE who received recommended initial BZD treatment. This improvement in management of SE did not significantly alter the rate of intubation or ICU admission, suggesting the need for further optimization of out-of-hospital SE care, particularly access to and timely use of second-line ASMs.

Accuracy of emergency medical services (EMS) telephone triage in identifying acute coronary syndrome (ACS) for patients with chest pain: a systematic literature review

ObjectiveTo systematically appraise the available evidence to determine the accuracy of decision aids for emergency medical services (EMS) telephone triage of patients with chest pain suspected to be caused by...

Statewide Emergency Medical Services Protocols for Status Epilepticus Management.

Although seizures are common in prehospital settings, standardized emergency medical services (EMS) treatment algorithms do not exist nationally. We examined nationwide variability in status epilepticus treatment by analyzing 33 publicly available statewide EMS protocols. All adult protocols recommend intravenous benzodiazepines (midazolam, n = 33; lorazepam, n = 23; diazepam, n = 24), 30 recommend intramuscular benzodiazepines (midazolam, n = 30; lorazepam, n = 8; diazepam, n = 3), and 27 recommend intranasal benzodiazepines (midazolam, n = 27; lorazepam, n = 3); pediatric protocols also frequently recommend rectal diazepam (n = 14). Recommended dosages vary widely, and first- and second-line agents are designated in only 18 and 2 states, respectively. Given this degree of variability, standardized national EMS guidelines are needed. ANN NEUROL 2021;89:604-609.

Impact of a Standardized Patient Hand-off Tool on Communication between Emergency Medical Services Personnel and Emergency Department Staff

Introduction Handoff communication between Emergency Medical Services (EMS) and Emergency Department (ED) staff is critical to ensure quality patient care. In January 2016, the Southwest Texas Regional Advisory Council (STRAC) implemented MIST (Mechanism, Injuries, vital Signs, Treatments), a standardized EMS to ED handoff tool. The En route Care Research Center conducted a Pre-MIST implementation survey of ED staff in December 2015 and a Post-MIST follow-up survey in July 2017 to determine the impact of the MIST handoff tool on the perceived quality of transmission of pertinent patient information and in the overall handoff experience. Methods We administered a nine-item Likert scale questionnaire to Brooke Army Military Medical Center (BAMC) ED providers and nurses before and after implementation of MIST. The questionnaire captured perceived competence and satisfaction with handoff communication (Cronbach’s alpha 0.73). We analyzed responses for the total sample and by occupation (providers and nurses), and we calculated odds ratios to determine items that may be most predictive of a positive handoff experience from the perspective of the ED staff. We performed chi-square tests and reported data as percentages. Results Total respondents Pre- and Post-MIST were 128 (62%) nurses and 80 (38%) providers (MDs, DOs, and PAs). Following the implementation of MIST, more respondents reported that they were "informed of prehospital treatments" (p < 0.001), that "Red/Blue Trauma Alert Criteria were conveyed” (p < 0.001), and that the "time to give the report was sufficient to convey pertinent information” (p < 0.001). Nurses more frequently reported that "Red/Blue Trauma Alert Criteria were conveyed" post-MIST (p < 0.01). Providers more frequently reported that "Assessment findings were conveyed" (p < 0.05), that they ‘interrupted the report for clarification" (p < 0.04), that "time to give the report was sufficient to convey pertinent information" (p < 0.001) and that they "felt positive about the overall handoff experience" (p < 0.03) Post-MIST. Overall satisfaction with the handoff was associated with frequently being informed of prehospital treatments (OR 5.5; 2.1–14.4) and frequently receiving a copy of the prehospital record (OR 2.9; 1.1–7.2). Conclusions These data demonstrate that providers and nurses reported an improvement in the handoff experience Post-MIST. This study supports the use of a standardized handoff tool at this critical step in patient care.

Cost-Consequence Analysis of Mobile Stroke Units vs. Standard Prehospital Care and Transport.

Background: Mobile stroke units (MSUs) are the latest approach to improving time-sensitive stroke care delivery. Currently, there are no published studies looking at the expanded value of the MSU to diagnose and transport patients to the closest most appropriate facility. The purpose of this paper is to perform a cost consequence analysis of standard transport (ST) vs. MSU.Methods and Results: A cost consequence analysis was undertaken within a decision framework to compare the incremental cost of care for patients with confirmed stroke that were served by the MSU vs. their simulated care had they been served by standard emergency medical services between July 2014 and October 2015. At baseline values, the incremental cost between MSU and ST was $70,613 ($856,482 vs. $785,869) for 355 patient transports. The MSU avoided 76 secondary interhospital transfers and 76 emergency department (ED) encounters. Sensitivity analysis identified six variables that had measurable impact on the model's variability and a threshold value at which MSU becomes the optimal strategy: number of stroke patients (>391), probability of requiring transfer to a comprehensive stroke center (CSC, >0.52), annual cost of MSU operations (<$696,053), cost of air transfer (>$8,841), probability initial receiving hospital is a CSC (<0.32), and probability of ischemic stroke with ST (<0.76).Conclusions: MSUs can avert significant costs in the administration of stroke care once optimal thresholds are achieved. A comprehensive cost-effectiveness analysis is required to determine not just the operational value of an MSU but also its clinical value to patients and the society.

Benefits of adding a physician-staffed ambulance to bystander-witnessed out-of-hospital cardiac arrest: a community-based, observational study in Niigata, Japan

ObjectiveThis study aimed to assess the benefits of adding a physician-staffed ambulance to bystander-witnessed out-of-hospital cardiac arrest using a community-based registry.DesignPopulation-based, retrospective cohort study.SettingAn urban city with approximately 800 000...

Abstract WMP114: Regional Stroke Program Coordinator Nurses Standardize EMS Feedback Utilizing Kurt Lewin’s Change Model

Background: The Oregon and South West Washington Cascade Region Stroke Coordinators (CRSC) formed in 2006. By 2015 active membership represented 15 hospitals by 5 health care systems, all certified as either comprehensive or primary stroke centers. Clinical practice guidelines recommend quality improvement processes involving Emergency Medical Services (EMS). April 2017, the CRSC initiated discussions to develop a standardized EMS feedback tool. Purpose: Develop and implement a standardized EMS feedback tool across multiple health care systems to provide feedback on acute ischemic stroke (AIS) treatment cases, while improving stroke coordinator and EMS satisfaction. Methods: April 2017 through April 2018 a core group led efforts, utilizing Lean principles, to develop a standardized EMS feedback tool for AIS treatment cases. The first step was reviewing the variability in existing tools. A survey was created for EMS to identify meaningful elements. From those results a standardized feedback tool was drafted and finalized based on CRSC input. Throughout development, the core-group applied Kurt Lewin’s change model by creating an environment ready for change, actively supporting the CRSC through the change to a new tool, and lastly reinforcing the new tool to sustain the desired change of a standardized EMS feedback tool. A survey 10 weeks post implementation captured stroke coordinators satisfaction. Results: The Portland Standardized Stroke feedback Tool for EMS (PSST EMS) was implemented in April 2018. All sites adopted the tool to provide EMS feedback on AIS treatment cases. Post implementation survey among stroke coordinators had 90% response rate. Seventy-five percent valued a standardized EMS feedback tool even if it meant more work. Ninety percent were satisfied and 10% were neutral with PSST EMS. Anecdotally EMS voiced a high degree of satisfaction with a standardized tool. Conclusion: Applying Kurt Lewin’s change model resulted in a standardized EMS feedback tool for AIS treatment cases in the Cascade region. It is feasible for stroke program coordinator nurses, across multiple health care systems, to collaborate and standardize EMS feedback.

Optimal Scene Time to Achieve Favorable Outcomes in Out-of-hospital Cardiac Arrest: How Long Is Too Long?

BackgroundDespite advances in resuscitation science and public health, out-of-hospital cardiac arrest (OOHCA) cases have an average survival rate of only 12% nationwide, compared to 24.8% of cases occurring in hospital. Many factors, including resuscitation interventions, contribute to positive patient outcomes and have, therefore, been studied in attempts to optimize emergency medical services (EMS) protocols to achieve higher rates of return of spontaneous circulation (ROSC) in the field. However, no consensus has been met regarding the appropriate amount of time for EMS to spend on scene.AimA favorable outcome is defined as patients that achieved the combination of ROSC and a final disposition of “ongoing resuscitation in the emergency department (ED).” The primary purpose of this preliminary study was to determine the scene time interval (STI) in which American urban EMS systems achieved the highest rates of favorable outcomes in non-traumatic OOHCAs.MethodsAll EMS-related data, including demographics, presenting rhythm, airway management, chemical interventions, and ROSC were recorded using a standardized EMS charting system by the highest-ranking EMS provider on the ambulance. The reports were retrospectively collected and analyzed.ConclusionOur data suggest that the optimal 20-minute STI for OOHCA patients in an urban EMS system is between 41 and 60 minutes. Interestingly, the 10-minute interval within the 41-60 minute cohort that provided the highest rate of ROSC was between 41 and 50 minutes. Generally, the longer the STI, the greater the percentage of favorable outcomes up to the 50-minute mark. Once past 50 minutes, a phenomenon of diminishing return was observed and the rates of favorable outcomes sharply declined. This suggests a possible “sweet spot” that may exist regarding the optimal scene time in a cardiac arrest encounter. Significant differences between the average number of interventions per patient were found, however, many confounding factors and the limited data set make the results difficult to generalize.

Gender Disparities in Out-of-hospital Cardiac Arrests.

BackgroundDespite advances in resuscitation science and public health, out-of-hospital cardiac arrest (OOHCA) has an average survival rate of only 12% nationwide, compared to 24.8% of patients who suffer from cardiac arrest while in hospital. Additionally, gender is an important element of human health, and there is a clear pattern for gender-specific survivability in cardiac arrest. This study examined differences in presentations, treatment, management, and outcomes.AimThe primary focus of this study was to shed light on differences in presentations, treatments, and outcomes between men and women suffering from an out-of-hospital cardiac arrest and the accompanying contributing factors.MethodsAll emergency medical services-related data, including age, date, initial rhythm, chemical interventions (i.e., epinephrine, dextrose), blood glucose levels, defibrillations, endotracheal tube (ETT) attempts, final airway management, achievement of return of spontaneous circulation (ROSC), and the conclusion of the case up to the emergency department, were recorded using a standardized emergency medical services (EMS) charting record by the highest-ranking EMS provider on the ambulance. The reports were retrospectively collected and analyzed.ConclusionThe study examined demographics, treatments rendered, and outcomes in OOHCA cases that occurred in a major United States (US) city in 2016. Several significant differences in care were noted between men and women. In general, women received less respiratory, chemical, and electrical interventions than men; however, statistically significant differences were only observed in the number of attempts of endotracheal intubations, number of doses of epinephrine per encounter, and number of defibrillations per encounter. In spite of generally receiving less care, women appeared to respond more favorably to cardiac arrest interventions, as demonstrated by higher rates of ROSC. Despite this, women were also found to be eight years older at the time of arrest. Future studies are needed to determine causality in discrepancies between the genders in addition to investigating differences in treatment in other areas of the United States.

Establishing Recommendations for Stroke Systems in the Thrombectomy Era: The Upstate New York Stakeholder Proceedings

The American Heart Association/American Stroke Association and Department of Health Stroke Coverdell Program convened a stakeholder meeting in upstate NY to develop recommendations to enhance stroke systems for acute large vessel occlusion. Prehospital, hospital, and Department of Health leadership were invited (n=157). Participants provided goals/concerns and developed recommendations for prehospital triage and interfacility transport, rating each using a 3-level impact (A [high], B, and C [low]) and implementation feasibility (1 [high], 2, and 3 [low]) scale. Six weeks later, participants finalized recommendations. Seventy-one stakeholders (45% of invitees) attended. Six themes around goals/concerns emerged: (1) emergency medical services capacity, (2) validated prehospital screening tools, (3) facility capability, (4) triage/transport guidelines, (5) data capture/feedback tools, and (6) facility competition. In response, high-impact (level A) prehospital recommendations, stratified by implementation feasibility, were (1) use of online medical control for triage (6%); (2) regional transportation strategy (31%), standardized emergency medical services checklists (18%), quality metrics (14%), standardized prehospital screening tools (13%), and feedback for performance improvement (7%); and (3) smartphone application algorithm for screening/decision-making (6%) and ambulance-based telemedicine (6%). Level A interfacility transfer recommendations were (1) standardized transfer process (32%)/timing goals (16%)/regionalized systems (11%), performance metrics (11%), image sharing capabilities (7%); (2) provider education (9%) and stroke toolbox (5%); and (3) interfacility telemedicine (7%) and feedback (2%). The methods used and recommendations generated provide models for stroke system enhancement. Implementation may vary based on geographic need/capacity and be contingent on establishing standard care practices. Further research is needed to establish optimal implementation strategies.

Abstract WP240: Ultra-acute Diagnostics for Stroke: Large-scale Implementation of Prehospital Biomarker Sampling

Background and purpose: Blood-based biomarkers could enable early and cost-effective diagnostics for acute stroke patients in the prehospital setting to support early initiation of treatments. However, large prehospital sample sets required for biomarker discovery and validation are missing, and the feasibility of large-scale blood sampling by emergency medical services (EMS) has not been determined. We set out to establish extensive prehospital blood sampling of thrombolysis candidates in the catchment area of our comprehensive stroke center, with a 1.5 million population base. Methods: EMS personnel were trained to collect prehospital blood samples using a cannula-adapter technique. Time delays, sample quality and performance bottlenecks were investigated between May 20, 2013 and May 19, 2014. Results: Prehospital blood sampling and study recruitment were successfully performed in 430 thrombolysis candidates, of which 55.3% were admitted outside office hours. The median (interquartile range) emergency call to prehospital sample time was 33 minutes (25-41), and the median time from reported symptom onset or wake-up to prehospital sample was 53 minutes (38-85; n=394). Prehospital sampling was performed 31 minutes (25-42) earlier than admission blood sampling, and 37 minutes (30-47) earlier than admission neuroimaging. Quality control data from 25 participating EMS units indicated a 4-minute increase in median transport time (from arrival on-scene to hospital door) for study patients compared to patients of the preceding year. The hemolysis rate in serum and plasma samples was 6.5% and 9.3% for EMS samples, and 0.7% and 1.6% for admission samples collected with venipuncture. Conclusions: Prehospital biomarker sampling is feasible in standard EMS units and provides a median timesaving of over 30 minutes to obtain first blood samples. Large biobanks of prehospital blood samples will facilitate development of ultra-acute stroke biomarkers.

Community-based automated external defibrillator only resuscitation for out-of-hospital cardiac arrest patients

Speed is the cornerstone of rescue for out-of-hospital cardiac arrest. As a consequence, community participation programs have been initiated to decrease response times. Even in the very best of these programs, however, short-term survival rates hover around 10% and long-term survival rates are half that. In most locales, survival is far worse. In Piacenza, Italy, responders have been trained for more than a decade to use publicly available automated external defibrillators (AEDs) and eschew the performance of cardiopulmonary resuscitation (CPR). It is known locally as "Progetto Vita." From 2001 to 2014, we prospectively collected outcome data on all Progetto Vita-treated patients and all 3271 standard emergency medical services (EMS) patients. Progetto Vita rescuers simply accessed a public AED, turned it on, and only followed its instructions. Progetto Vita rescuers did not do CPR of any sort. If EMS arrived prior to initiation or even completion of the Progetto Vita protocol, EMS-supplanted Progetto Vita efforts and patients were not included in the Progetto Vita cohort. Follow-up was collected by each responder's data files, medical record review, and use of the Italian system death index. All cardiac arrest patients' death status was validated in 100% of patients through August 1, 2014. Survival to hospital discharge occurred in 39 (41.4%) of the 95 patients treated by Progetto Vita and in 193 (5.9%) of the 3271 EMS patients. At 13-year follow-up, the Kaplan-Meier estimates of survival were 31.8% when AEDs only were used and 2.4% for standard EMS/CPR response. Estimates of survival are significantly better for Progetto Vita AED-only therapy when survival was stratified by time to respond, gender, location of cardiac arrest, and shockable rhythm. Relative to the 95 EMS patients with the fastest response times, Progetto Vita intervention was associated with a more than 2-fold increased rate of survival. This is the first demonstration of excellent long-term survival from out-of-hospital cardiac arrest by promoting speed and ease of lay AED response without CPR.

Abstract 12846: Resuscitation of Out-of-Hospital Cardiac Arrest Without CPR: The 13-Year Experience of Progetto Vita

Introduction: Cardiopulmonary resuscitation (CPR) currently represents standard of care in out-of-hospital cardiac arrest (OOHCA) despite the demonstration of its many side effects. To date, CPR has never been tested in a randomized, prospective clinical trial against an automated external defibrillator (AED) quick deployment, as such a trial is considered impossible for ethical reasons. Nevertheless, insights on the effective role of CPR when an AED is quickly available can be provided from the Progetto Vita of Piacenza, Italy: the first early defibrillation project established in Europe. Hypothesis: To compare differences in 13-year survival between OOHCA victims rescued by standard care and patients rescued by AED-only trained responders. Methods: Prospective, non-randomized parallel study comparing mortality when rescuers only used automated external defibrillators (AEDs) and did not perform CPR with mortality from the standard Emergency Medical Services (EMS) response, including CPR. Survival was followed over 13 years, from June 2001 to July 2014. Results: In 3366 OOHCAs, survival to hospital discharge occurred in 39 of the 95 patients treated with an AED only and in 193 of the 3271 patients treated by standard EMS (41.4% vs. 5.9%; p&lt;0.001) The Kaplan Meier estimates of survival after 13-years follow-up are 31.8% when AEDs only were used versus 2.4% for standard EMS response. Estimates of survival also are significantly better for Progetto Vita when survival was stratified by gender and location of cardiac arrest. Presence of a shockable rhythm at rescuers arrival was associated with a 16.8-fold increased chance of survival to discharge. Progetto Vita intervention was independently associated with a 2.8-fold increased chance of survival to discharge, regardless of minutes from dispatch to arrival, cardiac arrest location, rhythm presentation, and age. Conclusions: Progetto Vita demonstrates excellent long-term survival from out-of-hospital cardiac arrest without CPR use compared with standard resuscitation. The findings from the present study could provide solid "real-world" evidence for the broadscale dissemination of AEDs quickly available to layperson rescuers.

Prehospital Breech Delivery with Fetal Head Entrapment –A Case Report and Review

We present a case in which an emergency medical services (EMS) crew was called for a precipitous breech delivery with fetal head entrapment that was unrelieved following standard prehospital interventions and eventually resulted in neonatal cardiac arrest and death. Although this is a rare occurrence, EMS responders must have adequate training and guidelines on how to assist with vaginal delivery of breech presentation and how to appropriately manage fetal head entrapment in the field. There is little literature to provide guidance but it appears that standard EMS teaching does not represent current best obstetrical practice. We review the available literature, make expert recommendations, and provide a sample new treatment guideline for basic life support, advanced life support, and EMS physician response. Key words: prehospital; fetal head entrapment; breech delivery