Statewide Emergency Medical Services Research Articles

Effect of a peer-led emergency department behavioral intervention on non-fatal opioid overdose: 18-month outcome in the Navigator randomized controlled trial.

Emergency departments (EDs) provide an opportunity to identify people at risk of overdose and reduce the risk. We evaluated the effect of an ED behavioral intervention delivered by peer recovery support specialists (PRSSs) on non-fatal opioid overdose. Two-arm, randomized trial. Two EDs in Rhode Island, USA. ED patients presenting with an opioid overdose, complications of opioid use disorder or a recent history of opioid overdose (November 2018-May 2021). Among 648 participants, the mean age was 36.9years, 68.2% were male and 68.5% were White. Participants were randomized to receive a behavioral intervention from a PRSS (n = 323) or a licensed clinical social worker (LICSW) (n = 325). PRSS and LICSW used evidence-based interviewing and intervention techniques, informed by their lived experience (PRSS) or clinical theory and practice (LICSW). We identified non-fatal opioid overdoses in the 18 months following the ED visit through linkage to statewide emergency medical services data using a validated case definition. The primary outcome was any non-fatal opioid overdose during the 18-month follow-up period. Among 323 participants randomized to the PRSS arm, 81 (25.1%) had a non-fatal opioid overdose during follow-up, compared with 95 (29.2%) of 325 participants randomized to the LICSW arm (P = 0.24). There was no statistically significant difference in the effectiveness of randomization to the PRSS arm versus the LICSW arm on the risk of non-fatal opioid overdose, adjusting for the history of previous overdose (relative risk = 0.86, 95% confidence interval = 0.67-1.11). In Rhode Island, USA, over one-in-four emergency department patients at high risk of overdose experience a non-fatal opioid overdose in the 18 months post-discharge. We found no evidence that the risk of non-fatal opioid overdose differs for emergency department patients receiving a behavioral intervention from a peer recovery support specialist versus a licensed clinical social worker.

Growth of Statewide Emergency Medical Services Bypass Policies for Acute Stroke

Growth of Statewide Emergency Medical Services Bypass Policies for Acute Stroke

Exertional Heat Stroke Best Practices in US Emergency Medical Service Guidelines

BackgroundExertional heat illnesses (EHI), specifically exertional heat stroke (EHS) is a top cause of non-accidental death among US laborers. EHS management requires coordination between Emergency Medical Services (EMS) and workplace officials to implement cold water immersion (CWI) and cool first-transport second (CFTS). ObjectiveThe purpose was to 1) quantify and identify existing statewide EMS guidelines, 2) determine if statewide EHS guidelines improved outcomes for EHI in laborers, and 3) to examine the odds of laborer EHS fatalities due to EHS when best practices are present in EMS statewide guidelines. MethodsThe Paramedic Protocol Provider database and official EMS websites were examined if they had statewide EMS guidelines, and of those with statewide guidelines a two-way chi-square analysis with associated odds ratios examined EHI outcomes. Statewide EMS guidelines underwent a content analysis regarding EHS best practices by three independent reviewers. Significance was set a priori at p<0.05. ResultsOf 50 states, DC and Puerto Rico, 57.7% (n=30) had statewide EMS guidelines while 42.3% (n=22) did not. There was a significant association for EHI outcome for states recommending CWI as a cooling method vs those that did not (X2(1) = 3.336, p=0.049). The odds of EHS deaths for laborers were 3.0 times higher if CWI was not included in the EMS guidelines. There was a significant association in EHI outcomes for states without CFTS (X2(1) = 5.051, p=0.017. The odds of laborers dying from EHS were 3.7 times higher in states without CFTS. ConclusionsLaborers are 3.0-3.7 times less likely to die from EHS when statewide EMS guidelines contain CWI and CFTS, respectively.

When Should EMS Call a Child a Small Adult: Inconsistency in Protocol Definitions

Age may be a factor in Emergency Medical Services (EMS) treatment of patients, and understanding of age-related patient differences is important to those providing care in the prehospital environment. The US Health Resources and Services Administration’s Maternal Child Health Bureau (HRSA MCHB) through their Emergency Medical Services for Children (EMSC) program has coordinated a focus on pediatric EMS care. However, there is a wide variety of age and other categorizations used to define the pediatric EMS population. This paper reviews the current state of pediatric EMS categorization from several sources, including national-level agencies and organizations, EMS Protocols, and other sources, and provides an overview of the anatomic, physiologic, and behavioral parameters that are generally expected within the range of pediatric ages. We found that, of 32 states publishing statewide EMS protocols online, there was great variability in the definition of a pediatric patient. The age at which states identified the transition from pediatric to adult patient ranged from 12-18 years old, and several states used non-aged-based definitions.

Emergency Medical Services Protocols for Assessment and Treatment of Patients with Ventricular Assist Devices.

Patients with ventricular assist devices (VADs) represent a growing population presenting to Emergency Medical Services (EMS), but little is known about their prehospital care. This study aimed to characterize current EMS protocols in the United States for patients with VADs. States with state-wide EMS protocols were included. Protocols were obtained from the state EMS website. If not available, the office of the state medical director was contacted. For each state, protocols were analyzed for patient and VAD assessment and treatment variables. Of 32 states with state-wide EMS protocols, 21 had VAD-specific protocols. With 17 (81%) states noting a pulse may not be palpable, protocols recommended assessing alternate measures of perfusion and mean arterial pressure (MAP; 15 [71%]). Assessment of VAD was advised through listening for pump hum (20 [95%]) and alarms (20 [95%]) and checking the power supply (15 [71%]). For treatment, EMS prehospital consultation was required to begin chest compression in three (14%) states, and mechanical (device) chest compressions were not permitted in two (10%) states. Contact information for VAD coordinator was listed in a minority of five (24%) states. Transport of VAD equipment/backup bag was advised in 18 (86%) states. This national analysis of EMS protocols found VAD-specific EMS protocols are not universally adopted in the United States and are variable when implemented, highlighting a need for VAD teams to partner with EMS agencies to inform standardized protocols that optimize these patients' care.

Abstract WP93: Providing Stroke Reports to Emergency Medical Services (EMS) Agencies Improves Data Quality in Michigan's Statewide EMS Data Repository

Intro: The Michigan Stroke Program (MiSP) monitors statewide EMS stroke care performance and data quality. Starting in 2018, quarterly performance and outcome benchmark data were shared with EMS agency partners to support prehospital quality improvement (QI) for stroke patients. Objective: To improve EMS data quality and prehospital stroke care performance. Methods: This is a retrospective before and after study of the impact of tailored QI interventions to improve EMS compliance with three prehospital stroke quality metrics selected by MiSP EMS partners: (prehospital stroke scale documentation, last known well documentation, and prehospital notification). Five MiSP EMS partners participated in the intervention which consisted of provision of quarterly performance reports generated from linked data from Michigan’s EMS Information System and the Michigan Stroke Registry. The MiSP team reviewed agency performance with EMS leadership to select the target measures for intervention and then assisted in development of a QI plan to improve agency performance. Measure compliance was compared from three months prior to and six months after data quality solutions were implemented. Results: Through data sharing and communication with EMS agencies and EMS software data vendors, common themes were identified related to poor data quality beginning in January 2020. A sample of agencies and resolutions to address these issues are displayed in the Table. Compliance with the targeted metric improved significantly at each agency at three and six months following intervention. Conclusions: Analysis of EMS data and sharing performance data directly with EMS agency partners identified correctable data quality issues negatively impacting EMS quality measures. Correcting these issues led to dramatic and sustained improvement in EMS quality metric compliance. This approach may serve as a model for improving the accuracy of EMS performance data in state-level EMS registries.

Acute Severe Behavioral Disturbance Requiring Parenteral Sedation in Pediatric Mental Health Presentations to Emergency Medical Services: A Retrospective Chart Review

To describe the epidemiological factors of mental health presentations in young people to emergency medical services (EMS) and define those experiencing acute severe behavioral disturbance by reviewing parenteral sedation use. We performed a retrospective review of records of EMS attendance for young people (aged <18 years) with mental health presentations between July 2018 and June 2019 to a statewide EMS system in Australia of a population of 6.5 million persons. In addition, epidemiological data and information about parenteral sedation for acute severe behavioral disturbance and any adverse events were extracted from the records and analyzed. A total of 7,816 patients had mental health presentations with a median age of 15 years (IQR 14-17). The majority (60%) were female. These presentations accounted for 14% of all pediatric presentations to EMS. Out of them, 612 (8%) received parenteral sedation for acute severe behavioral disturbance. A number of factors were associated with increased odds of parenteral sedative medication being used, including autism spectrum disorder (odds ratio [OR] 3.3; confidence interval [CI], 2.7 to 3.9), posttraumatic stress disorder (OR 2.8; CI, 2.2 to 3.5) and intellectual disability (OR 3.6; CI, 2.6 to 4.8). The majority (460, 75%) of young people received midazolam as their first-line medication, with the remaining patients being provided ketamine (152, 25%). No serious adverse events were noted. Mental health conditions were a common presentation to EMS. A history of autism spectrum disorder, posttraumatic stress disorder, or an intellectual disability increased the odds of receiving parenteral sedation for acute severe behavioral disturbance. Sedation appears generally safe in the out-of-hospital setting.

Emergency Medical Services Management of Bronchospasm in the United States: A Cross-Sectional Analysis and Nationwide Quality Assessment

Background/Objective: Bronchospasm, caused by asthma and other related conditions, is a significant cause of morbidity and mortality commonly managed by emergency medical services (EMS). We aimed to evaluate the quality of prehospital management of bronchospasm by EMS in the US. Methods: The National EMS Information System Public Release Research dataset, a nationwide convenience sample of prehospital patient care report data from 2018 to 2019, was used to capture 9-1-1 activations where patients aged ≥2 years were treated and transported by EMS for suspected bronchospasm. First, we described the extent to which EMS care met eight quality measures identified from available statewide EMS protocols, existing quality measures, and national guidelines. Second, we quantified the extent of risk-standardized agency-level variation in administration of inhaled beta agonists and systemic corticosteroids using logistic regression models, accounting for patient characteristics, severity, and clustering by agencies. Third, we compared rates of completed prehospital interventions between pediatric (age <18 years) versus adult patients using two-sample t-tests. Results: A total of 1,336,988 EMS encounters for suspected bronchospasm met inclusion criteria. Median age of patients was 66 years, with only 4% pediatric; 55% were female. Advanced life support (ALS) units managed 94% of suspected bronchospasm. Respiratory rate (98%) and pulse oximetry (96%) were documented in nearly all cases. Supplemental oxygen was administered to hypoxic patients by 65% of basic life support (BLS) and 73% of ALS units. BLS administered inhaled beta-agonist therapy less than half the time (48%), compared to 77% by ALS. ALS administered inhaled anticholinergic therapy in 38% of cases, and systemic corticosteroids in 19% of cases. Pediatric patients were significantly less likely to receive supplemental oxygen when hypoxic, inhaled beta-agonists, inhaled anticholinergics, or systemic corticosteroids. Conclusions: We found important gaps in recent EMS practice for prehospital care of suspected bronchospasm. We highlight three targets for improvement: inhaled beta-agonist administration by BLS, systemic corticosteroid administration by ALS, and increased interventions for pediatric patients. These findings indicate important areas for research, protocol modification, and quality improvement efforts to improve EMS management of bronchospasm.

The Maryland (USA) Critical Care Coordination Center (C4): From Pandemic to Permanence.

The 2019 coronavirus disease (COVID-19) pandemic created overwhelming demand for critical care services within Maryland's (USA) hospital systems. As intensive care units (ICUs) became full, critically ill patients were boarded in hospital emergency departments (EDs), a practice associated with increased mortality and costs. Allocation of critical care resources during the pandemic requires thoughtful and proactive management strategies. While various methodologies exist for addressing the issue of ED overcrowding, few systems have implemented a state-wide response using a public safety-based platform. The objective of this report is to describe the implementation of a state-wide Emergency Medical Services (EMS)-based coordination center designed to ensure timely and equitable access to critical care. The state of Maryland designed and implemented a novel, state-wide Critical Care Coordination Center (C4) staffed with intensivist physicians and paramedics purposed to ensure appropriate critical care resource management and patient transfer assistance. A narrative description of the C4 is provided. A retrospective cohort study design was used to present requests to the C4 as a case series report to describe the results of implementation. Providing a centralized asset with regional situational awareness of hospital capability and bed status played an integral role for directing the triage process of critically ill patients to appropriate facilities during and after the COVID-19 pandemic. A total of 2,790 requests were received by the C4. The pairing of a paramedic with an intensivist physician resulted in the successful transfer of 67.4% of requests, while 27.8% were managed in place with medical direction. Overall, COVID-19 patients comprised 29.5% of the cohort. Data suggested increased C4 usage was predictive of state-wide ICU surges. The C4 usage volume resulted in the expansion to pediatric services to serve a broader age range. The C4 concept, which leverages the complimentary skills of EMS clinicians and intensivist physicians, is presented as a proposed public safety-based model for other regions to consider world-wide. The C4 has played an integral role in the State of Maryland's pledge to its citizens to deliver the right care to the right patient at the right time and can be considered as a model for adoption by other regions world-wide.

An Analysis of Prehospital Pediatric Medication Dosing Errors after Implementation of a State-Wide EMS Pediatric Drug Dosing Reference

Background Medication dosing errors are common in prehospital pediatric patients. Prior work has shown the overall medication error rate by emergency medical services (EMS) in Michigan was 34.7%. To reduce these errors, the state of Michigan implemented a pediatric dosing reference in 2014 listing medication doses and volume to be administered. Objective To examine changes in pediatric dosing errors by EMS in Michigan after implementation of the pediatric dosing reference. Methods We conducted a retrospective review of the Michigan Emergency Medical Services Information System of children ≤ 12 years of age from June 2016–May 2017 treated by 16 EMS agencies. Agencies were a mix of public, private, third-service, and fire-based. A dosing error was defined as >20% deviation from the weight-appropriate dose listed on the pediatric dosing reference. Descriptive statistics with confidence intervals and standard deviations are reported. Results During the study period, there were 9,247 pediatric encounters, of whom 727 (7.9%) received medications and are included in the study. There were 1078 medication administrations, with 380 dosing errors (35.2% [95% CI 25.3–48.4]). The highest error rates were for dextrose 50% (3/4 or 75% [95% CI 32.57–100.0]) and glucagon (3/4 or 75% [95% CI 32.57–100.0]). The next highest proportions of incorrect doses were opioids: intranasal fentanyl (11/16 or 68.8% [95% CI 46.04–91.46]) and intravenous fentanyl (89/130 or 68.5% [95% CI 60.47–76.45]). Morphine had a much lower error rate (24/51 or 47.1% [95% CI 33.36–60.76]). Midazolam had the third highest error rate, for intravenous (27/50 or 54.0% [95% CI (40.19–67.81]) and intramuscular (25/68 or 36.8% [95% CI 40.19–67.81]) routes. Epinephrine 1 mg/10 ml had an incorrect dosage rate of 35/119 (29.4% [95% CI 20.64–36.99]). Asthma medications had the lowest rate of incorrect dosing (albuterol sulfate 9/247 or 3.6% [95% CI 1.31–5.98]). Conclusions Medications administered to prehospital pediatric patients continue to demonstrate dosing errors despite pediatric dosing reference implementation. Although there have been improvements in error rates in asthma medications, the overall error rate has increased. Continued work to build patient safety strategies to reduce pediatric medication dosing errors by EMS is needed.

The Ability of Paramedics to Accurately Locate Correct Anatomical Sites for Intraosseous Needle Insertion.

Introduction Intraosseous (IO) access is an alternative to peripheral intravenous access, in which a needle is inserted through the cortical bone into the medullary spaceusing either a manual driver or an electric drill. Although studies report high success rates of IO access, failures are often attributed to incorrect site placement due tofailure to adhere to anatomical landmarks. This study was designed to evaluate the ability of paramedics to locatethe correct anatomic location for IO needle insertion. Methods Participants were paramedics who were recruited at Pennsylvania's annual statewide Emergency Medical Services (EMS) conference. After completinga demographics survey which included information about their training and practice environment, they were asked to identify which IO sites were permitted for IO placement using the EZ IO® drill and to place a sticker at those locations on a human volunteer. A transfer sheet was utilized, and the distance between the participants' sticker and the location as marked by a physician board-certified in both Emergency Medicine and Emergency Medical Services was recorded. Descriptive statistics and t-tests were calculated from the records. Results Of 30 paramedics who participated in the study, 25 (83%) had been in practice for more than five years (range: 1-37 years), 13 (46%) reported running more than 20 calls per week, and 23 (79%) reported that they only or mostly provide 9-1-1 EMS response. Ten (36%) participants were currently certified in PHTLS, and 16 (57%) had previously been PHTLS certified. All participants reported having been trained in IO insertion. Seventeen (57%) reported having utilized an IO ≤10 times in the field, and 13 (43%) reported >10 field IO insertions. When asked to identify appropriate IO insertion sites for the EZ IO drill, 26 paramedics (90%) correctly identified both the proximal humerus and proximal tibia. The average distance from the landmark for the humeral insertion site was 5.06 cm, with a statistically significant difference in the means for those who didand did not rotate the arm internally before identifying the humeral IO insertion site (p < .01). The average distance from the landmark at the tibial insertion site was 4.13 cm. Conclusion Although a high percentage of paramedics were able to verbally identify the correct location for IO placement, fewer were able to locate the insertion site on a human volunteer. Our results suggest a need for hands-on refresher training to maintain competency at IO insertion, as it is a rarely utilized procedure in the field.

Emergency Medical Services Stroke Care Performance Variability in Michigan: Analysis of a Statewide Linked Stroke Registry.

Background Emergency medical services (EMS) compliance with recommended prehospital care for patients with acute stroke is inconsistent; however, sources of variability in compliance are not well understood. The current analysis utilizes a linkage between a statewide stroke registry and EMS information system data to explore patient and EMS agency-level contributions to variability in prehospital care. Methods and Results This is a retrospective analysis of a cohort of confirmed stroke cases transported by EMS to hospitals participating in a statewide stroke registry. Using EMS information system data, the authors quantified EMS compliance with 6 performance measures derived from national guidelines for prehospital stroke care: prehospital stroke scale performance, glucose check, stroke recognition, on-scene time ≤15 minutes, time last known well documentation, and hospital prenotification. Multilevel multivariable logistic regression analysis was then used to examine associations between patient-level demographic and clinical characteristics and EMS compliance while accounting for and quantifying the variation attributable to agency of transport and recipient hospital. Over an 18-month period, EMS and stroke registry records were linked for 5707 EMS-transported stroke cases. Compliance ranged from 24% of cases for last known well documentation to 82% for documentation of a glucose check. The other measures were documented in approximately half of cases. Older age, higher National Institutes of Health Stroke Scale, and earlier presentation were associated with more compliant prehospital care. EMS agencies accounted for more than half of the variation in EMS prehospital stroke scale documentation and last known well documentation and 27% of variation in glucose check but <10% of stroke recognition and prenotification variability. Conclusions EMS stroke care remains highly variable across different performance measures and EMS agencies. EMS agency and electronic medical record type are important sources of variability in compliance with key prehospital performance metrics for stroke.

Temporal Changes in Epinephrine Dosing in Out-of-Hospital Cardiac Arrest: A Review of EMS Protocols across the United States.

Administration of epinephrine has been associated with worse neurological outcomes for survivors of out-of-hospital cardiac arrest. The publication of the 2018 PARAMEDIC-2 trial, a randomized and double-blind study of epinephrine in out-of-hospital cardiac arrest, provides the strongest evidence to date that epinephrine increases return of spontaneous circulation (ROSC) but not neurologically intact survival. This study aims to determine if Emergency Medical Services (EMS) cardiac arrest protocols have changed since the publication of PARAMEDIC-2. States in the US utilizing mandatory or model state-wide EMS protocols, including Washington DC, were included in this study. The nontraumatic cardiac arrest protocol as of January 1, 2018 was compared to the protocol in effect on January 1, 2021 to determine if there was a change in the administration of epinephrine. Protocols were downloaded from the relevant state EMS website. If a protocol could not be obtained, the state medical director was contacted. A 2021 state-wide protocol was found for 32/51 (62.7%) states. Data from 2018 were available for 21/51 (41.2%) states. Of the 11 states without data from 2018, all follow Advanced Cardiac Life Support (ACLS) guidelines in the 2021 protocol. Five (15.6%) of the states with a state-wide protocol made a change in the cardiac arrest protocols. Maximum cumulative epinephrine dose was limited to 4mg in Maryland and 3mg in Vermont. Rhode Island changed epinephrine in shockable rhythms to be administered after three cycles of cardiopulmonary resuscitation (CPR) and an anti-arrhythmic. Rhode Island also added an epinephrine infusion as an option. No states removed epinephrine administration from their cardiac arrest protocol. Simple statistical analysis was performed with Microsoft Excel. Several states have adjusted cardiac arrest protocols since 2018. The most frequent change was limiting the maximum cumulative dosage of epinephrine. One state changed timing of epinephrine dosing depending on the rhythm and also provided an option of an epinephrine infusion in place of bolus dosing. While the sample size is small, these changes may reflect the future direction of prehospital cardiac arrest protocols. Significant limitations apply, including the exclusion of local and regional protocols which are more capable of quickly adjusting to new research. Additionally, this study is only focused on EMS in the United States.

185 Identification of At-Risk Patients in a Statewide EMS “Naloxone Leave Behind” Program

Naloxone Leave Behind (NLB) programs are an effective intervention Emergency Medical Services (EMS) can utilize to expand access to naloxone and reduce opioid overdose deaths in high-risk patients with opioid use disorder (OUD). Identification of “At-Risk” persons, patients who experience an opioid-related overdose or have indicators of OUD, is critical for successful program implementation. While many EMS systems have implemented NLB programs, few have reported on program success or areas for improvement.

Paramedic Understanding of Tension Pneumothorax and Needle Thoracostomy (NT) Site Selection.

IntroductionTension pneumothorax is an immediate threat to life. Treatment in the prehospital setting is usually achieved by needle thoracostomy (NT). Prehospital personnel are taught to perform NT, frequently in the second intercostal space (ICS) at the mid-clavicular line (MCL). Previous literature has suggested that emergency physicians have difficulty identifying this anatomic location correctly. We hypothesized that paramedics would also have difficulty accurately identifying the proper location for NT.MethodsA prospective, observational study was performed to assess paramedic ability to identify the location for treatment with NT. Participants were recruited during a statewide Emergency Medical Services (EMS) conference. Subjects were asked the anatomic site for NT and asked to mark the site on a shirtless male volunteer. The site was copied onto a transparent sheet lined up against predetermined points on the volunteer’s chest. It was then compared against the correct location that had been identified using palpation, measuring tape, and ultrasound.Results29 paramedics participated, with 24 (83%) in practice for more than five years and 23 (79%) doing mostly or all 9-1-1 response. All subjects (100%) reported training in NT, although six (21%) had never performed a NT in the field. Nine paramedics (31%) recognized the second ICS at the MCL as the desired site for NT, with 12 (41%) specifying only the second ICS, 11 (38%) specifying second or third ICS, and six (21%) naming a different location (third, fourth, or fifth ICS). None (0%) of the 29 paramedics identified the exact second ICS MCL on the volunteer. Mean distance from the second ICS MCL was 1.37 cm (interquartile range (IQR): 0.7-1.90) in the medial-lateral direction and 2.43 cm in the superior-inferior direction (IQR: 1.10-3.70). Overall mean distance was 3.12 cm from the correct location (IQR: 1.90-4.50). Most commonly, the identified location was too inferior (93%). Allowing for a 2 cm radius from the correct position, eight (28%) approximated the correct placement. 25 (86%) were within a 5 cm radius.ConclusionIn this study, paramedics had difficulty identifying the correct anatomic site for NT. EMS medical directors may need to rethink training or consider alternative techniques.

Variation in Prehospital Protocols for Pediatric Respiratory Distress Management in the United States.

This study aimed to compare statewide emergency medical services protocols for the management of pediatric respiratory distress. We performed a descriptive study of emergency medical services protocols for the management of pediatric respiratory distress in the United States, excluding those without model or mandatory protocols. We compared medication recommendations for specific disease processes, including asthma, croup, epiglottitis, anaphylaxis, generalized respiratory distress, intubation, and drug assisted intubation. Thirty-four state protocols were included. All had protocols to address the management of pediatric respiratory distress. There was high agreement in albuterol use for bronchospasm and epinephrine use in anaphylaxis. Epinephrine was recommended in all anaphylaxis protocols, 27 croup protocols (79%), and 3 epiglottitis protocols (9%). Six states (18%) called for albuterol in patients with generalized respiratory distress. Steroid recommendations and indications had variance among states; 26 states (76%) allowed steroid use in patients with asthma, 19 states (56%) recommended steroid use in anaphylaxis, and 11 (32%) recommended steroid use in croup protocols. The route for steroid administration also varied among protocols. Five states (15%) allowed continuous positive airway pressure application in pediatric patients, whereas endotracheal intubation and rapid sequence intubations had varying requirements as well as recommendations for use. Twelve (35%) listed impending or current respiratory failure as an indication, whereas other states had specific markers, such as Glasgow Coma Scale or oxygen saturation, as indications. All included states had specific recommendations for the management of pediatric respiratory distress. There was consistency in recommendations for albuterol use for wheezing and epinephrine use for anaphylaxis. However, there was wide variability in other uses for epinephrine, steroid administration, continuous positive airway pressure use, and specific treatments for croup and epiglottitis. The findings of this study provide a base for important future evidence-based protocol developments and changes in prehospital pediatric respiratory distress treatment.

A Statewide EMS Viral Syndrome Pandemic Triage Protocol: 24 Hour Outcomes

Background: Early during the COVID-19 pandemic, Emergency Medical Services (EMS) systems encountered many challenges that prompted crisis-level strategies. Maryland’s statewide EMS system implemented the Viral Syndrome Pandemic Triage Protocol which contained a decision tool to help identify patients potentially safe for self-care at home. Objectives: This study assessed the effects of the Maryland Viral Syndrome Pandemic Triage Protocol and the safety of referring patients for self-care at home. Methods: This is a retrospective statewide analysis of EMS patients from March 19 thru September 4, 2020, who were not transported and had documentation of the Viral Syndrome Pandemic Triage Protocol’s decision support tool completed, as well as a random sample of 150 patients who were not transported and did not have documentation of the decision tool. Descriptive statistics were performed as well as a two-stage multivariable logistic regression model for the outcomes of ED presentation within 24 hours and subsequent hospitalization. Results: 301 EMS patients were documented as triaged to home using the protocol and outcomes data were available for 282 (94%). 41(14.5%) patients presented to an ED within 24 hours and 14 (5% of 282) required inpatient hospitalization. Nine (3.2%) patients were subsequently hospitalized with a diagnosis of COVID-19 illness. Of those patients for whom the decision tool was not documented, 35 (23%) had an ED visit within 24 hours and 15 (10%) were hospitalized (p = 0.075). Multivariate logistic regression model results (N = 432) suggest that those with documentation of triage protocol use had some advantage over those patients without documentation. The 95% CIs of the estimated effect of Triage/No Triage protocol documented were wide and crossed the 1.0 limit but overall, all effects Odds Ratios and Adjust Odds Ratios were consistently over 1.0 with the lowest value of 1.3 and the highest value of 2.1. Conclusion: Most patients (95%) who were triaged to self-care at home with home documented decision support tool use did not require hospitalization within 24 hours following EMS encounter and this appears to be safe. Future opportunity exists to incorporate such tools into comprehensive pandemic preparedness strategies along with appropriate follow up and quality improvement mechanisms.

Linking Emergency Medical Services and Emergency Department Data to Improve Overdose Surveillance in North Carolina.

IntroductionLinking emergency medical services (EMS) data to emergency department (ED) data enables assessing the continuum of care and evaluating patient outcomes. We developed novel methods to enhance linkage performance and analysis of EMS and ED data for opioid overdose surveillance in North Carolina.MethodsWe identified data on all EMS encounters in North Carolina during January 1–November 30, 2017, with documented naloxone administration and transportation to the ED. We linked these data with ED visit data in the North Carolina Disease Event Tracking and Epidemiologic Collection Tool. We manually reviewed a subset of data from 12 counties to create a gold standard that informed developing iterative linkage methods using demographic, time, and destination variables. We calculated the proportion of suspected opioid overdose EMS cases that received International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for opioid overdose in the ED.ResultsWe identified 12 088 EMS encounters of patients treated with naloxone and transported to the ED. The 12-county subset included 1781 linkage-eligible EMS encounters, with historical linkage of 65.4% (1165 of 1781) and 1.6% false linkages. Through iterative linkage methods, performance improved to 91.0% (1620 of 1781) with 0.1% false linkages. Among statewide EMS encounters with naloxone administration, the linkage improved from 47.1% to 91.1%. We found diagnosis codes for opioid overdose in the ED among 27.2% of statewide linked records.Practice ImplicationsThrough an iterative linkage approach, EMS–ED data linkage performance improved greatly while reducing the number of false linkages. Improved EMS–ED data linkage quality can enhance surveillance activities, inform emergency response practices, and improve quality of care through evaluating initial patient presentations, field interventions, and ultimate diagnoses.

Administration of epinephrine by advanced emergency medical technicians for out-of-hospital cardiac arrest in a rural emergency medical services system.

ObjectiveEpinephrine in out‐of‐hospital cardiac arrest (OHCA) remains controversial and understudied in rural emergency medical services (EMS) systems. We evaluated the effects of allowing advanced emergency medical technicians (AEMTs) to administer epinephrine during OHCA in a rural EMS system.MethodsAn interrupted time series study was conducted using statewide EMS electronic records. Patients with OHCA before (phase I) and after (phase II) a protocol change expanding the AEMT scope of practice to include epinephrine for OHCA were identified. Number and timing of initial epinephrine administration, return of spontaneous circulation, and 30‐day survival rates were compared using descriptive statistics, logistic regression, regression discontinuity, and propensity score matching.ResultsA total of 1037 OHCAs met the inclusion criteria. In phase 1 compared with phase 2, 275 (56.12%) patients received epinephrine versus 624 (83.53%; P < 0.001). The mean time to first administration of epinephrine for unwitnessed and bystander‐witnessed OHCA were 11.73 minutes versus 8.17 minutes (P < 0.001) and 11.59 minutes versus 8.85 minutes (P < 0.01), respectively. Unadjusted analysis showed a decrease in 30‐day survival rates among patients receiving epinephrine from 18.01% to 12.66% (P < 0.05). Adjusted analysis showed an increase in 30‐day survival with decreased time to first epinephrine dose(OR 0.960, 1.005; 95% confidence interval, 0.929, 0.992).ConclusionAdding epinephrine for OHCA to the AEMT scope of practice was associated with an increased percentage of patients receiving epinephrine and decreased time to first administration of epinephrine for patients with unwitnessed OHCA. Unadjusted analysis showed a decrease in 30‐day survival rates among patients receiving epinephrine. Adjusted analysis found that earlier administrationof epinephrine was associated with increased ROSC and 30‐day survival.

Statewide Emergency Medical Services Protocols for Suspected Stroke and Large Vessel Occlusion

Statewide Emergency Medical Services Protocols for Suspected Stroke and Large Vessel Occlusion