Urban Emergency Medical Services Research Articles

What causes Emergency Medical Services (EMS) delay? Unravel high-risk buildings using citywide ambulance trajectory data

Emergency Medical Services (EMS) delay poses a challenge to public health, especially in ultra-dense cities and aging societies. The potential relationship between the built environment and the ambulance response time (ART) has not been thoroughly investigated at the building-level. This impedes the unraveling of high-risk buildings for EMS delay, and thus the precise optimization of urban EMS systems. Our study develops a quantitative-qualitative approach to construct a building-level ART prediction model and then validated it with ambulance drivers' experiences. A comprehensive theoretical framework is tailored for ART prediction incorporating neglected built environment factors of land use and development intensity. Based on 73,129 ambulance trajectories, a machine learning model is constructed and then employed to predict the ART for each of the 253,475 buildings in central Shanghai under multiple combinations of traffic periods and weather conditions. The results show that the accuracy of high-risk buildings for EMS delay achieves 91%. Moreover, three of the neglected built environment factors, medical POIs density, business POIs density and floor area ratio, rank high in the factor importance. The ambulance drivers’ experiences validate the importance of these built environment factors and emphasize the value of bus priority lanes for ambulance to borrow for swift access. In addition, to illustrate potential applications, we simulated the effects of built environment interventions in case areas predicted to concentrate high-risk buildings. This work provides a new computer-based tool to pinpoint the service blind spots of such urban emergency systems and to develop built environment interventions.

A Comparison of Ketamine to Midazolam for the Management of Acute Behavioral Disturbance in the Out-of-Hospital Setting

ObjectiveAcute behavioral disturbance is characterized by altered mental status and psychomotor agitation. Pharmacological sedation may be required, risking potential respiratory compromise. We compared the need for emergent airway support following administration of midazolam or ketamine to treat acute behavioral disturbance in the prehospital setting. MethodsIn this retrospective cohort study of patients with acute behavioral disturbance in an urban Emergency Medical Service (EMS) system between 2017-2021, we compared the likelihood of prehospital advanced airway management following administration of midazolam or ketamine. Advanced airway management was defined as prehospital endotracheal intubation or supraglottic airway insertion. ResultsAmong 376 eligible patients, the median age was 35; and 78% were male. The most common etiologies of acute behavioral disturbance were substance use (51%), trauma (18%), and presumed postictal agitation (11%). In all, 162 patients (43%) initially received midazolam and 214 (57%) ketamine. The frequency of advanced airway management was similar between these respective groups (12% [n=19] vs 11% [n=24], difference 0.5%, 95% CI -6.0% to 7.0%). Adjusted for potential confounders, the odds of receiving advanced airway management did not differ between midazolam and ketamine (aOR 1.02, 95% CI 0.44 to 2.38), nor were differences observed in emergency department intubation rates (14% in midazolam recipients, 11% for ketamine) or overall mortality (2% in midazolam recipients, 1% for ketamine). ConclusionIn this cohort study of patients with acute behavioral disturbance, emergent airway support nor other outcomes differed following prehospital treatment with midazolam or ketamine.

Evaluation of the Implementation of a Novel Fluid Resuscitation Device in the Prehospital Care of Sepsis Patients: Application of the Implementation Outcomes Framework

Objectives Early identification and fluid resuscitation are recognized performance measures within sepsis care. Despite fluid resuscitation, fluid goals are often not achieved in the prehospital environment. Furthermore, description of implementation process and evaluation of implementation success are historically underreported in prehospital research. The objective of this study was to contextualize and evaluate the system-wide implementation of a novel fluid resuscitation device, the LifeFlow PLUS®, in the treatment of prehospital sepsis patients. Methods A single urban emergency medical services (EMS) system internally decided to adopt a novel fluid resuscitation device. This EMS system added the device to the clinical care guidelines of suspected sepsis patients. Prior to and during implementation of the new guidelines, several strategies were undertaken to promote consistent, appropriate system-wide use of the device. A mixed methods study design was deployed. Surveys of EMS clinicians and leaders assessed perceptions of the device and sepsis education prior to field implementation of the device. Clinician and leader semi-structured interviews assessed implementation experience and device adoption. Document analysis evaluated deployment of implementation strategies. Data were triangulated to contextualize implementation and evaluate success. Results Clinician (88%) and leader (91%) confidence in appropriate clinician device use and device superiority for sepsis care (73 and 100%, respectively) were high. Clinicians (58%) were less likely to view the device as easy to implement compared to leaders (73%). Three themes were developed from semi-structured interviews, including “exposure” to the device, “reinforcing factors” to prompt device use, and “clinician buy-in.” Twenty unique implementation strategies (e.g., dynamic trainings, mandating change) were used to promote successful system-wide device adoption. Conclusions The overall implementation success of this novel fluid resuscitation device was moderate. Barriers to adoption included complexity of clinical decision-making and ease of device use. Facilitators to adoption included the use of multiple modes of education, clinical reminders, presenting evidence of device benefit, and prehospital culture. Prior to future prehospital implementation programs, EMS systems should focus on identifying and addressing key barriers and facilitators to improve adoption.

The Performance of ChatGPT-4 and Gemini Ultra 1.0 for Quality Assurance Review in Emergency Medical Services Chest Pain Calls

Objectives This study assesses the feasibility, inter-rater reliability, and accuracy of using OpenAI's ChatGPT-4 and Google’s Gemini Ultra large language models (LLMs), for Emergency Medical Services (EMS) quality assurance. The implementation of these LLMs for EMS quality assurance has the potential to significantly reduce the workload on medical directors and quality assurance staff by automating aspects of the processing and review of patient care reports. This offers the potential for more efficient and accurate identification of areas requiring improvement, thereby potentially enhancing patient care outcomes. Methods Two expert human reviewers, ChatGPT GPT-4, and Gemini Ultra assessed and rated 150 consecutively sampled and anonymized prehospital records from 2 large urban EMS agencies for adherence to 2020 National Association of State EMS metrics for cardiac care. We evaluated the accuracy of scoring, inter-rater reliability, and review efficiency. The inter-rater reliability for the dichotomous outcome of each EMS metric was measured using the kappa statistic. Results Human reviewers showed high interrater reliability, with 91.2% agreement and a kappa coefficient 0.782 (0.654-0.910). ChatGPT-4 achieved substantial agreement with human reviewers in EKG documentation and aspirin administration (76.2% agreement, kappa coefficient 0.401 (0.334-0.468), but performance varied across other metrics. Gemini Ultra’s evaluation was discontinued due to poor performance. No significant differences were observed in median review times: 01:28 min (IQR 1:12 − 1:51 min) per human chart review, 01:24 min (IQR 01:09 − 01:53 min) per ChatGPT-4 chart review (p = 0.46), and 01:50 min (IQR 01:10-03:34 min) per Gemini Ultra review (p = 0.06). Conclusions Large language models demonstrate potential in supporting quality assurance by effectively and objectively extracting data elements. However, their accuracy in interpreting non-standardized and time-sensitive details remains inferior to human evaluators. Our findings suggest that current LLMs may best offer supplemental support to the human review processes, but their current value remains limited. Enhancements in LLM training and integration are recommended for improved and more reliable performance in the quality assurance processes.

Improving urban emergency medical service systems through brownfield transformation in Huangshi, China

A comprehensive emergency medical service (EMS) system significantly enhances a city’s capacity to prevent and mitigate disasters. Using Huangshi as a case study, this research evaluated the service radium coverage rate of the current EMS system by examining its transport capacity, population density, and prevalence rate, finding it to be only 61.49% with an inefficient spatial layout. To address this, we proposed transforming urban brownfields into EMS parks. By selecting the most suitable brownfields based on capacity and service radius, we increased the coverage rate to 90.21%. We introduced a new "consultation-referral" model, where existing EMS facilities serve as pre-diagnosis and triage centers, and the urban brownfield EMS parks function as isolation and centralized treatment centers. GIS network analysis confirmed the feasibility, showing all transit times to be under 30 min. The methodology outlined in this study—comprising "demand assessment, supply optimization, and feasibility verification"—not only strengthens the city’s EMS system but also facilitates the renewal of urban brownfields. This approach can serve as a valuable reference for enhancing EMS systems in other cities.

Outcomes of Out-of-Hospital Cardiac Arrest Patients Who Received Naloxone in an Emergency Medical Services System With a High Prevalence Of Opioid Overdose

BackgroundOpioid-associated out-of-hospital cardiac arrest (OA-OHCA) is a subset of cardiac arrests that could benefit from measures outside of standard Advanced Cardiac Life Support (ACLS), such as naloxone. Study ObjectivesIn this study, we sought to examine whether OHCA patients chosen for naloxone therapy by emergency medical services (EMS) clinicians in a system with high rates of opioid overdose would have increased rates of return of spontaneous circulation (ROSC) and survival to hospital discharge. MethodsThe study took place in an urban EMS system with a high prevalence of opioid overdose. Paramedics could administer naloxone in cardiac arrest in addition to ACLS. It was often administered based on clinical gestalt for suspected OA-OHCA. The outcomes of OHCA patients who received naloxone were compared against those who received usual care in both an adjusted and unadjusted fashion. Lastly, we created a logistic regression model to test for an independent association of naloxone administration on ROSC and survival to hospital discharge. ResultsA consecutive sample of 769 OHCA patients was obtained, of which 175 (23%) received naloxone. On average, patients who received naloxone had significantly fewer comorbidities and were younger. There was no difference in ROSC, survival to hospital discharge, or modified Rankin Scores. Using logistic regression modeling, there was no statistically significant effect of naloxone administration on these outcomes. ConclusionOHCA patients who received naloxone, despite being younger and having fewer comorbidities, had similar outcomes compared to those who received usual care. The difference in baseline characteristics suggests that paramedic gestalt reasonably selected for OA-OHCA.

Pediatric Outcomes of Emergency Medical Services Non-Transport Before and During the COVID-19 Pandemic.

Pediatric patients account for 6-10% of emergency medical services (EMS) activations in the United States. Approximately 30% of these children are not transported to an emergency department (ED). Adult data in the literature reports higher hospitalization and complications following non-transport. Few studies discuss epidemiology and characteristics of pediatric non-transport; however, data on outcome is limited. Our primary aim was to determine outcomes of non-transported children within our urban EMS system before and during the COVID-19 pandemic. Our secondary objective was to explore reasons for non-transport. This was a prospective, descriptive pilot study. We compared EMS data for September 2019 (pre-COVID-19) to September 2020 (pandemic). Included were children aged 0-17years who activated EMS and did not receive transport to the primary hospital for the EMS capture area. We defined outcomes as repeat EMS activation, ED visits, and hospital admissions, all within 72 hours. Data was obtained via electronic capture. We used descriptive statistics to analyze our data, chi square for categorical data, stepwise logistic regression, and univariate logistic regression to test for association of covariates with non-transport. There were 1,089 pediatric EMS activations in September 2019 and 780 in September 2020. Non-transport occurred in 633 (58%) in September 2019 and 412 (53%) in September 2020. Emergency medical services was reactivated within 72 hours in the following: 9/633 (1.4%) in 2019; and 5/412 (1.2%) in 2020 (P = 0.77). Visits to the ED occurred in 57/633 (9%) in 2019 and 42/412 (10%) in 2020 (P = 0.53). Hospital admissions occurred in 10/633 (1.5%) in 2019 and 4/412 (0.97%) in 2020 (P = 0.19). One non-transported patient was admitted to the intensive care unit in September 2020 (<1%) and survived. Hispanic ethnicity, age >12years, and fever were associated with repeat EMS activation. The most common reason for non-transport in both study periods was that the parent felt an ambulance was not necessary (47%). In our system, non-transport of pediatric patients occurred in >50% of EMS activations with no significant adverse outcome. Age >12years, fever, and Hispanic ethnicity were more common in repeated EMS activations. The most common reason for non-transport was parents feeling it was not necessary. Future studies are needed to develop reliable EMS guidelines for pediatric non-transport.

Comparison of Palliative Knowledge and Self-Efficacy Expectation of German Paramedics Between a Rural and an Urban Structured Emergency Medical Service Area.

Differences in the German emergency medical service (EMS) can be seen in the countryside in contrast to the city with regard to travel distances to hospitals and in the access routes of EMS-physicians. In order to investigate the success of establishment of palliative crisis cards associated with training and the rural and urban EMS structures, two urban and two rural EMS areas were compared using the Paramedic Palliative Care Test (PARPACT). Methods: The PARPACT includes test items on palliative knowledge (PK, maximum score: 15 points) and palliative self-efficacy expectations (PSE, maximum score: 18 points), as well as items on palliative attitudes in dealing with palliative care patients. We used a 4-point Likert-type scale. For data analysis, nonparametric tests (χ-test and Mann-Whitney U test) were used in addition to descriptive analysis (frequencies, means, medians, standard deviations, and ranges). Results: In total, 291 out of 750 ambulance or EMS personnel participated in the voluntary survey. Rural ambulance or EMS personnel answered the PK-questions correctly more often on average (mean: 11.19, SD: 1.85) than urban ambulance or EMS personnel (mean: 9.18, SD: 2.39; Mann-Whitney U test: U=5040.000, P=.001). In addition, ambulance or EMS personnel with the highest level of training (3-year-trained paramedics) performed better in PK (mean: 10.38, SD: 2.31) than less intensively training ambulance or EMS personnel (mean: 9.58, SD: 2.43; Mann-Whitney U-test: U=8446.500, P=.004). In terms of PSE, rural ambulance or EMS personnel also achieved higher mean PSE-scores (mean: 12.55, SD: 2.60) than urban ambulance or EMS personnel (mean: 9.77, SD: 3.41; Mann-Whitney U-test: U=5148.500, P=.001). Conclusions: Better training in the EMS is associated with improved PK compared to less qualified nonphysician EMS staff. The establishment of palliative crisis cards and the structures in the city alone do not lead to improved knowledge and PSE.

The effect of power stretchers on occupational injury rates in an urban emergency medical services system.

To examine occupational injury rates in a dual-response emergency medical services(EMS) system before and after implementation of a power-lift stretcher system. The seasonally-adjusted occupational injury rate was estimated relative to medical call volume (per 1000 calls) and workers (per 100 FTEs) from 2009 to 2019, and stratified by severity (lost-time, healthcare only), role (EMS, FIRE) and type (patient-handling). Power-lift stretchers were adopted between 2013 and 2015. Preinjury versus postinjury rates were compared using binomial tests. Interrupted time series (ITS) analysis was used to estimate the trend and change in injuries related to patient-handling, with occupational illnesses serving as control. Binomial tests revealed varied results, with reductions in the injury rate per 1000 calls (-14.0%) and increases in the rate per 100 FTEs (+14.1%); rates also differed by EMS role and injury severity. ITS analysis demonstrated substantial reductions in patient-handling injuries following implementation of power-lift stretchers, both in the injury rate per 1000 calls (-50.4%) and per 100 FTEs (-46.6%), specifically among individuals deployed on the ambulance. Injury rates were slightly elevated during the winter months (+0.8 per 100 FTEs) and lower during spring (-0.5 per 100 FTEs). These results support the implementation of power-lift stretchers for injury prevention in EMS systems and demonstrate advantages of ITS analysis when data span long preintervention and postintervention periods.

Haemodynamic response to pre-hospital emergency anaesthesia in trauma patients within an urban helicopter emergency medical service.

Pre-hospital emergency anaesthesia is routinely used in the care of severely injured patients by pre-hospital critical care services. Anaesthesia, intubation, and positive pressure ventilation may lead to haemodynamic instability. The aim of this study was to identify the frequency of new-onset haemodynamic instability after induction in trauma patients with a standardised drug regime. A retrospective database analysis was undertaken of all adult patients treated by a physician-led urban pre-hospital care service over a 6-year period. The primary outcome measure was the frequency of new haemodynamic instability following pre-hospital emergency anaesthesia. The association of patient characteristics and drug regimes with new haemodynamic instability was also analysed. A total of 1624 patients were included. New haemodynamic instability occurred in 231 patients (17.4%). Patients where a full-dose regime was administered were less likely to experience new haemodynamic instability than those who received a modified dose regime (9.7% vs 24.8%, p < 0.001). The use of modified drug regimes became more common over the study period (p < 0.001) but there was no change in the rates of pre-existing (p = 0.22), peri-/post-anaesthetic (p = 0.36), or new haemodynamic instability (p = 0.32). New haemodynamic instability within the first 30min following pre-hospital emergency anaesthesia in trauma patients is common despite reduction of sedative drug doses to minimise their haemodynamic impact. It is important to identify non-drug factors that may improve cardiovascular stability in this group to optimise the care received by these patients.

Association of small adult ventilation bags with return of spontaneous circulation in out of hospital cardiac arrest

IntroductionLittle is known about the impact of tidal volumes delivered by emergency medical services (EMS) to adult patients with out-of-hospital cardiac arrest (OHCA). A large urban EMS system changed from standard adult ventilation bags to small adult bags. We hypothesized that the incidence of return of spontaneous circulation (ROSC) at the end of EMS care would increase after this change. MethodsWe performed a retrospective analysis evaluating adults treated with advanced airway placement for nontraumatic OHCA between January 1, 2015 and December 31, 2021. We compared rates of ROSC, ventilation rate, and mean end tidal carbon dioxide (ETCO2) by minute before and after the smaller ventilation bag implementation using linear and logistic regression. ResultsOf the 1,994 patients included, 1,331 (67%) were treated with a small adult bag. ROSC at the end of EMS care was lower in the small bag cohort than the large bag cohort, 33% vs 40% (p = 0.003). After adjustment, small bag use was associated with lower odds of ROSC at the end of EMS care [OR 0.74, 95% CI 0.61 – 0.91]. Ventilation rates did not differ between cohorts. ETCO2 values were lower in the large bag cohort (33.2 ± 17.2 mmHg vs. 36.9 ± 19.2 mmHg, p < 0.01). ConclusionUse of a small adult bag during OHCA was associated with lower odds of ROSC at the end of EMS care. The effects on acid base status, hemodynamics, and delivered minute ventilation remain unclear and warrant additional study.

Paramedic perspectives on sex and gender equity in prehospital electrocardiogram acquisition

Acute coronary syndrome (ACS) makes up a substantial healthcare burden. Previous research has demonstrated that women fare worse than men across a range of hospital-based ACS processes and outcomes. In the prehospital setting, the 12-lead electrocardiogram (ECG) can identify critical ACS cases and speed access to definitive treatment. However, studies on rates of ECG acquisition among patients at risk of ACS in the prehospital setting have shown that women receive the test less frequently than men. The purpose of this study was to investigate the reasons for observed gender differences in rates of ECG acquisition in the prehospital setting. This is a cross-sectional study of paramedics in an urban emergency medical service agency. An experienced qualitative researcher conducted 26 semi-structured interviews. Using a subjectivist inductive approach, the study team analyzed interview transcripts following the six-step process described by Braun and Clarke (2006). Qualitative rigor was maintained through consistent review, discussion, and revision at each stage. Four themes were identified among diverse views around the 12-lead acquisition. (1) Safety (feelings of physical comfort and psychological safety related to administering a 12-lead). (2) Knowledge (subject-matter knowledge involving the protocols and procedures as well as self-knowledge of participants’ own practice). (3) Training and learning (perceptions of foundational training and on-the-job learning, and how those have influenced their perceptions of how to care for patients experiencing ACS). (4) Professionalism (perceptions of behavior and attitudes and how they influence patient care). These four interrelated themes were integrated to represent a model of prehospital cardiac care. This study addressed a gap in the literature by documenting prehospital providers’ attitudes and beliefs around cardiac care. The resulting model of prehospital cardiac care offers both a template for evaluating the equity of current treatment and a road map for improvement.

Descriptive analysis of emergency medical services 72-hour repeat patient encounters in a single, Urban Agency

IntroductionEmergency department unscheduled return visits within 72-h of discharge, called a “bounceback”, have been used as a metric of quality of care. We hypothesize that specific demographics and dispositions may be associated with Emergency Medical Services (EMS) 72-h bouncebacks. MethodsFor all patient encounters within one calendar year from a large, urban EMS agency, we recorded demographics (name, date of birth, race, gender), primary impression, disposition, and vital signs for EMS encounters. A bounceback was defined as a patient, identified by matching first name, last name and date of birth, with more than one EMS encounter within 72 h. We performed descriptive statistics for patients that did and did not have a subsequent bounceback using median (interquartile range) and Wilcoxon Rank Sum test for age and frequency (percent) and chi square test for gender, race and run disposition. For patients with a bounceback, we describe the frequency and percentage of EMS professional primary impressions on initial encounter. Results98,043 encounters from January 1, 2021 to December 31, 2021, were analyzed. The median age was 50 years (IQR 32–65); 49.4% (46,147) were female and 50.7% (47,376) were White patients. 3951 encounters had a subsequent bounceback, and compared to those without bouncebacks, they were more often male patients (58.7% versus 50.2%, p < 0.001) and more commonly not transported (22.3% versus 15.5%, p < 0.001). A multivariable logistic regression model estimated the odds of bounceback were lower for females [OR 0.64 (95% CI 0.61–0.68)], Asian and Latino patients compared to White patients [OR 0.33 (95% CI 0.21–0.53) and 0.42 (95% CI 0.34–0.51)], respectively, no significant difference for Black patients compared to White patients, and higher for non-transported patients [OR 1.25 (95% CI 1.16–1.34)]. The The most common EMS primary impression for initial and subsequent encounters was mental health [576 (14.7%) and 944 (17.0%), respectively]. For subsequent encounters, the primary impression was cardiac arrest or death in 67 (1.2%) of cases. ConclusionBouncebacks were common in this single year study of a high-volume urban EMS agency. Male and non-transported patients most often experienced bouncebacks. The most common primary impression for encounters with bounceback was mental health related. Out-of-hospital cardiac arrest occurred in 1 % of bounceback cases. Further study is necessary to understand the effect on patient-centered outcomes.

Prehospital Time Interval for Urban and Rural Emergency Medical Services: A Systematic Literature Review.

The aim of this study was to discuss the differences in pre-hospital time intervals between rural and urban communities regarding emergency medical services (EMS). A systematic search was conducted through various relevant databases, together with a manual search to find relevant articles that compared rural and urban communities in terms of response time, on-scene time, and transport time. A total of 37 articles were ultimately included in this review. The sample sizes of the included studies was also remarkably variable, ranging between 137 and 239,464,121. Twenty-nine (78.4%) reported a difference in response time between rural and urban areas. Among these studies, the reported response times for patients were remarkably variable. However, most of them (number (n) = 27, 93.1%) indicate that response times are significantly longer in rural areas than in urban areas. Regarding transport time, 14 studies (37.8%) compared this outcome between rural and urban populations. All of these studies indicate the superiority of EMS in urban over rural communities. In another context, 10 studies (27%) reported on-scene time. Most of these studies (n = 8, 80%) reported that the mean on-scene time for their populations is significantly longer in rural areas than in urban areas. On the other hand, two studies (5.4%) reported that on-scene time is similar in urban and rural communities. Finally, only eight studies (21.6%) reported pre-hospital times for rural and urban populations. All studies reported a significantly shorter pre-hospital time in urban communities compared to rural communities. Conclusions: Even with the recently added data, short pre-hospital time intervals are still superior in urban over rural communities.

Abstract 330: Effect Of Covid-19 Mitigation On Resource Utilization And Rates Of Acute Myocardial Infarction In Areas Of Higher And Lower Socioeconomic Vulnerability

Background: Multiple reports demonstrate decreased emergency department (ED) utilization for cardiovascular emergencies during COVID-19. It is possible this decrease had downstream effects on the later severity of cardiovascular disease, especially in patients with higher social vulnerability. The purpose of this study was to determine the effect of early COVID-19 mitigation strategies on hospital resource utilization and acute myocardial infarction (AMI) admissions by social vulnerability. Methods: We retrospectively analyzed patients transported by emergency medical services (EMS) with a diagnosis of chest pain and/or AMI from a large urban Midwest EMS and single hospital system from Jan 1-Dec 31, 2020. Hospital office, telehealth, ED visits for chest pain, and hospital admissions for AMI were identified using the electronic health record. The 3 phases of COVID-19 mitigation were compared (pre-mitigation-Jan 1 st to Feb 28 th , mitigation-March 1 st to April 30 th , and post-mitigation-May 1 st -December 31 st ). The socioeconomic status theme of the Social Vulnerability Index (SVI) was determined. The primary outcome was rate of AMI per ED chest pain visit, which was compared between the highest and lowest SVI quartiles. Statistical comparisons were made using binary logistic regression and Chi-squared tests. Results: Overall, there was a similar increase in telehealth visits and a decrease in office visits during mitigation in both highest and lowest SVI quartiles. In the post-mitigation phase, patients with the highest social vulnerability had a 30% relative increase rate of AMI per ED chest pain visit (7.3% vs 5.5%, p=0.048) compared to patients with lower social vulnerability. This increase was not seen in the pre-mitigation (5.8% vs 6.1%) or mitigation (4.9% vs 5.4%, each p=ns) phases. Conclusions: After initial COVID-19 mitigation strategies were implemented patients with higher socioeconomic vulnerability presented to the ED with AMI at a higher rate than patients with a lower socioeconomic vulnerability, despite no differences in office, telehealth, or EMS transport. Understanding the complex effect of pandemic mitigation strategies on vulnerable populations can provide guidance for resource management in future crises.

Patient Demographics are Associated with Differences in Prehospital Pain Management Among Trauma Patients

Objective: Disparities have been observed in the treatment of pain in emergency department patients. However, few studies have evaluated such disparities in emergency medical services (EMS). We describe pain medication administration for trauma indications in an urban EMS system and how it varies with patient demographics. Methods: We performed a retrospective review of the electronic medical records of adult patients transported for isolated trauma (without accompanying medical complaint) from 1/1/18 to 6/30/2020 by a third service EMS agency in a major United States metropolitan area. We performed descriptive statistics on epidemiology, type of pain medications administered, and pain scores. Kruskall-Wallis and chi-square or Fisher’s exact tests were used to compare continuous and categorical variables, respectively. We constructed a logistic regression model to estimate the odds of nontreatment of pain by age, race, sex, transport interval, pain score, and Glasgow Coma Scale (GCS) score for patients with pain scores of at least four on a one to ten scale, the threshold for pain treatment per the EMS protocol. Results: Of 32,463 EMS patients with traumatic injuries included in the analysis, 40% (12,881/32,463) were African American, 50% (16,284/32,463) were female, the median age was 27 years (IQR 45-64), and the median initial pain score was 5 (IQR 2-8). Fifteen percent (4,989/32,463) received any analgesic. Initial pain scores were significantly higher for African American and female patients. African American patients were less likely to receive analgesia compared to White and Hispanic patients (19% versus 25% and 23%, respectively, p < 0.0001). Adjusting for age, pain score, transport interval, and GCS, African American compared to White, and female compared to male patients were less likely to be treated for pain, OR 1.59 (95% CI 1.47-1.72) and OR 1.20 (95% CI 1.11-1.28), respectively. Conclusion: Among patients with isolated traumatic injuries treated in a single, urban EMS system, African American and female patients were less likely to receive analgesia than White or male patients. Analgesics were given to a small percentage of patients who were eligible for treatment by protocol, and intravenous opioids were used in the vast majority patients who received treatment.

184EMF Implementation of a Novel Fluid Resuscitation Device for the Care of Sepsis Patients: Processes and Perceptions in the Out-of-Hospital Setting

Early fluid infusion is a key performance metric in the care of sepsis patients, yet this benchmark is often unmet. Emergency Medical Services (EMS) transports one-third of sepsis patients, presenting an opportunity for increased achievement of fluid goals. To enhance sepsis care, one large urban EMS system (∼120,000 EMS responses/year) introduced a novel rapid fluid infusion device, LifeFlow® Plus, to its sepsis protocol (∼700 patients/year). The study objective is to assess the implementation of this device in EMS fluid administration for out-of-hospital sepsis care.

220 Emergent Medicine: Impact of Out-of-Hospital Red Lights and Sirens (RLS) on Time to Antibiotic Administration in Sepsis Alert Patients

220 Emergent Medicine: Impact of Out-of-Hospital Red Lights and Sirens (RLS) on Time to Antibiotic Administration in Sepsis Alert Patients

Environmental Factors Associated with Severe Motorcycle Crash Injury in University Neighborhoods: A Multicenter Study in Taiwan.

University neighborhoods in Taiwan have high-volume traffic, which may increase motorcyclists’ risk of injury. However, few studies have analyzed the environmental factors affecting motorcycle crash injury severity in university neighborhoods. In this multicenter cross-sectional study, we explored the factors that increase the severity of such injuries, especially among young adults. We retrospectively connected hospital data to the Police Traffic Accident Dataset. Areas within 500 m of a university were considered university neighborhoods. We analyzed 4751 patients, including 513 with severe injury (injury severity score ≥ 8). Multivariate analysis revealed that female sex, age ≥ 45 years, drunk driving, early morning driving, flashing signals, and single-motorcycle crashes were risk factors for severe injury. Among patients aged 18–24 years, female sex, late-night and afternoon driving, and flashing signals were risk factors. Adverse weather did not increase the risk. Time to hospital was a protective factor, reflecting the effectiveness of urban emergency medical services. Lifestyle habits among young adults, such as drunk driving incidents and afternoon and late-night driving, were also explored. We discovered that understanding chaotic traffic in the early morning, flashing signals at the intersections, and roadside obstacles is key for mitigating injury severity from motorcycle crashes in university neighborhoods.

Disparities in Survival Outcomes of Out-of-Hospital Cardiac Arrest Patients between Urban and Rural Areas and the Identification of Modifiable Factors in an Area of South Korea

This retrospective study aimed to compare the survival outcomes of adult out-of-hospital cardiac arrest (OHCA) patients between urban (Busan, Ulsan, Changwon) and rural (Gyeongnam) areas in South Korea and identify modifiable factors in the chain of survival. The primary and secondary outcomes were survival to discharge and modifiable factors in the chain of survival were identified using logistic regression analysis. In total, 1954 patients were analyzed. The survival to discharge rates in the whole region and in urban and rural areas were 6.9%, 8.7% (Busan 8.7%, Ulsan 10.3%, Changwon 7.2%), and 3.4%, respectively. In the urban group, modifiable factors associated with survival to discharge were no advanced airway management (adjusted odds ratio (aOR) 2.065, 95% confidence interval (CI): 1.138–3.747), no mechanical chest compression (aOR 3.932, 95% CI: 2.015–7.674), and an emergency medical service (EMS) transport time of more than 8 min (aOR 3.521, 95% CI: 2.075–5.975). In the rural group, modifiable factors included an EMS scene time of more than 15 min (aOR 0.076, 95% CI: 0.006–0.883) and an EMS transport time of more than 8 min (aOR 4.741, 95% CI: 1.035–21.706). To improve survival outcomes, dedicated resources and attention to EMS practices and transport time in urban areas and EMS scene and transport times in rural areas are needed.