Achieving Equity in EMS Care and Patient Outcomes Through Quality Management Systems: A Position Statement.

Improving health and safety in our communities requires deliberate focus and commitment to equity. Inequities are differences in access, treatment, and outcomes between individuals and across populations that are systemic, avoidable, and unjust. Within health care in general, and Emergency Medical Services (EMS) in particular, there are demonstrated inequities in the quality of care provided to patients based on a number of characteristics linked to discrimination, exclusion, or bias. Given the critical role that EMS plays within the health care system, it is imperative that EMS systems reduce inequities by delivering evidence-based, high-quality care for the communities and patients we serve. To achieve equity in EMS care delivery and patient outcomes, the National Association of EMS Physicians recommends that EMS systems and agencies: make health equity a strategic priority and commit to improving equity at all levels.assess and monitor clinical and safety quality measures through the lens of inequities as an integrated part of the quality management process.ensure that data elements are structured to enable equity analysis at every level and routinely evaluate data for limitations hindering equity analysis and improvement.involve patients and community stakeholders in determining data ownership and stewardship to ensure its ongoing evolution and fitness for use for measuring care inequities.address biases as they translate into the quality of care and standards of respect for patients.pursue equity through a framework rooted in the principles of improvement science.

EMS Involvement in COVID-19 Vaccination Efforts - Results of a North Carolina Statewide Survey.

Objective: The COVID-19 pandemic has necessitated the vaccination of large numbers of people across the United States, mobilizing public health resources on a massive scale. The purpose of this study is to determine how emergency medical services (EMS) clinicians and agencies in North Carolina have been utilized in these vaccination efforts.Methods: This retrospective survey was sent to EMS medical directors and EMS system administrators for all 100 county EMS systems in North Carolina. Participation was voluntary, and survey questions asked about the contribution of EMS systems to vaccination efforts, the levels of EMS clinicians being utilized, the activities carried out by those clinicians, and any identifiable barriers to EMS involvement in COVID-19 vaccination efforts.Results: Ninety-eight of the 100 counties in North Carolina responded to the survey, with 88 contributing to vaccination efforts in the communities. Reasons cited by the 10 counties for not being involved in vaccination efforts include: county health departments not needing assistance (two counties), vaccine hesitancy amongst clinicians and the politicization of COVID (three counties), inadequate staffing (one county), and the presence of "robust vaccination clinics" in the community (one county). An additional 12 counties listed staffing shortages as limiting their vaccination efforts. Among the counties supporting vaccine efforts, activities included planning and logistics (54 counties), non-medical roles (38 counties), vaccine preparation (35 counties), medical screening pre-vaccination (41 counties), vaccine administration (74 counties), medical observation post-vaccination (79 counties), and home vaccinations (53 counties). Of the 74 counties that used EMS personnel in vaccine administration, 27 used EMTs (37%), 36 used Advanced EMTs (49%), and 73 used Paramedics (99%).Conclusion: This study demonstrates the large role that EMS clinicians and systems have played and continue to play in COVID-19 vaccination efforts in the state of North Carolina, including planning and logistics, patient screening and observation, vaccine preparation and administration, and home vaccination. Furthermore, it supports the expanded use of EMTs as a potential vaccination workforce. As the public health response to this pandemic continues, EMS clinicians and systems are a valuable resource to their communities and states.

Disparities in Emergency Medical Services Time Intervals for Patients with Suspected Acute Coronary Syndrome: Findings from the North Carolina Prehospital Medical Information System.

Background Timely emergency medical services (EMS) response, management, and transport of patients with suspected acute coronary syndrome (ACS) significantly reduce delays to emergency treatment and improve outcomes. We evaluated EMS response, scene, and transport times and adherence to proposed time benchmarks for patients with suspected ACS in North Carolina from 2011 to 2017. Methods and Results We conducted a population-based, retrospective study with the North Carolina Prehospital Medical Information System, a statewide electronic database of all EMS patient care reports. We analyzed 2011 to 2017 data on patient demographics, incident characteristics, EMS care, and county population density for EMS-suspected patients with ACS, defined as a complaint of chest pain or suspected cardiac event and documentation of myocardial ischemia on prehospital ECG or prehospital activation of the cardiac care team. Descriptive statistics for each EMS time interval were computed. Multivariable logistic regression was used to quantify relationships between meeting response and scene time benchmarks (11 and 15 minutes, respectively) and prespecified covariates. Among 4667 patients meeting eligibility criteria, median response time (8 minutes) was shorter than median scene (16 minutes) and transport (17 minutes) time. While scene times were comparable by population density, patients in rural (versus urban) counties experienced longer response and transport times. Overall, 62% of EMS encounters met the 11-minute response time benchmark and 49% met the 15-minute scene time benchmark. In adjusted regression analyses, EMS encounters of older and female patients and obtaining a 12-lead ECG and venous access were independently associated with lower adherence to the scene time benchmark. Conclusions Our statewide study identified urban-rural differences in response and transport times for suspected ACS as well as patient demographic and EMS care characteristics related to lower adherence to scene time benchmark. Strategies to reduce EMS scene times among patients with ACS need to be developed and evaluated.

Emergency Medical Services Time Intervals for Acute Chest Pain in the United States, 2015-2016.

Background: Chest pain is a leading complaint in emergency settings. Timely emergency medical services (EMS) responses can reduce delays to treatment and improve clinical outcomes for acute myocardial infarction patients and other medical emergencies. We investigated national-level EMS response, scene, and transport times for acute chest pain patients in the United States. Methods: A retrospective analysis was performed using 2015-2016 data from the National EMS Information System (NEMSIS). Eligible patients were identified as having a provider impression of chest pain or discomfort and not due to trauma or resulting in cardiac arrest during EMS care. Descriptive analyses of prehospital time intervals and patient-, response-, and system-level covariates were performed. Multivariable logistic regression was used to measure associations between meeting response and scene time benchmarks (8-min and 15-min, respectively) and covariates. Results: Our study identified 1,672,893 eligible EMS encounters of chest pain. Patients had a mean age of 63.1 years (SD = 14.8). The population was evenly distributed by sex (51% male; 49% female). Most encounters occurred in home or residence (58%) and had lights and sirens response to scene (84%). Most encounters were in urban areas (78%). The median (interquartile range, IQR) response time was 7 (5-10) minutes. The median (IQR) scene time was 16 (12-20) minutes. The median (IQR) transport time was 13 (8-20) minutes. Generally, median response and transport times were longer in rural and frontier areas compared to urban and suburban areas. Only 65% and 49% met the 8-min response and 15-min scene time benchmarks. Responding with lights and sirens was associated with greater compliance with EMS response time benchmark. EMS care of older age groups and females was less likely to meet the scene time benchmark. Conclusions: Substantial proportions of EMS encounters for chest pain did not meet response and scene time benchmarks. Regional and urban-rural differences were observed in adherence with the response time benchmark. Our findings also suggest age and gender disparities in on-scene delays by EMS. Our study contributes important evidence on timely EMS responses for cardiac chest pain and provides suggestions for EMS system benchmarking and quality improvement.

Feasibility of prehospital delivery of remote ischemic conditioning by emergency medical services in chest pain patients: protocol for a pilot study.

BACKGROUND: Remote ischemic conditioning (RIC) is a non-invasive procedure with hypothesized therapeutic benefits for patients experiencing an acute ST-elevation myocardial infarction (STEMI). Further study of emergency medical services (EMS) delivery of RIC in the prehospital setting is needed to inform the design and methods for future clinical trials of RIC in STEMI patients. The main objective of this pilot study is to assess the feasibility of prehospital delivery of RIC by EMS providers in the United States. METHODS: We will conduct a single-arm study of the standard RIC procedure (i.e., up to 4 cycles of alternating 5-min inflation and 5-min deflation of an upper arm cuff) administered by EMS paramedics in 50 patients experiencing acute onset chest pain. The investigational autoRIC® device (CellAegis Devices, Inc., Toronto, Ontario) will be initiated by paramedics during ground ambulance transport. Automated RIC cycles will continue through emergency department arrival and stay. The primary endpoint will be the completion of all 4 cycles of RIC without interruption. We will also examine study procedures and collect qualitative data from study participants and paramedics. DISCUSSION: To our knowledge, this will be the first study in the United States to assess the feasibility of completing the 40-min RIC procedure when initiated during ground ambulance transport. Findings from this pilot study will be used to optimize the design and methods for a future efficacy trial of RIC in acute STEMI patients. TRIAL REGISTRATION: NCT03400579 (ClinicalTrials.gov). Registered on 17 January 2018.

Measuring a Crisis: Questioning the Use of Naloxone Administrations as a Marker for Opioid Overdoses in a Large U.S. EMS System.

OBJECTIVE: The United States is currently experiencing a public health crisis of opioid overdoses. To determine where resources may be most needed, many public health officials utilize naloxone administration by EMS as an easily-measured surrogate marker for opioid overdoses in a community. Our objective was to evaluate whether naloxone administration by EMS accurately represents EMS calls for opioid overdose. We hypothesize that naloxone administration underestimates opioid overdose. METHODS: We conducted a chart review of suspected overdose patients and any patients administered naloxone in Wake County, North Carolina, from January 2013 to December 2015. Patient care report narratives and other relevant data were extracted from electronic patient care records and the resultant database was analyzed by two EMS physicians. Cases were divided into categories including "known opioid use," "presumed opioid use," "no known opioid," "altered mental status," "cardiac arrest with known opioid use," "cardiac arrest with no known opioid use," or "suspected alcohol intoxication," and then further separated based on whether naloxone was administered. Patient categories were compared by patient demographics and incident year. Using the chart review classification as the gold standard, we calculated the sensitivity and positive predictive value (PPV) of naloxone administration for opioid overdose. RESULTS: A total of 4,758 overdose cases from years 2013-15 were identified. During the same period, 1,351 patients were administered naloxone. Of the 1,431 patients with known or presumed opioid use, 57% (810 patients) received naloxone and 43% (621 patients) did not. The sensitivity of naloxone administration for the identification of patients with known or presumed opioid use was 57% (95% CI: 54%-59%) and the PPV was 60% (95% CI: 57%-63%). CONCLUSION: Among patients receiving care in this large urban EMS system in the United States, the overall sensitivity and positive predictive value for naloxone administration for identifying opioid overdoses was low. Better methods of identifying opioid overdose trends are needed to accurately characterize the burden of opioid overdose within and among communities.

Repeated Emergency Medical Services Use by Older Adults: Analysis of a Comprehensive Statewide Database.

STUDY OBJECTIVE: The objective of this study is to characterize repeated emergency medical services (EMS) transports among older adults across a large and socioeconomically diverse region. METHODS: Using the North Carolina Prehospital Medical Information System, we analyzed the frequency of repeated EMS transports within 30 days of an index EMS transport among adults aged 65 years and older from 2010 to 2015. We used multivariable logistic regressions to determine characteristics associated with repeated EMS transport. RESULTS: During the 6-year period, EMS performed 1,711,669 transports for 689,664 unique older adults in North Carolina. Of these, 303,099 transports (17.7%) were followed by another transport of the same patient within 30 days. The key characteristics associated with an increased adjusted odds ratio of repeated transport within 30 days include transport from an institutionalized setting (odds ratio [OR] 1.42; 95% confidence interval [CI] 1.38 to 1.47), blacks compared with whites (OR 1.29; 95% CI 1.24 to 1.33), a dispatch complaint of psychiatric problems (OR 1.38; 95% CI 1.25 to 1.52), back pain (OR 1.35; 95% CI 1.26 to 1.45), breathing problems (OR 1.21; 95% CI 1.15 to 1.30), and diabetic problems (OR 1.14; 95% CI 1.06 to 1.22). Falls accounted for 15.6% of all transports and had a modest association with repeated transports (OR 1.07; 95% CI 1.00 to 1.14). CONCLUSION: More than 1 in 6 EMS transports of older adults in North Carolina are followed by a repeated transport of the same patient within 30 days. Patient characteristics and chief complaints may identify increased risk for repeated transport and suggest the potential for targeted interventions to improve outcomes and manage EMS use.

Prehospital Fluid Administration in Trauma Patients: A Survey of State Protocols.

OBJECTIVE: The optimal resuscitation approach during the initial treatment of hypotensive trauma patients remains unknown, but some clinical trials have observed a survival benefit from restricting fluid administration prior to definitive hemorrhage control. We sought to characterize emergency medical services (EMS) protocols for the administration of intravenous fluids in this setting. METHODS: Publicly accessible statewide EMS protocols for the treatment of hypotensive trauma patients were included and characterized by: 1) goal of fluid administration, 2) dosing strategy, 3) maximum dose, 4) type of fluid, and 5) specific protocols for head trauma, if present. RESULTS: Of the 27 states with a publicly available, statewide protocol, 21 have a numeric systolic blood pressure (SBP) target for resuscitation. Of these, 16 describe a goal of maintaining SBP ≥90 mmHg with or without additional goals, three specify a goal that is less than 90 mmHg, and two specify a goal ≥100 mHg. Dosing strategies also vary and include both standard bolus strategies (200 mL, 250 mL, 500 mL, and 1 L with repeat) as well as weight-based strategies (20 mL/kg). Nine states specify a maximum dose of 2 L without medical control. Fifteen protocols recommend the use of normal saline, 1 recommends the use of lactated Ringer's, and 11 recommend the use of either normal saline or lactated Ringer's. Nine states have distinct protocols for patients with head trauma, all of which indicate maintaining a higher SBP than for trauma patients without head trauma. CONCLUSION: State EMS protocols for fluid administration for hypotensive trauma patients vary in regard to SBP goal, fluid dose, and fluid type. Clinical trials to determine the optimal use of intravenous fluids for hypotensive trauma patients are needed to define the optimal approach.

The use of video laryngoscopy during air medical transport: a manikin study.

INTRODUCTION: This study simulated intubation with direct laryngoscopy and with a GlideScope Ranger video laryngoscope using a standard Laerdal airway manikin in a medical helicopter under various conditions. We hypothesized that the intubation times would be greater using direct laryngoscopy compared with the GlideScope under all conditions. METHODS: Twenty crew members of a single helicopter emergency medical service participated in the study. Participants intubated an airway manikin using both direct laryngoscopy and the GlideScope Ranger in varying conditions, including standing in a room with the lights on and off, in the helicopter while stationary on the ground and unbelted during both daytime and nighttime, and finally in the aircraft while in flight belted during both daytime and nighttime. A study investigator recorded the intubation times and independently confirmed tracheal placement of the endotracheal tube. RESULTS: For all 6 environments, the mean time for intubation was slightly greater using the GlideScope (18.7 seconds; 95% confidence interval, 17.4-20.0 seconds) compared with direct laryngoscopy (15.5 seconds; 95% confidence interval, 14.7-16.4). There was a statistically significant difference in times to intubation, in favor of direct laryngoscopy, in the settings of standing with the room lights on (P = 0.0013), on the ground in the helicopter unbelted during the daytime (P = 0.009), and in flight belted at nighttime (P = 0.0012), with the 3 other environments not reaching statistical significance. CONCLUSIONS: Using the GlideScope took more time to intubate compared with direct laryngoscopy in all tested environments. Although this difference in intubation times was statistically significant, it was not clinically significant, suggesting that both modalities may be comparable in nondifficult airways.