Examining the association between ethnicity and out-of-hospital cardiac arrest interventions in Salt Lake City, Utah.

Aims: Previous research has reported racial disparities in out-of-hospital cardiac arrest (OHCA) interventions, including bystander CPR and AED use. However, studies on other prehospital interventions are limited. The primary objective of this study was to investigate race/ethnic disparities in out-of-hospital cardiac arrest (OHCA) interventions: EMS response times, medication administration, and decisions for intra-arrest transport. The secondary objective was to evaluate differences in the provision of Bystander CPR (CPR) and application of AED. Methods: We retrospectively analyzed data from the Salt Lake City Fire Department (2010-2023). We included adults 18 years or older with EMS-treated OHCA. Race/ethnicity was categorized as White people, Asian people, Black people, Hispanic people, and others. We employed multivariable regression analysis to evaluate the association between race/ethnicity and the outcomes of interest. Results: Unadjusted analyses revealed no significant differences across ethnic groups in EMS response, medication administration, bystander CPR, or intra-arrest transport decisions. However, significant ethnic disparities were observed in Automated External Defibrillator (AED) utilization, Black people having the lowest rate (6.5%) and Asian people the highest (21.8%). The adjusted analysis found no significant association between race/ethnicity and all OHCA intervention measures, nor between race/ethnicity and survival outcomes. Conclusions: Our multivariable analysis found no statistically significant association between race/ethnicity and EMS response time, epinephrine administration, antiarrhythmic medication use, bystander CPR, AED intervention, or intra-arrest transport. These results imply regional variations in ethnic disparities in OHCA may not be consistent across all areas, warranting further research into disparities in other regions and additional influential factors like neighborhood conditions and socioeconomic status.

Epidemiology and outcome of out-of-hospital cardiac arrest in Salt Lake City: Sex-based investigations.

Objectives: Prior research indicates sex disparities in the incidence and outcomes of out-of-hospital cardiac arrest (OHCA). This study investigates the presence of such differences in Salt Lake City, Utah. Methods: We analyzed data from the Salt Lake City Fire Department (2008‒2023). We included adults with non-traumatic OHCA. We calculated the annual incidence of OHCA and examined sex-specific survival outcomes using multivariable logistic regression, adjusting for OHCA characteristics known to be associated with survival. Results: The annual incidence of OHCA was 76 per 100,000 person-years. Among the 894 OHCA cases included in the analysis, 67.5% were males, 37.3% achieved return of spontaneous circulation (ROSC), and 13.6% survived hospital discharge. Unadjusted analysis revealed that males had significantly higher OHCA in public locations (43.9% vs. 28.6%), witnessed arrests (54.5% vs. 47.8%), and shockable rhythms (33.3% vs. 22.9%). Males also showed higher rates of ROSC (37.5% vs. 36.9%), hospital discharge survival (14.5% vs. 11.7%), and neurologically intact survival. After adjusting for the OHCA characteristics, there was no significant differences between males and females in ROSC, survival to hospital discharge, and favorable neurological function with adjusted odds ratios (male vs. female) of 0.92 (95% confidence interval [CI] 0.73‒1.16), 0.85 (95% CI 0.59‒1.22), and 0.92 (95% CI 0.62‒1.40), respectively. Conclusion: Approximately, 128 adults suffer OHCA in Salt Lake City annually. Males initially showed higher crude survival rates, but after adjusting for OHCA characteristics, no significant sex differences in survival outcomes were found. Enhancing OHCA characteristics could benefit both sexes. Investigations into the relationship between sex- and region-specific factors influencing OHCA outcomes are needed.

A Pathway for Community-Acquired Pneumonia With Rapid Conversion to Oral Therapy Improves Health Care Value.

BACKGROUND: Evidence supports streamlined approaches for inpatients with community-acquired pneumonia (CAP) including early transition to oral antibiotics and shorter therapy. Uptake of these approaches is variable, and the best approaches to local implementation of infection-specific guidelines are unknown. Our objective was to evaluate the impact of a clinical decision support (CDS) tool linked with a clinical pathway on CAP care. METHODS: This is a retrospective, observational pre-post intervention study of inpatients with pneumonia admitted to a single academic medical center. Interventions were introduced in 3 sequential 6-month phases; Phase 1: education alone; Phase 2: education and a CDS-driven CAP pathway coupled with active antimicrobial stewardship and provider feedback; and Phase 3: education and a CDS-driven CAP pathway without active stewardship. The 12 months preceding the intervention were used as a baseline. Primary outcomes were length of intravenous antibiotic therapy and total length of antibiotic therapy. Clinical, process, and cost outcomes were also measured. RESULTS: The study included 1021 visits. Phase 2 was associated with significantly lower length of intravenous and total antibiotic therapy, higher procalcitonin lab utilization, and a 20% cost reduction compared with baseline. Phase 3 was associated with significantly lower length of intravenous antibiotic therapy and higher procalcitonin lab utilization compared with baseline. CONCLUSIONS: A CDS-driven CAP pathway supplemented by active antimicrobial stewardship review led to the most robust improvements in antibiotic use and decreased costs with similar clinical outcomes.

Reducing Diabetic Ketoacidosis Intensive Care Unit Admissions Through an Electronic Health Record-Driven, Standardized Care Pathway.

Diabetic ketoacidosis (DKA) is a common condition, with wide variation in admission location and clinical practice. We aimed to decrease intensive care unit (ICU) admission for DKA by implementing a standardized, electronic health record-driven clinical care pathway that used subcutaneous insulin, rather than a continuous insulin infusion, for patients with nonsevere DKA. This is a retrospective, observational preintervention to postintervention study of 214 hospital admissions for DKA that evaluated the effect of our intervention on clinical, safety, and cost outcomes. The primary outcome was ICU admission, which decreased from 67.0% to 41.7% (p < .001). Diabetes nurse educator consultation increased from 45.3% to 63.9% (p = .006), and 30-day Emergency Department (ED) return visit decreased from 12.3% to 2.8% (p = .008). Time to initiation of basal insulin increased from 18.19 ± 1.25 hours to 22.47 ± 1.76 hours (p = .05) and reopening of the anion gap increased from 4.7% to 13.9% (p = .02). No changes in ED length of stay (LOS), hospital LOS, hypoglycemia, treatment-induced hypokalemia, 30-day hospital readmission, or inpatient mortality were observed. The implementation of a standardized DKA care pathway using subcutaneous insulin for nonsevere DKA resulted in decreased ICU use and increased diabetes education, without affecting patient safety.

Advanced Airway Type and Its Association with Chest Compression Interruptions During Out-of-Hospital Cardiac Arrest Resuscitation Attempts.

OBJECTIVE: To assess interruptions in chest compressions associated with advanced airway placement during cardiopulmonary resuscitation (CPR) of out-of-hospital cardiac arrest (OHCA) victims. METHODS: The method used was observational analysis of prospectively collected clinical and defibrillator data from 339 adult OHCA victims, excluding victims with <5 minutes of CPR. Interruptions in CPR, summarized by chest compression fraction (CCF), longest pause, and the number of pauses greater than 10 seconds, were compared between patients receiving bag valve mask (BVM), supraglottic airway (SGA), endotracheal intubation (ETI) via direct laryngoscopy (DL), and ETI via video laryngoscopy (VL). Secondary outcomes included first pass success and the effect of multiple airway attempts on CPR interruptions. RESULTS: During the study period, paramedics managed 23 cases with BVM, 43 cases with SGA, 148 with DL, and 125 with VL. There were no statistically significant differences between the airway groups with regard to longest compression pause (BVM 18 sec [IQR 11-33], SGA 29 sec [IQR 15-65], DL 26 sec [IQR 12-59], VL 22 sec [IQR 14-41]), median number of pauses greater than 10 seconds (BVM 2 [IQR 1-3], SGA 2 [IQR 1-3], DL 2 [IQR 1-4], VL 2 [IQR 1-3]), or CCF (0.92 for all groups). However, each additional attempt following failed initial DL was associated with an increase in the risk of additional chest compression pauses (relative risk 1.29, 95% confidence interval 1.02-1.64). Such an association was not observed with additional attempts using VL or SGA. First pass success was highest with SGA (77%), followed by between DL (68%) and VL (67%); these differences were not statistically significant. CONCLUSIONS: While summary measures of chest compression delivery did not differ significantly between airway classes in this observational study, repeated attempts following failed initial DL during cardiopulmonary resuscitation were associated with an increase in the number of pauses in chest compression delivery observed.

Implementation of Pit Crew Approach and Cardiopulmonary Resuscitation Metrics for Out-of-Hospital Cardiac Arrest Improves Patient Survival and Neurological Outcome.

INTRODUCTION: Survival from out-of-hospital cardiac arrest (OHCA) varies by community and emergency medical services (EMS) system. We hypothesized that the adoption of multiple best practices to focus EMS crews on high-quality, minimally interrupted cardiopulmonary resuscitation (CPR) would improve survival of OHCA patients in Salt Lake City. METHODS AND RESULTS: In September 2011, Salt Lake City Fire Department EMS providers underwent a systemwide restructuring of care for OHCA patients that focused on the adoption of high-quality CPR with minimal interruptions and offline medical review of defibrillator data and feedback on CPR metrics. Victims were directed to ST-elevation myocardial infarction receiving centers. Prospectively collected data on patient survival and neurological outcome for all OHCAs were compared. In the postintervention period, there were 407 cardiac arrests with 65 neurologically intact survivors (16%), compared with 330 cardiac arrests with 25 neurologically intact survivors (8%) in the preintervention period. Among patients who survived to hospital admission, a higher proportion in the postintervention period survived to hospital discharge (71/141 [50%] versus 36/98 [37%], P=0.037) and had a favorable neurological outcome (65 [46%] versus 25 [26%], P=0.0005) compared with patients treated before the protocol changes. The univariate odds ratio or the association between neurologically intact survival (cerebral performance category 1 and 2) and protocol implementation was 2.3 (95% CI 1.4 to 3.7, P=0.001). Among discharged patients, the distribution of cerebral performance category scores was more favorable in the postintervention period (P<0.0001). CONCLUSIONS: A multifaceted protocol, including several American Heart Assocation best practices for the resuscitation of patients with OHCA, was associated with improved survival and neurological outcome.

Evidence-based care pathway for cellulitis improves process, clinical, and cost outcomes.

BACKGROUND: Cellulitis is a common infection with wide variation of clinical care. OBJECTIVE: To implement an evidence-based care pathway and evaluate changes in process metrics, clinical outcomes, and cost for cellulitis. DESIGN: A retrospective observational pre-/postintervention study was performed. SETTING: University of Utah Health Care, a 500-bed academic medical center in Salt Lake City, Utah. PATIENTS: All patients 18 years or older admitted to the emergency department observation unit or hospital with a primary diagnosis of cellulitis. INTERVENTION: Development of an evidence-based care pathway for cellulitis embedded into the electronic medical record with education for all emergency and internal medicine physicians. MEASUREMENTS: Primary outcome of broad-spectrum antibiotic use. Secondary outcomes of computed tomography/magnetic resonance imaging orders, length of stay (LOS), 30-day readmission, and pharmacy, lab, imaging, and total facility costs. RESULTS: A total of 677 visits occurred, including 370 visits where order sets were used. Among all patients, there was a 59% decrease in the odds of ordering broad-spectrum antibiotics (P < 0.001), 23% decrease in pharmacy cost (P = 0.002), and 13% decrease in total facility cost (P = 0.006). Compared to patients for whom order sets were not used, patients for whom order sets were used had a 75%, 13%, and 25% greater decrease in the odds of ordering broad-spectrum antibiotics (P < 0.001), clinical LOS (P = 0.041), and pharmacy costs (P = 0.074), respectively. CONCLUSION: The evidence-based care pathway for cellulitis improved care at an academic medical center by reducing broad-spectrum antibiotic use, pharmacy costs, and total facility costs without an adverse change in LOS or 30-day readmissions.

Intranasal sufentanil for the treatment of acute pain in a winter resort clinic.

INTRODUCTION: Painful extremity injuries are common patient complaints in resort clinics, urgent care clinics, and emergency departments. We hypothesized that intranasal (IN) sufentanil could provide rapid, noninvasive, effective pain relief to patients presenting with acute extremity injuries. METHODS: This was an unblinded, nonrandomized, observational study that enrolled a convenience sample of patients presenting to a university-affiliated ski clinic with acute moderate to severe pain associated with a traumatic injury between the months of January and March 2011. Patients were excluded if they reported an allergy to sufentanil or had hypoxia, significant head injury, or hypotension. Nurses administered IN sufentanil using an IN atomizer device. The nurse recorded patient-reported pain scores (0-10 scale) on arrival and at 10, 20, and 30 minutes after administration of sufentanil. RESULTS: During the study period, 40 patients were enrolled; 75% were men. The average age was 32 years (range, 16-60 years). The average dose of sufentanil was 37.7 µg. Five patients (12.5%) were given additional IN analgesia. Average pain on arrival was 9 (on a 10-point scale), and the mean reduction in pain scores was 4.7 (95% confidence interval [CI], 3.67-5.57) at 10 minutes, 5.79 (95% CI, 4.81-6.77) at 20 minutes, and 5.74 (95% CI, 4.72-6.76) at 30 minutes. CONCLUSION: In this limited observational trial, IN sufentanil provided rapid, safe, and noninvasive pain relief to patients presenting with acute traumatic extremity injuries. Given the ease of administration, this may serve as a viable option for use in other settings, such as urgent care clinics and emergency departments.

Does limiting oral contrast decrease emergency department length of stay?

INTRODUCTION: The purpose of this study was to examine the impact on emergency department (ED) length of stay (LOS) of a new protocol for intravenous (IV)-contrast only abdominal/pelvic computed tomography (ABCT) compared to historical controls. METHODS: This was a retrospective case-controlled study performed at a single academic medical center. Patients ≥ 18 undergoing ABCT imaging for non-traumatic abdominal pain were included in the study. We compared ED LOS between historical controls undergoing ABCT imaging with PO/IV contrast and study patients undergoing an IV-contrast-only protocol. Imaging indications were the same for both groups and included patients with clinical suspicion for appendicitis, diverticulitis, small bowel obstruction, or perforation. We identified all patients from the hospital's electronic storehouse (imaging code, ordering department, imaging times), and we abstracted ED LOS and disposition from electronic medical records. RESULTS: Two hundred and eleven patients who underwent PO/IV ABCT prep were compared to 184 patients undergoing IV-contrast only ABCT prep. ED LOS was shorter for patients imaged with the IV-contrast only protocol (4:35 hrs vs. 6:39 hrs, p < 0.0001). CONCLUSION: Implementation of an IV-contrast only ABCT prep for select ED patients presenting for evaluation of acute abdominal pain significantly decreased ED LOS.

Prospective evaluation of the treatment of pain in the ED using computerized physician order entry.

BACKGROUND: Treatment of pain in the emergency department (ED) is a significant area of focus, as previous studies have noted generally inadequate treatment of pain in ED patients. Previous studies have not evaluated the impact of computerized physician order entry (CPOE) on the treatment of pain in the ED. We sought to evaluate treatment of pain before and after implementation of CPOE in an academic ED. METHODS: We prospectively enrolled a convenience sample of patients presenting to the ED with a pain-related complaint in 4-month periods before and after CPOE implementation. We compared numbers who received pain medications, time from registration to administration of pain medication, and repeat dosing of pain medication. RESULTS: Six hundred forty-six ED patients participated in the pre-CPOE period, whereas 592 patients participated post-CPOE. Similar numbers of patients received pain medications in the pre-CPOE and post-CPOE periods (55% vs 59%; P = .139), whereas those in the post-CPOE period were more likely to receive a repeat dose of pain medications (10.5% vs 17.6%; P < .001). CONCLUSION: The use of CPOE in the ED may offer modest benefits in the treatment of patients with pain-related complaints.

Helicopter emergency medical services utilization for winter resort injuries.

INTRODUCTION: Helicopter and ground emergency medical services (EMS) units are frequently called to transport patients from winter resorts to area trauma centers. OBJECTIVE: The purpose of this study was to examine helicopter EMS (HEMS) utilization for such patients, and to investigate out-of-hospital clinical variables that might help providers determine the most appropriate utilization of HEMS. METHODS: The study included patients aged ≥ 12 years who were transported by ground EMS (GEMS) or HEMS to a regional trauma center with an acute injury sustained at a winter resort. The decision to transport via HEMS was based on field provider judgment. Injury information was prospectively obtained and combined with emergency department (ED) and hospital data abstracted from trauma registry and hospital records. For the purpose of this study, appropriate HEMS utilization was defined according to two different schemes. Limited utilization of HEMS was defined as the need for an emergent ED or out-of-hospital intervention (intubation, chest tube or needle thoracostomy, central line placement, or cardiopulmonary resuscitation). Expanded utilization of HEMS was defined as the need for an emergent intervention and/or an Injury Severity Score (ISS) ≥ 16 and/or need for emergent nonorthopedic surgery. Provider judgment alone was compared with results of recursive partitioning to predict the need for HEMS. RESULTS: Of 815 patients enrolled between 2006 and 2009, 65 (8.0%) patients met the expanded criteria for appropriate HEMS utilization. Of these, 30 (46.2%) were transported by GEMS and 35 (53.8%) were transported by HEMS. Twenty-seven of the 65 patients (41.5%) required an emergent ED or out-of-hospital intervention. Activation of HEMS by out-of-hospital providers was (at best) 55.6% sensitive and 89.1% specific (85.2% overtriage rate) for predicting the need for an emergent out-of-hospital or ED intervention. Recursive partitioning, using a Glasgow Coma Scale score (GCS) ≤ 13 or pulse oximetry value <89%, was superior to provider judgment in predicting the need for an emergent procedure (57.9% sensitive, 98.6% specific, 45% overtriage rate). CONCLUSION: Use of a simple prediction rule was superior to provider judgment in predicting the need for an emergent ED or out-of-hospital procedure in patients injured at winter resorts. If validated, this rule may be a resource to help out-of-hospital providers decide when to activate HEMS in these unique areas.

Outcome of elderly patients injured at winter resorts.

OBJECTIVE: This study examined hospital outcomes in elderly patients injured at winter resorts. METHODS: The study included patients age 12 and over who presented to a regional trauma center with an acute injury sustained at a winter resort. Injury information was prospectively obtained using a questionnaire. Emergency department and hospital data were obtained from trauma registry and hospital records. RESULTS: Six hundred ninety-three patients presented during the study period (67 were ≥65 years). Elderly patients were more likely to have a preexisting health condition (31% vs 4%, P < .05), undergo hospital admission (76% vs 56%, P < .05), have longer hospital length of stay (P < .05), and have lower injury severity (P < .05). Both groups had a similar proportion of predefined in-hospital complications and comparable hospital discharge outcomes. CONCLUSION: Active elderly patients injured at winter resorts had higher inpatient admission rates and longer hospital length of stay when compared with a younger cohort, despite lower injury severity scores and comparable discharge outcomes.

Terrain park injuries.

BACKGROUND: This study examined demographics, injury pattern, and hospital outcome in patients injured in winter resort terrain parks. METHODS: The study included patients >/=12 years of age who presented to a regional trauma center with an acute injury sustained at a winter resort. Emergency department (ED) research assistants collected patient injury and helmet use information using a prospectively designed questionnaire. ED and hospital data were obtained from trauma registry and hospital records. RESULTS: Seventy-two patients were injured in a terrain park, and 263 patients were injured on non-terrain park slopes. Patients injured in terrain parks were more likely to be male [68/72 (94%) vs. 176/263 (67%), p<0.0001], younger in age [23 +/- 7 vs. 36 +/- 17, p<0.0001], live locally [47/72 (65%) vs. 124/263 (47%), p=0.006], use a snowboard [50/72 (69%) vs. 91/263 (35%), p<0.0001], hold a season pass [46/66 (70%) vs. 98/253 (39%), p<0.0001], and sustain an upper extremity injury [29/72 (40%) vs. 52/263 (20%), p<0.001] when compared to patients injured on non-terrain park slopes. There were no differences between the groups in terms of EMS transport to hospital, helmet use, admission rate, hospital length of stay, and patients requiring specialty consultation in the ED. CONCLUSIONS: Patients injured in terrain parks represent a unique demographic within winter resort patrons. Injury severity appears to be similar to those patients injured on non-terrain park slopes.