Association between a Post-Resuscitation Care Bundle and the Odds of Field Rearrest after Successful Resuscitation from Out-of-Hospital Cardiac Arrest: A Pre/Post Study.

OBJECTIVES: Rearrest after successful resuscitation from out-of-hospital cardiac arrest (OHCA) is common and is associated with worse patient outcomes. However, little is known about the effect of interventions designed to prevent rearrest. We assessed the association between a prehospital care protocol for immediate management after return of spontaneous circulation (ROSC) and rates of field rearrest and survival to discharge in patients with prehospital ROSC. METHODS: This was a retrospective study of adult patients with OHCA and field ROSC within a large EMS system before (April 2017-August 2018) and after (April 2019-February 2020) implementation of a structured prehospital post-ROSC care protocol. The protocol was introduced in September 2018 and provided on-scene stabilization direction including guidance on ventilation and blood pressure support. Field data and hospital outcomes were used to compare the frequency of field rearrest, hospital survival, and survival with good neurologic outcome before and after protocol implementation. Logistic regression was used to assess the association between the post-implementation period and these outcomes, and odds ratios were reported. The association between individual interventions on these outcomes was also explored. RESULTS: There were 2,706 patients with ROSC after OHCA in the pre-implementation period and 1,780 patients in the post-implementation period. The rate of prehospital rearrest was 43% pre-implementation vs 45% post-implementation (RD 2%, 95% CI -1, 4%). In the adjusted analysis, introduction of the protocol was not associated with decreased odds of rearrest (OR 0.87, 95% CI 0.73, 1.04), survival to hospital discharge (OR 1.01, 95% CI 0.81, 1.24), or survival with good neurologic outcome (OR 0.81, 95% CI 0.61, 1.06). Post-implementation, post-ROSC administration of saline and push-dose epinephrine increased from 11% to 25% (RD 14%, 95% CI 11, 17%) and from 3% to 12% (RD 9% 95% CI 7, 11%), respectively. In an exploratory analysis, push-dose epinephrine was associated with a decreased odds of rearrest (OR 0.68, 95% CI 0.50, 0.94). CONCLUSIONS: Introduction of a post-ROSC care protocol for patients with prehospital ROSC after OHCA was not associated with reduced odds of field rearrest. When elements of the care bundle were considered individually, push-dose epinephrine was associated with decreased odds of rearrest.

Short-Term Outcomes and Patient Perceptions after Paramedic Non-Transport during the COVID-19 Pandemic.

BACKGROUND: EMS frequently encounter patients who decline transport, yet there are little data to inform the safety of patient and/or paramedic-initiated assess, treat, and refer (ATR) protocols. We determined patient decision-making and short-term outcomes after non-transport by EMS during the COVID-19 pandemic. METHODS: This was a prospective, observational study of a random sample of patients evaluated and not transported by EMS from August 2020 to March 2021. From the EMS database, we randomly selected a daily sample of adult patients with disposition of ATR. We excluded patients dispositioned against medical advice (AMA) and those in police custody. Investigators contacted patients by phone to administer a standardized survey regarding decision-making, symptom progression, follow-up care, and satisfaction with non-transport decision. We also determined the proportion of patients who re-contacted 9-1-1 within 72 h, and unexpected deaths within 72 h using coroner data. Descriptive statistics were calculated. RESULTS: Of 4613 non-transported patients, 3330 (72%) patients for whom the disposition was ATR were included. Patients were 46% male with a median age of 49 (inter-quartile range (IQR) 31-67). Median vital signs measurements fell within the normal range. Investigators successfully contacted 584/3330 patients (18%). The most common reason for failure was lack of accurate phone number. The most common reasons patients reported for not going to the ED on initial encounter were: felt reassured after the paramedic assessment (151/584, 26%), medical complaint resolved (113/584, 19%), paramedic suggested transport was not required (73/584, 13%), concern for COVID-19 exposure (57/584, 10%), and initial concern was not medical (46/584, 8%). Ninety-five percent (552/584) were satisfied with the non-transport decision and 49% (284/584) had sought follow-up care. The majority (501/584, 86%) reported equal, improved, or resolved symptoms, while 80 patients (13%) reported worse symptoms, of whom (64/80, 80%) remained satisfied with the non-transport decision. Overall, there were 154 of 3330 (4.6%) 9-1-1 recontacts within 72 h. Based on coroner data, three unexpected deaths (0.09%) occurred within 72 h of the initial EMS calls. CONCLUSION: Paramedic disposition by ATR protocols resulted in a low rate of 9-1-1 recontact. Unexpected deaths were extremely rare. Patient satisfaction with the non-transport decision was high.

Use of i-Gel Supraglottic Airway in a Simulated Cardiac Arrest Resuscitation During Boat Rescue Transport by Los Angeles County Fire Lifeguard Division: A Proof-of-Concept Study.

OBJECTIVE: The Los Angeles County Fire Department Lifeguard Division responds to water rescues and medical and dive emergencies across 72 miles of Southern California coastline and Catalina Island. Limited advanced life support resources make cardiac arrest resuscitations logistically challenging during transport to shore or the hyperbaric chamber. This proof-of-concept study looked to determine if an i-Gel (Intersurgical Complete Respiratory Systems, Wokingham, Berkshire, UK) supraglottic airway device would either become dislodged or compromise ventilations during prolonged resuscitation at high speeds over open water with an ongoing automatic chest compression device (ACCD). METHODS: A simulated resuscitation was performed on the Los Angeles County Lifeguard rescue boat while underway at speeds up to 25 knots. A LUCAS ACCD (Jolife AB, Ideon Science Park, Lund, Sweden) and a size 3 i-Gel were used. The volume of ventilations and depth of compressions were continuously monitored using the AmbuMan Advanced manikin (Ambu, Ballerup, Denmark). RESULTS: The i-Gel supraglottic airway device delivered appropriate ventilations measuring between 300 and 400 mL/breath when delivered on the upstroke of compression. The i-Gel did not dislodge during transport. CONCLUSION: The i-Gel supraglottic airway device appears to provide adequate ventilations without dislodgment during ongoing compressions with an ACCD during high-speed water transport.

Implementation of a regional extracorporeal membrane oxygenation program for refractory ventricular fibrillation out-of-hospital cardiac arrest.

BACKGROUND: eCPR, the modality of extracorporeal membrane oxygenation (ECMO) applied in the setting of cardiac arrest, has emerged as a novel therapy which may improve outcomes in select patients with out-of-hospital cardiac arrest (OHCA). To date, implementation has been mainly limited to single academic centres. Our objective is to describe the feasibility and challenges with implementation of a regional protocol for eCPR. METHODS: The Los Angeles County Emergency Medical Services (EMS) Agency implemented a regional eCPR protocol in July 2020, which included coordination across multiple EMS provider agencies and hospitals to route patients with refractory ventricular fibrillation (rVF) OHCA to eCPR-capable centres (ECCs). Data were entered on consecutive patients with rVF with suspected cardiac aetiology into a centralized database including time intervals, field and in-hospital care, survival and neurologic outcome. RESULTS: From July 27, 2020 through July 31, 2022, 35 patients (median age 57 years, 6 (17%) female) were routed to ECCs, of whom 11 (31%) received eCPR and 3 (27%) treated with eCPR survived, all of whom had a full neurologic recovery. Challenges encountered during implementation included cost to EMS provider agencies for training, implementation, and purchase of automatic chest compression devices, maintenance of system awareness, hospital administrative support for staffing and equipment for the ECMO program, and interdepartmental coordination at ECCs. CONCLUSION: We describe the successful implementation of a regional eCPR program with ongoing patient enrolment and data collection. These preliminary findings can serve as a model for other EMS systems who seek to implement regional eCPR programs.

Longitudinal Assessment of Coronavirus Disease 2019 Vaccine Acceptance and Uptake Among Frontline Medical Workers in Los Angeles, California.

BACKGROUND: Sentiments of vaccine hesitancy and distrust in public health institutions have complicated the government-led coronavirus disease 2019 (COVID-19) vaccine control strategy in the United States. As the first to receive the vaccine, COVID-19 vaccine attitudes among frontline workers are consequential for COVID-19 control and public opinion of the vaccine. METHODS: In this study, we used a repeated cross-sectional survey administered at 3 time points between 24 September 2020 and 6 February 2021 to a cohort of employees of the University of California, Los Angeles Health and the Los Angeles County Fire Department. The primary outcome of interest was COVID-19 vaccination intent and vaccine uptake. RESULTS: Confidence in COVID-19 vaccines and vaccine uptake rose significantly over time. At survey 1, confidence in vaccine protection was 46.4% among healthcare workers (HCWs) and 34.6% among first responders (FRs); by survey 3, this had risen to 90.0% and 75.7%, respectively. At survey 1, about one-third of participants intended to receive a vaccine as soon as possible. By survey 3, 96.0% of HCWs and 87.5% of FRs had received a COVID-19 vaccine. CONCLUSIONS: Attitudes toward vaccine uptake increased over the study period, likely a result of increased public confidence in COVID-19 vaccines, targeted communications, a COVID-19 winter surge in Los Angeles County, and ease of access from employer-sponsored vaccine distribution.

Humoral responses to SARS-CoV-2 mRNA vaccines: Role of past infection.

Two mRNA vaccines (BNT162b2 and mRNA-1273) against severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) are globally authorized as a two-dose regimen. Understanding the magnitude and duration of protective immune responses is vital to curbing the pandemic. We enrolled 461 high-risk health services workers at the University of California, Los Angeles (UCLA) and first responders in the Los Angeles County Fire Department (LACoFD) to assess the humoral responses in previously infected (PI) and infection naïve (NPI) individuals to mRNA-based vaccines (BNT162b2/Pfizer- BioNTech or mRNA-1273/Moderna). A chemiluminescent microparticle immunoassay was used to detect antibodies against SARS-CoV-2 Spike in vaccinees prior to (n = 21) and following each vaccine dose (n = 246 following dose 1 and n = 315 following dose 2), and at days 31-60 (n = 110) and 61-90 (n = 190) following completion of the 2-dose series. Both vaccines induced robust antibody responses in all immunocompetent individuals. Previously infected individuals achieved higher median peak titers (p = 0.002) and had a slower rate of decay (p = 0.047) than infection-naïve individuals. mRNA-1273 vaccinated infection-naïve individuals demonstrated modestly higher titers following each dose (p = 0.005 and p = 0.029, respectively) and slower rates of antibody decay (p = 0.003) than those who received BNT162b2. A subset of previously infected individuals (25%) required both doses in order to reach peak antibody titers. The biologic significance of the differences between previously infected individuals and between the mRNA-1273 and BNT162b2 vaccines remains uncertain, but may have important implications for booster strategies.

Use of Naloxone in 9-1-1 Patients without Respiratory Depression in Los Angeles County, California (USA).

INTRODUCTION: Along with an increase in opioid deaths, there has been a desire to increase the accessibility of naloxone. However, in the absence of respiratory depression, naloxone is unlikely to be beneficial and may be deleterious if it precipitates withdrawal in individuals with central nervous system (CNS) depression due to non-opioid etiologies. OBJECTIVE: The aim of this study was to evaluate how effective prehospital providers were in administering naloxone. METHODS: This is a retrospective study of naloxone administration in two large urban Emergency Medical Service (EMS) systems. The proportion of patients who had a respiratory rate of at least 12 breaths per minute at the time of naloxone administration by prehospital providers was determined. RESULTS: During the two-year study period, 2,580 patients who received naloxone by prehospital providers were identified. The median (interquartile range) respiratory rate prior to naloxone administration was 12 (6-16) breaths per minute. Using an a priori respiratory rate of under 12 breaths per minute to define respiratory depression, only 1,232 (47.8%; 95% CI, 50.3%-54.2%) subjects who received naloxone by prehospital providers had respiratory depression. CONCLUSION: This study showed that EMS providers in Los Angeles County, California (USA) frequently administered naloxone to individuals without respiratory depression.

The Performance of Manual Versus Mechanical Cardiopulmonary Resuscitation During a Simulated Rescue Boat Transport in Cardiac Arrest.

OBJECTIVE: Catalina Island's Casino Point is a popular scuba diving site and is located 11.6 nautical miles from the University of Southern California Catalina Hyperbaric Chamber. We sought to determine the best method of providing high-performance CPR during a dive emergency, comparing manual cardiopulmonary resuscitation (CPR) with 2 mechanical compression devices during a simulated boat transport. METHODS: This study was performed on a Los Angeles County Lifeguard rescue boat using 3 manikins and comparing 3 arms: 1) manual compressions with 2 rescuers, 2) mechanical CPR with the Autopulse (ZOLL, Chelmsford, MA), and 3) mechanical CPR with the LUCAS III (Stryker, Kalamazoo, WI). CPR data were collected using ZOLL Stat Padz with an accelerometer connected to ZOLL X Series monitor/defibrillators. The manikins were filmed using mounted cameras. Data were reviewed using ZOLL Case Review. RESULTS: In video footage, all 3 arms appeared to provide high-performance CPR during the 30-minute transport. The compression fractions for manual CPR, the Autopulse, and the LUCAS were 99.57%, 95.51%, and 98.4%, respectively. Engine noise (94.6-101.3 dB) prevented the manual arm from hearing their audio prompts, and motion caused significant artifact on the accelerometers. CONCLUSION: High-performance CPR can successfully be performed on a rescue boat by either manual or mechanical methods. Mechanical CPR offered many logistical advantages.

Use of 911 for Rapid Re-Triage of Critical Trauma Patients.

OBJECTIVES: The objective of this study was to evaluate the effectiveness of a 911 trauma re-triage protocol implemented at a new community hospital in a region with a high volume of trauma and frequent transports by private vehicle. METHODS: This retrospective cohort study included all trauma patients ≥15 years old transferred via 911 trauma re-triage from a new community hospital over a 10-month period from August 2015 through April 2016. Criteria for 911 trauma re-triage were developed with input from local Emergency Medical Services (EMS) and trauma experts. An educational module, along with the criteria and implementation steps, was distributed to the emergency department (ED) personnel at the community hospital. Data were abstracted from the regional trauma registry, and the EMS patient care records were reviewed. Primary outcomes were: (1) median total transport time; and (2) proportion of patients who met the 911 re-triage criteria. RESULTS: During the study period, 32 patients with traumatic injuries were transferred via 911 re-triage to the closest trauma center (TC). The median age of patients was 31 years (IQR 24-45 years) with 78% male and 66% suffering from a penetrating mechanism. The median prehospital provider scene time was 10 minutes (IQR 8-12 minutes) and transport time was seven minutes (IQR 6-9 minutes). Median total transport time was 17 minutes (IQR 15-20 minutes). Seventeen patients (53%) met 911 re-triage criteria as determined by study investigators. The most common criteria met was "penetrating injury to the head, neck, or torso" in 14 cases. CONCLUSION: This study demonstrated that 911 re-triage was a feasible strategy to expeditiously transfer critical trauma patients to a TC within a mature trauma system in an urban-suburban setting with a median total transport time of 17 minutes.

Critical Medication Shortages: Effective Strategies to Maintain Continuous Medication Availability for Emergency Medical Services.

Objective: Critical shortages of generic injectable medications are an ongoing challenge for Emergency Medical Services (EMS) systems. Mitigation strategies have been proposed to address the issue, but a limited amount of data exists quantifying the scope of the problem or describing strategies being used to ensure access to essential medications for prehospital care. In this study, we sought to quantify specific medication shortages and to determine the most frequently employed mitigation strategies to maintain medication availability in a large, regional EMS system. Methods: A survey was distributed to the 30 public advanced life support (ALS) provider agencies in Los Angeles County (LAC) to assess the prevalence of specific medication shortages and types of shortage mitigation strategies implemented. Survey responses were reviewed and presented using descriptive statistics. Results: Survey responses were received from 29 of 30 (97%) provider agencies. All but one of the responding agencies reported being impacted by medication shortages. Strategies to maintain the supply of medications included use of alternative vendors 20/28 (71%), rotating medications from low to high volume units (54%), utilizing expired medication FDA-approved extensions (50%), substituting medications (43%), borrowing medications from the LAC EMS Agency (39%) or other EMS provider agencies (32%), utilizing expired medications with medical director approval (29%), diluting medications to obtain desired concentration (18%), reducing minimum periodic automatic replacement (PAR) levels (14%), and using alternate medication concentrations/formulations (14%). The medications most frequently reported to have shortages included epinephrine (0.1 mg/mL), morphine, dextrose 10%, and normal saline. None of the provider agencies self-reported adverse events due to the shortages. Conclusions: Critical medication shortages remain a problem for many EMS systems. EMS medical directors need to implement multiple mitigation strategies to maintain supply of critical medications for prehospital patient care.

The Digital EMS California Academy of Learning: One State's Innovative Approach to EMS Fellow Education.

INTRODUCTION: Emergency medical services (EMS) fellowships are growing in significance within the United States prehospital health care system. While fellowships represent a cornerstone of EMS subspecialty education, an individual learner's experiences are limited by local resources and practices. California EMS fellowships have developed an innovative method for expanding fellows' educational experiences outside their immediate programs. THE INNOVATIVE EDUCATION METHOD: Each month, fellows, fellowship directors, and local EMS medical directors from throughout the state participate in a video conference. This meeting is divided into four distinct components: book chapter presentation, board-style question review, call review, and an EMS literature review. CHAPTER REVIEW: The two-volume text Emergency Medical Services: Clinical Practice and Systems Oversight has been categorized into 12 modules, one for each month of the fellowship. Every meeting, one fellow prepares a didactic presentation summarizing the highlights from that month's chapters. QUESTION REVIEW: Fellows each create five multiple-choice questions and answers, based on the section reading. Questions are assessed by the group, both for informational content and for appropriate formatting. After completion, these questions are submitted for future review for the EMS fellowship in-service examination. CALL REVIEW: Based on that month's module topics, a call is chosen and reviewed. Regional protocol and practice differences from different systems are discussed. The online medical oversight provided and the prehospital provider performance are evaluated by the group. LITERATURE REVIEW: Fellows not assigned to present a call or didactic segment each choose one paper focusing on a subject relevant to the module or call. Strengths of the study design, analysis, outcomes, and relevance to EMS practice are discussed. OUTCOMES: Fellows and experienced EMS attendings are exposed to different protocol and system approaches in an interactive and accessible format. This partnership expands educational opportunities for fellows and promotes collaboration across EMS systems.