Perceived Work Demands and Emergency Department Crowding as Predictors of Objective Stress among Emergency Physicians: A Shift-Level Approach.

OBJECTIVE: To understand shift-level determinants of emergency physician (EP) burnout, relationships were tested between EP shift demands, stress, and fatigue. METHOD: EP (N = 16) were assessed over 114 shifts that occurred before and during the COVID-19 pandemic. Salivary cortisol (an indicator of stress) and self-reported fatigue were collected prior to and following each shift. An objective crowding score (NEDOCS) per shift was calculated. Shift demands were assessed at the end of each shift. RESULTS: Multilevel models revealed that shift demands, NEDOCS, and the pandemic were related to higher levels of end-of-shift cortisol, but not fatigue. Cortisol levels were higher for shifts with a higher number of demands, greater crowding, and during the pandemic. CONCLUSIONS: Shift demands predicted objective indicators of stress, but not self-reported fatigue. Interventions are needed to decrease stress and shift demands to reduce EP burnout.

Determinants of Persistent, Multi-Year, Frequent Emergency Department Use Among Children and Young Adults in Three US States.

OBJECTIVE: This study examines the factors associated with persistent, multi-year, and frequent emergency department (ED) use among children and young adults. METHODS: We conducted a retrospective secondary analysis using the 2012-2017 Healthcare Cost and Utilization Project State Emergency Department Databases for children and young adults aged 0-19 who visited any ED in Florida, Massachusetts, and New York. We estimated the association between persistent frequent ED use and individuals' characteristics using multivariable logistic regression models. RESULTS: Among 1.3 million patients with 1.8 million ED visits in 2012, 2.9% (37,558) exhibited frequent ED use (≥4 visits in 2012) and accounted for 10.2% (181,138) of all ED visits. Longitudinal follow-up of frequent ED users indicated that 15.4% (5770) remained frequent users periodically over the next 1 or 2 years, while 2.2% (831) exhibited persistent frequent use over the next 3-5 years. Over the 6-year study period, persistent frequent users had 31,551 ED visits at an average of 38.0 (standard deviation = 16.2) visits. Persistent frequent ED use was associated with higher intensity of ED use in 2012, public health insurance coverage, inconsistent health insurance coverage over time, residence in non-metropolitan and lower-income areas, multimorbidity, and more ED visits for less medically urgent conditions. CONCLUSIONS: Clinicians and policymakers should consider the diverse characteristics and needs of pediatric persistent frequent ED users compared to broader definitions of frequent users when designing and implementing interventions to improve health outcomes and contain ED visit costs.

Sudden-Onset Disaster Mass-Casualty Incident Response: A Modified Delphi Study on Triage, Prehospital Life Support, and Processes.

The application and provision of prehospital care in disasters and mass-casualty incident response in Europe is currently being explored for opportunities to improve practice. The objective of this translational science study was to align common principles of approach and action and to identify how technology can assist and enhance response. To achieve this objective, the application of a modified Delphi methodology study based on statements derived from key findings of a scoping review was undertaken. This resulted in 18 triage, eight life support and damage control interventions, and 23 process consensus statements. These findings will be utilized in the development of evidence-based prehospital mass-casualty incident response tools and guidelines.

Factors associated with persistent multiyear frequent emergency department use.

BACKGROUND: Although frequent emergency department (ED) users have been widely studied in cross-sectional settings, there is some evidence suggesting that most frequent ED users do not remain frequent users over multiple consecutive years. The objective of this study was to explore the association between persistent multiyear frequent ED use and individuals' characteristics. METHODS: A retrospective analysis using the Healthcare Cost and Utilization Project State Emergency Department Databases (2012-2017) for individuals aged 18-59 who visited any ED in Florida, Massachusetts and New York was conducted. Multivariable regression models were used to estimate the association between persistent frequent ED use over time (≥4 ED visits in each data year) and individuals' characteristics and clinical factors compared with non-persistent frequent users (≥4 ED visits only in the baseline year). RESULTS: The databases for the three states included 3.3 million patients, who accounted for 4.5 million ED visits in the baseline year (2012). Of those, 3.2% of patients were frequent ED users (≥4 visits) accounting for 13.2% of all ED visits in the baseline year. Longitudinal follow-up revealed that 14.9% (15 617) of frequent users in 2012 remained persistently frequent ED users for 2-3 consecutive years and 3.6% (3774) for 4-6 consecutive years. Persistent frequent ED users differed significantly from non-persistent frequent ED users; they had more ED visits in the index year, were more likely to have no health insurance or public health insurance coverage, and had a higher prevalence of chronic conditions and comorbidities, and more ED visits for less medically urgent conditions. CONCLUSION: Differences exist between persistent and non-persistent frequent ED users that should be considered when implementing interventions designed to improve health outcomes and curtail healthcare expenditures generated by the broad population of frequent ED users.

Emergency department utilization and disposition outcomes by pediatric patients with cancer in Maryland and New York from 2013 to 2017.

BACKGROUND: Pediatric patients with cancer commonly seek emergency department (ED) care, yet there is limited evidence on ED utilization patterns and disposition outcomes among these patients. METHODS: Retrospective analysis of the Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases for Maryland and New York from 2013 to 2017. We compared ED visits and disposition outcomes for 5.8 million pediatric patients (<18 years old) with and without cancer, and used multivariable regressions to estimate associations between the number of ED visits, hospital (inpatient) admissions through the ED, and ED or inpatient mortality and sociodemographic and clinical factors within the cancer cohort. RESULTS: Pediatric patients with cancer had more ED visits per year on average (2.4 vs. 1.5, p < .001), higher shares of admissions (56.8% vs. 6.6%, p < .001) and mortality (1.2% vs. 0.1%, p < .001) compared to those without cancer. Among patients with cancer, uninsured pediatric patients had fewer ED visits and lower risk of admission to a hospital through the ED compared to those with Medicaid coverage (total visits: incidence rate ratio [IRR]: 0.82, 95% confidence intervals [CI]: 0.75-0.90; admission: IRR: 0.75, 95% CI: 0.65-0.86). Mortality risks were higher for pediatric patients with cancer residing in areas with the lowest median household income, and with no health insurance coverage (IRR: 2.81, 95% CI: 1.21-6.51) compared to Medicaid. CONCLUSIONS: Our findings emphasize the importance of enhancing health insurance coverage policies and social services for pediatric patients with cancer and their families to address clinical and nonclinical needs.

The Effect of Prehospital Blood Transfusion on Patient Body Temperature from the Time of Emergency Medical Services Transfusion to Arrival at the Emergency Department.

BACKGROUND: Transfusion of blood products is life-saving and time-sensitive in the setting of acute blood-loss anemia, and is increasingly common in the emergency medical services (EMS) setting. Prehospital blood products are generally "cold-stored" at 4°C, then warmed with a portable fluid-warming system for the purpose of preventing the "lethal triad" of hypothermia, acidosis, and coagulopathy. This study aims to evaluate body temperature changes of EMS patients receiving packed red blood cells (PRBC) and/or fresh frozen plasma (FFP) when using the LifeWarmer Quantum Blood & Fluid Warming System (LifeWarmer, https://www.lifewarmer.com/). METHODS: From 1 January 2020 to 31 August 2021, patients who qualified for and received PRBC and/or FFP were retrospectively reviewed. Body-temperature homeostasis pre- and post-transfusion were evaluated with attention given to those who arrived to the emergency department (ED) hypothermic (<36°C). RESULTS: For all 69 patients analyzed, the mean initial prehospital temperature (°C) was 36.5 ± 1.0, and the mean initial ED temperature was 36.7 ± 0.6, demonstrating no statically significant change in value pre- or post-transfusion (0.2 ± 0.8, p = .09). Shock index showed a statistically significant decrease following transfusion: 1.5 ± 0.5 to 0.9 ± 0.4 (p < .001). CONCLUSION: Use of the Quantum prevents the previously identified risk of hypothermia with respect to unwarmed prehospital transfusions. The data is favorable in that body temperature did not decrease in critically ill patients receiving cold-stored blood warmed during administration with the Quantum.

A data driven policy to minimise the tuberculosis testing cost among healthcare workers.

INTRODUCTION: The Centres for Disease Control and Prevention (CDC) mandates that healthcare employees at high-risk exposure to Tuberculosis (TB) undergo annual testing. Currently, two methods of TB testing are used: a two-step skin test (TST) or a whole-blood test (IGRA). Healthcare leadership's test selection must account for not only direct costs such as procedure and resources but also indirect costs, including employee workplace absence. METHODS: A mathematical model based on Upstate South Carolina's largest health system affecting over 18,000 employees on six campuses was developed to investigate the value loss perspective of these testing methods and assist in decision-making. A process flow map identified the varied direct and indirect costs for each test for four employee types, and 6 travel-to-testing-site times were calculated. RESULTS: The switching point between testing procedures that minimised total system costs was most influenced by employee salary compared to travel distance. Switching from the current hospital policy to an integrated TST/IGRA testing could reduce TB compliance costs by 28%. CONCLUSIONS: This study recommends an integrated approach as cost-effective for large health systems with multiple campuses while considering the direct and indirect costs. When accounting for 'inconvenience costs' (stress, etc.) associated with visits, IGRAs are recommended irrespective of employee salary.

Diabetes Patient Surveillance in the Emergency Department: Proof of Concept and Opportunities.

INTRODUCTION: The purpose of this study was to characterize the at-risk diabetes and prediabetes patient population visiting emergency department (ED) and urgent care (UC) centers in upstate South Carolina. METHODS: We conducted this retrospective study at the largest non-profit healthcare system in South Carolina, using electronic health record (EHR) data of patients who had an ED or UC visit between February 2, 2016-July 31, 2018. Key variables including International Classification of Diseases, 10th Revision codes, laboratory test results, family history, medication, and demographic characteristics were used to classify the patients as healthy, having prediabetes, having diabetes, being at-risk for prediabetes, or being at-risk for diabetes. Patients who were known to have diabetes were classified further as having controlled diabetes, management challenged, or uncontrolled diabetes. Population analysis was stratified by the patient's annual number of ED/UC visits. RESULTS: The risk stratification revealed 4.58% unique patients with unrecognized diabetes and 10.34% of the known patients with diabetes considered to be suboptimally controlled. Patients identified as diabetes management challenged had more ED/UC visits. Of note, 33.95% of the patients had unrecognized prediabetes/diabetes risk factors identified during their ED/UC with 87.95% having some form of healthcare insurance. CONCLUSION: This study supports the idea that a single ED/UC unscheduled visit can identify individuals with unrecognized diabetes and an at-risk prediabetes population using EHR data. A patient's ED/UC visit, regardless of their primary reason for seeking care, may be an opportunity to provide early identification and diabetes disease management enrollment to augment the medical care of our community.

Emergency Physicians' Workstation Design: An Observational Study of Interruptions and Perception of Collaboration During Shift-End Handoffs.

BACKGROUND: Frequent external interruptions and lack of collaboration among team members are known to be common barriers in end-of-shift handoffs between physicians in the emergency department. In spite of being the primary location for this crucial and cognitively demanding task, workstations are not designed to limit barriers and support handoffs. OBJECTIVE: The purpose of this study is to examine handoff characteristics, actual and perceived interruptions, and perceived collaboration among emergency physicians performing end-of-shift handoffs in physician workstations with varying levels of enclosures-(a) open-plan workstation, (b) enclosed workstation, and (c) semi-open workstation. METHOD: Handoff and interruption characteristics were captured through in-person observations of 60 handoffs using an iPad-based tool. Additionally, physicians participating in the handoffs responded to a survey pertaining to their perception of interruptions and collaboration with clinicians during each phase. Other organizational and demographic data were obtained from the hospital database, surveys, and observations. RESULTS: Physicians working in the open workstation experienced a significantly higher number of interruptions/hour (18.08 int/hr) as compared to the semi-open (13.62 int/hr) and enclosed workstations (11.41 int/hr). Most physicians perceived that they were interrupted in the semi-open and open workstations. In addition, majority of physicians in the enclosed pod perceived high collaboration with clinicians involved in and present in the workstation during handoff. CONCLUSION: This correlational study showed positive outcomes experienced by physician working in the enclosed workstation as compared to the open and semi-open workstations.

Dispatcher CPR Instructions Across the Age Continuum.

BACKGROUND: Survival rates following out-of-hospital cardiac arrest (OHCA) increase two to three times when cardiopulmonary resuscitation (CPR) is started by bystanders, as compared to starting CPR when Emergency Medical Services (EMS) arrives. Municipalities that have implemented dispatcher-assisted bystander CPR programs have seen increased rates of bystander CPR. Cardiopulmonary resuscitation instructions are given for victims of all ages, but it is unknown if offering instructions results in similar rates of EMS-documented bystander CPR across the age continuum in these municipalities. OBJECTIVES: The aim of this study was to determine if there is a difference in EMS-documented bystander CPR rates based on the age group of the OHCA victim when dispatcher CPR instructions are available in the community. METHODS: This was a three-year, retrospective chart review of OHCA patients in two municipalities within a single county that provided dispatcher-assisted CPR instructions. Bystander CPR and patient age were determined based on EMS documentation. Age was stratified into three groups: child (0-12 years), adult (13-54 years), and geriatric (≥55 years). Chi square was used to compare the rate of bystander CPR in each age group. RESULTS: During the study period, 1,993 patients were identified as being in OHCA at the time of EMS arrival. The overall bystander CPR rate was 10%. The highest rate of bystander CPR was in the child age group (19%). The lowest rate of bystander CPR was in the geriatric age group (9%). There was a statistically significant difference between age groups (P≤.01). CONCLUSIONS: The rate of EMS-documented bystander CPR was low, even though these municipalities provided dispatcher-assisted CPR instructions. The highest rates of bystander CPR were observed in children (0-12 years). Future investigations should determine why this occurs and if there are opportunities to modify dispatcher coaching based on patient age so that bystander CPR rates improve. WeinmeisterKL, LernerEB, GuseCE, AteyyahKA, PirralloRG. Dispatcher CPR instructions across the age continuum. Prehosp Disaster Med. 2018;33(3):342-345.

Effect of clinical decision rules, patient cost and malpractice information on clinician brain CT image ordering: a randomized controlled trial.

BACKGROUND: The frequency of head computed tomography (CT) imaging for mild head trauma patients has raised safety and cost concerns. Validated clinical decision rules exist in the published literature and on-line sources to guide medical image ordering but are often not used by emergency department (ED) clinicians. Using simulation, we explored whether the presentation of a clinical decision rule (i.e. Canadian CT Head Rule - CCHR), findings from malpractice cases related to clinicians not ordering CT imaging in mild head trauma cases, and estimated patient out-of-pocket cost might influence clinician brain CT ordering. Understanding what type and how information may influence clinical decision making in the ordering advanced medical imaging is important in shaping the optimal design and implementation of related clinical decision support systems. METHODS: Multi-center, double-blinded simulation-based randomized controlled trial. Following standardized clinical vignette presentation, clinicians made an initial imaging decision for the patient. This was followed by additional information on decision support rules, malpractice outcome review, and patient cost; each with opportunity to modify their initial order. The malpractice and cost information differed by assigned group to test the any temporal relationship. The simulation closed with a second vignette and an imaging decision. RESULTS: One hundred sixteen of the 167 participants (66.9%) initially ordered a brain CT scan. After CCHR presentation, the number of clinicians ordering a CT dropped to 76 (45.8%), representing a 21.1% reduction in CT ordering (P = 0.002). This reduction in CT ordering was maintained, in comparison to initial imaging orders, when presented with malpractice review information (p = 0.002) and patient cost information (p = 0.002). About 57% of clinicians changed their order during study, while 43% never modified their imaging order. CONCLUSION: This study suggests that ED clinician brain CT imaging decisions may be influenced by clinical decision support rules, patient out-of-pocket cost information and findings from malpractice case review. TRIAL REGISTRATION: NCT03449862 , February 27, 2018, Retrospectively registered.

Paramedic-Initiated CMS Sepsis Core Measure Bundle Prior to Hospital Arrival: A Stepwise Approach.

BACKGROUND: To improve patient outcomes, the Center for Medicare and Medicaid Services (CMS) implemented core measures that outline the initial treatment of the septic patient. These measures include initial blood culture collection prior to antibiotics, adequate intravenous fluid resuscitation, and early administration of broad spectrum antibiotics. We sought to determine if Paramedics can initiate the CMS sepsis core measure bundle in the prehospital field reliably. METHODS: This is a retrospective, case series from a 3rd service EMS system model in Greenville, South Carolina between November 17, 2014 and February 20, 2016. An adult Prehospital Sepsis Assessment Tool was created using the 2012 Surviving Sepsis guidelines: 2 of 3 signs of systemic inflammatory response (heart rate, respiratory rate, oral temperature) and a known or suspected source of infection. A "Sepsis Alert" was called by paramedics and upon IV access a set of blood cultures and blood for lactate analysis was collected prior to field antibiotic administration. The Sepsis Alert was compared to serum lactate levels and ICD 9 or 10 admitting diagnosis of Sepsis, Severe Sepsis, or Septic Shock. Blood culture contamination, serum lactate, and antibiotic match were determined by in-hospital laboratory analysis. RESULTS: A total of 120 trained paramedics called 1,185 "Sepsis Alerts" on 56,643 patients (50.3% Male, mean age 70). Patients with missing discharge diagnosis were eliminated (n = 31). The admitting diagnosis of sepsis overall was 73.5% (848/1154): Sepsis 50% (578/1154), Severe Sepsis 14.6% (169/1154), Septic Shock 8.9% (101/1154). A total of 946 blood cultures were collected in the prehospital setting, with a 95.04% (899/946) no contamination rate. Contamination was found in 4.96% (47/946). A total of 179 (18.9%) of the uncontaminated blood cultures were found to have positive growth with 720 (76.1%) having no growth. EMS administered antibiotics matched blood culture positive growth in 72% of patients. The lactate level was greater than 2.2 in 46.9% of patients. No adverse effects were reported after prehospital administration of antibiotics. CONCLUSION: This study demonstrates the successful implementation of an EMS-driven CMS Sepsis Core Measure bundle in the prehospital setting. Paramedics can acquire uncontaminated blood cultures, and safely administer antibiotics prior to hospital arrival among patients who were recognized as sepsis alerts.

Public Perception of Emergency Medical Services in the United States.

OBJECTIVE: The objective of this study was to assess the public's experience, expectations, and perceptions related to Emergency Medical Services (EMS). METHODS: A population-based telephone interview of adults in the United States was conducted. The survey instrument consisted of 112 items. Demographic variables including age, race, political beliefs, and household income were collected. Data collection was performed by trained interviewers from Kent State University's (Kent, Ohio USA)Social Research Laboratory. Descriptive statistics were calculated. Comparative analyses were conducted between those who used EMS at least once in the past five years and those who did not use EMS using χ2 and t tests. RESULTS: A total of 2,443 phone calls were made and 1,348 individuals agreed to complete the survey (55.2%). There were 297 individuals who requested to drop out of the survey during the phone interview, leaving a total of 1,051 (43.0%) full responses. Participants ranged in age from 18 to 94 years with an average age of 57.5 years. Most were Caucasian or white (83.0%), married (62.8%), and held conservative political beliefs (54.8%). Three-fourths of all respondents believed that at least 40% of patients survive cardiac arrest when EMS services are received. Over half (56.7%) believed that Emergency Medical Technician (EMT)-Basics and EMT-Paramedics provide the same level of care. The estimated median hours of training required for EMT-Basics was 100 hours (IQR: 40-200 hours), while the vast majority of respondents estimated that EMT-Paramedics are required to take fewer than 1,000 clock hours of training (99.3%). The majority believed EMS professionals should be screened for illegal drug use (97.0%), criminal background (95.9%), mental health (95.2%), and physical fitness (91.3%). Over one-third (37.6%) had used EMS within the past five years. Of these individuals, over two-thirds (69.6%) rated their most recent experience as "excellent." More of those who used EMS at least once in the past five years reported a willingness to consent to participate in EMS research compared with those who had not used EMS (69.9% vs. 61.4%, P=.005). CONCLUSIONS: Most respondents who had used EMS services rated their experience as excellent. Nevertheless, expectations related to survival after cardiac arrest in the out-of-hospital setting were not realistic. Furthermore, much of the public was unaware of the differences in training hour requirements and level of care provided by EMT-Basics and EMT-Paramedics. Crowe RP , Levine R , Rodriguez S , Larrimore AD , Pirrallo RG . Public perception of Emergency Medical Services in the United States. Prehosp Disaster Med. 2016;31(Suppl. 1):s112-s117.

Effect of System-Wide Interventions on the Assessment and Treatment of Pain by Emergency Medical Services Providers.

BACKGROUND: An estimated 20% of patients arriving by ambulance to the emergency department are in moderate to severe pain. However, the management of pain in the prehospital setting has been shown to be inadequate. Untreated pain may have negative physiologic and psychological consequences. The prehospital community has acknowledged this inadequacy and made treatment of pain a priority. OBJECTIVES: To determine if system-wide pain management improvement efforts (i.e. education and protocol implementation) improve the assessment of pain and treatment with opioid medications in the prehospital setting and to determine if improvements are maintained over time. METHODS: This was a retrospective before and after study of a countywide prehospital patient care database. The study population included all adult patients transported by EMS between February 2004 and February 2012 with a working assessment of trauma or burn. EMS patient care records were searched for documentation of pain scores and opioid administration. Four time periods were examined: 1) before interventions, 2) after pediatric specific pain management education, 3) after pain management protocol implementation, and 4) maintenance phase. Frequencies and 95% confidence intervals were calculated for all patients meeting the inclusion criteria in each time period and Chi-square was used to compare frequencies between time periods. RESULTS: 15,228 adult patients transported by EMS during the study period met the inclusion criteria. Subject demographics were similar between the four time periods. Pain score documentation improved between the time periods but was not maintained over time (13% [95%CI 12-15%] to 32% [95%CI 31-34%] to 29% [95 CI 27-30%] to 19% [95%CI 18-21%]). Opioid administration also improved between the time periods and was maintained over time (7% [95%CI 6-8%] to 18% [95%CI 16-19%] to 24% [95%CI 22-25%] to 23% [95% CI 22-24%]). CONCLUSIONS: In adult patients both pediatric-focused education and pain protocol implementation improved the administration of opioid pain medications. Documentation and assessment of pain scores was less affected by specific pain management improvement efforts.

A Novel Use of a Metronome in Dispatcher-assisted Cardiopulmonary Resuscitation.

Abstract Early, high-quality cardiopulmonary resuscitation (CPR) is the key to increasing the likelihood of successful resuscitation in cardiac arrest. The use of dispatch-assisted (DA) CPR can increase the likelihood of bystander CPR. We describe a case in which a metronome was introduced to guide DA-CPR. The wife of a 52-year-old male activated 9-1-1 after her husband suffered a cardiac arrest. During her 9-1-1 call she received CPR instructions and heard a metronome over the phone while following the instructions. Return of spontaneous circulation of the patient occurred during paramedic on scene care. The patient was transported to hospital and discharged 6 days later with no neurological deficit. This case supports the use of a metronome by emergency medical dispatchers during the provision of DA-CPR to improve bystander CPR.

A consensus-based gold standard for the evaluation of mass casualty triage systems.

INTRODUCTION: Accuracy and effectiveness analyses of mass casualty triage systems are limited because there are no gold standard definitions for each of the triage categories. Until there is agreement on which patients should be identified by each triage category, it will be impossible to calculate sensitivity and specificity or to compare accuracy between triage systems. OBJECTIVE: To develop a consensus-based, functional gold standard definition for each mass casualty triage category. METHODS: National experts were recruited through the lead investigators' contacts and their suggested contacts. Key informant interviews were conducted to develop a list of potential criteria for defining each triage category. Panelists were interviewed in order of their availability until redundancy of themes was achieved. Panelists were blinded to each other's responses during the interviews. A modified Delphi survey was developed with the potential criteria identified during the interview and delivered to all recruited experts. In the early rounds, panelists could add, remove, or modify criteria. In the final rounds edits were made to the criteria until at least 80% agreement was achieved. RESULTS: Thirteen national and local experts were recruited to participate in the project. Six interviews were conducted. Three rounds of voting were performed, with 12 panelists participating in the first round, 12 in the second round, and 13 in the third round. After the first two rounds, the criteria were modified according to respondent suggestions. In the final round, over 90% agreement was achieved for all but one criterion. A single e-mail vote was conducted on edits to the final criterion and consensus was achieved. CONCLUSION: A consensus-based, functional gold standard definition for each mass casualty triage category was developed. These gold standard definitions can be used to evaluate the accuracy of mass casualty triage systems after an actual incident, during training, or for research.

Emergency preparedness law and willingness to respond in the EMS workforce.

INTRODUCTION: For effective responses to emergencies, individuals must have the ability to respond and also be willing to participate in the response. A growing body of research points to gaps in response willingness among several occupational cohorts with response duties, including the Emergency Medical Services (EMS) workforce. Willingness to respond is particularly important during an influenza or other pandemic, due to increased demands on EMS workers and the potential for workforces to be depleted if responders contract influenza or stay home to care for sick dependents. State emergency preparedness laws are one possible avenue to improve willingness to respond. Hypothesis Presence of certain state-level emergency preparedness laws (ie, ability to declare a public health emergency; requirement to create a public health emergency plan; priority access to health resources for responders) is associated with willingness to respond among EMS workers. METHODS: Four hundred twenty-one EMS workers from the National Registry of Emergency Medical Technicians' (NREMT's) mid-year Longitudinal EMT Attributes and Demographics Study (LEADS) were studied. The survey, which included questions about willingness to respond during an influenza pandemic, was fielded from May through June 2009. Survey data were merged with data about the presence or absence of the three emergency preparedness laws of interest in each of the 50 US states. Unadjusted logistic regression analyses were performed with the presence/absence of each law and were adjusted for respondents' demographic/locale characteristics. RESULTS: Compared to EMS workers in states that did not allow the government to declare a public health emergency, those in states that permitted such declarations were more likely to report that they were willing to respond during an influenza pandemic. In adjusted and unadjusted analyses, this difference was not statistically significant. Similar results were found for the other state-level emergency preparedness laws of interest. CONCLUSION: While state-level emergency preparedness laws are not associated with willingness to respond, recent research suggests that inconsistencies between the perceived and objective legal environments for EMS workers could be an alternative explanation for this study's findings. Educational efforts within the EMS workforce and more prominent state-level implementation of emergency preparedness laws should be considered as a means to raise awareness of these laws. These types of actions are important steps toward determining whether state-level emergency preparedness laws have the potential to promote response willingness among EMS workers.

One-year outcomes of out-of-hospital administration of intravenous glucose, insulin, and potassium (GIK) in patients with suspected acute coronary syndromes (from the IMMEDIATE [Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency Care] Trial).

The Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency care Trial of very early intravenous glucose-insulin-potassium (GIK) for acute coronary syndromes (ACS) in out-of-hospital emergency medical service (EMS) settings showed 80% reduction in infarct size at 30 days, suggesting potential longer-term benefits. Here we report 1-year outcomes. Prespecified 1-year end points of this randomized, placebo-controlled, double-blind, effectiveness trial included all-cause mortality and composites including cardiac arrest, mortality, or hospitalization for heart failure (HF). Of 871 participants randomized to GIK versus placebo, death occurred within 1 year in 11.6% versus 13.5%, respectively (unadjusted hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.57 to 1.23, p = 0.36). The composite of cardiac arrest or 1-year mortality was 12.8% versus 17.0% (HR 0.71, 95% CI 0.50 to 1.02, p = 0.06). The composite of hospitalization for HF or mortality within 1 year was 17.2% versus 17.2% (HR 0.98, 95% CI 0.70 to 1.37, p = 0.92). The composite of mortality, cardiac arrest, or HF hospitalization within 1 year was 18.1% versus 20.4% (HR 0.85, 95% CI 0.62 to 1.16, p = 0.30). In patients presenting with suspected ST elevation myocardial infarction, HRs for 1-year mortality and the 3 composites were, respectively, 0.65 (95% CI 0.33 to 1.27, p = 0.21), 0.52 (95% CI 0.30 to 0.92, p = 0.03), 0.63 (95% CI 0.35 to 1.16, p = 0.14), and 0.51 (95% CI 0.30 to 0.87, p = 0.01). In patients with suspected acute coronary syndromes, serious end points generally were lower with GIK than placebo, but the differences were not statistically significant. However, in those with ST elevation myocardial infarction, the composites of cardiac arrest or 1-year mortality, and of cardiac arrest, mortality, or HF hospitalization within 1 year, were significantly reduced.