Management Considerations for Air Medical Transport Programs Transfusing RhD-Positive Red Blood Cell-Containing Products to Females of Childbearing Potential.

Recent years have seen increased discussion surrounding the benefits of damage control resuscitation, prehospital transfusion (PHT) of blood products, and the use of whole blood over component therapy. Concurrent shortages of blood products with the desire to provide PHT during air medical transport have prompted reconsideration of the traditional approach of administering RhD-negative red cell-containing blood products first-line to females of childbearing potential (FCPs). Given that only 7% of the US population has blood type O negative and 38% has O positive, some programs may be limited to offering RhD-positive blood products to FCPs. Adopting the practice of giving RhD-positive blood products first-line to FCPs extends the benefits of PHT to such patients, but this practice does incur the risk of future hemolytic disease of the fetus and newborn (HDFN). Although the risk of future fetal mortality after an RhD-incompatible transfusion is estimated to be low in the setting of acute hemorrhage, the number of FCPs who are affected by this disease will increase as more air medical transport programs adopt this practice. The process of monitoring and managing HDFN can also be time intensive and costly regardless of the rates of fetal mortality. Air medical transport programs planning on performing PHT of RhD-positive red cell-containing products to FCPs should have a basic understanding of the pathophysiology, prevention, and management of hemolytic disease of the newborn before introducing this practice. Programs should additionally ensure there is a reliable process to notify receiving centers of potentially RhD-incompatible PHT because alloimmunization prophylaxis is time sensitive. Facilities receiving patients who have had PHT must be prepared to identify, counsel, and offer alloimmunization prophylaxis to these patients. This review aims to provide air medical transport professionals with an understanding of the pathophysiology and management of HDFN and provide a template for the early management of FCPs who have received an RhD-positive red cell-containing PHT. This review also covers the initial workup and long-term anticipatory guidance that receiving trauma centers must provide to FCPs who have received RhD-positive red cell-containing PHT.

TeleEMS: An EMS Telemedicine Pilot Program Barriers to Implementation.

INTRODUCTION: In response to the COVID-19 pandemic, emergency medical services (EMS) and hospitals recognized the need for innovative programs addressing 9-1-1 utilization and ambulance transport to provide patient-centered, safe, cost-effective care. The ET3 (Emergency Triage, Treatment, and Transport) model provides flexibility and new payments to ambulance care teams for Medicare beneficiaries for alternate strategies of care. This includes providing treatment in place through telehealth after a 9-1-1 call and ambulance response. Our objective is to evaluate the implementation barriers of a telemedicine service to 9-1-1 responding ambulances providing treatment in place for low-acuity conditions. METHODS: The TeleEMS program was piloted in a large, urban fire-based EMS system with eight ambulances geographically surrounding one hospital. Paramedics received training on the telemedicine software and screening criteria, which were age 1-70 and vital sign parameters. Pregnant, combative, and patients with no clear need for emergency department transport were excluded. Three emergency physicians with additional training in EMS provided the TeleEMS service from 8am to 6 pm on Monday - Friday. The telemedicine software was application-based and provided HIPAA-compliant two-way, real-time audio and video communication through the 4G network on a tablet. The TeleEMS physicians had access to a database of clinics and hospitals that coordinate health care. The TeleEMS physician contacted the patient within 24-72 hours after the encounter for follow-up. RESULTS: The TeleEMS pilot program ran for 12 weeks from April - June 2021. During this time, there were seven completed consults with treatment in place, one completed consult with transport to an emergency department, and five consult attempts that failed due to technological issues with resultant transport. Each of the consults (13/13) met the TeleEMS screening criteria. Post-pilot focus group sessions were held to determine paramedic feedback. Barriers to an EMS telemedicine program include paramedic buy-in, patient expectations for emergency care, technology limitations, and qualified physician resources. CONCLUSIONS: An EMS telemedicine program can be successfully implemented in urban fire-based EMS systems for 9-1-1 responding ambulances. Barriers to implementation should be addressed at the paramedic, patient, technology, and program levels to improve success.

Interhospital variability in Out-of-Hospital cardiac arrest survival in a large metropolitan area.

Background: Out-of-hospital cardiac arrest (OHCA) survival varies widely across the United States. The impact of hospital OHCA volume and ST-elevation myocardial infarction (STEMI) Receiving Center (SRC) designation on survival is not fully understood. Methods: This was a retrospective analysis of adult OHCA who survived to hospital admission reported to the Chicago Cardiac Arrest Registry to Enhance Survival (CARES) database from May 1, 2013 to December 31, 2019. Hierarchical logistic regression models were generated and adjusted by hospital characteristics. Survival to hospital discharge (SHD) and cerebral performance category (CPC) 1-2 at each hospital were calculated after adjusting for arrest characteristics. Hospitals were assigned quartiles (Q1-Q4) based on total arrest volume to allow for comparison of SHD and CPC 1-2 between quartiles. Results: 4,020 patients met inclusion criteria. 21 of the 33 Chicago hospitals included in this study were designated SRCs. Adjusted SHD and CPC 1-2 rates ranged from 27.3% to 37.0% and from 8.9% to 25.1%, respectively, by hospital. SRC designation did not significantly affect SHD (OR 0.96; 95% CI, 0.71-1.30) nor CPC 1-2 (OR 1.17; 95% CI, 0.74-1.84). OHCA volume quartiles did not significantly affect SHD (Q2: OR 0.94; 95% CI, 0.54-1.60; Q3: OR 1.30; 95% CI, 0.78-2.16; Q4: OR 1.25; 95% CI, 0.74-2.10) nor CPC 1-2 (Q2: OR 0.75; 95% CI, 0.36-1.54; Q3: OR 0.94; 95% CI, 0.48-1.87; Q4: OR 0.97; 95% CI, 0.48-1.97). Conclusion: Interhospital variability in both SHD and CPC 1-2 cannot be explained by hospital arrest volume nor SRC status. Further research is warranted to explore reasons for interhospital variability.

Prehospital Intranasal Glucagon for Hypoglycemia.

BACKGROUND: Prehospital hypoglycemia is usually treated with oral or intravenous (IV) dextrose in a variety of concentrations. In the absence of vascular access, intramuscular (IM) glucagon is commonly administered. Occupational needle-stick injury remains a significant risk while attempting to obtain vascular access or administer medications intramuscularly in the prehospital setting. We sought to determine if intranasal (IN) glucagon is effective in the prehospital treatment of hypoglycemia. METHODS: We performed a retrospective analysis of all consecutive cases where recombinant glucagon was administered IN by paramedics from January 1, 2015 through December 31, 2020. Excluded were cases without pre or post administration blood glucose documentation, and cases where another form of treatment for hypoglycemia was administered at any time during the EMS encounter. The primary outcome was clinical response to IN glucagon documented by paramedics; secondary outcomes included pre and post administration blood glucose values. RESULTS: Out of 44 cases that met study inclusion criteria, 14 patients (32%) had substantial improvement, 13 patients (30%) had slight improvement, and 17 patients (38%) had no improvement in mental status after administration of IN glucagon. In cases with substantial improvement (n = 14), the mean pre administration blood glucose was 33.8 mg/dl and the mean post administration blood glucose was 87.1 mg/dl (mean increase 53.3 mg/dl, 95% CI: 21.5 to 85.1). In cases with slight improvement (n = 13), the mean pre administration blood glucose was 23.9 mg/dl and the mean post administration blood glucose was 53.8 mg/dl (mean increase 29.9 mg/dl, 95% CI = 2.9 to 56.9). In case with no improvement (n = 17) the mean pre administration blood glucose was 30.1 mg/dl and the mean post administration glucose was 33.1 mg/dl (mean difference 3.1 mg/dl, 95% CI: -10.1 to 3.9). CONCLUSION: Intranasal administration of recombinant glucagon for hypoglycemia resulted in a clinically significant improvement in mental status and a corresponding increase in blood glucose levels in select cases in the prehospital setting.

Utilizing community level factors to improve prediction of out of hospital cardiac arrest outcome using machine learning.

OBJECTIVES: To evaluate the impact of community level information on the predictability of out-of-hospital cardiac arrest (OHCA) survival. METHODS: We used the Cardiac Arrest Registry to Enhance Survival (CARES) to geocode 9,595 Chicago incidents from 2014 to 2019 into community areas. Community variables including crime, healthcare, and economic factors from public data were merged with CARES. The merged data were used to develop ML models for OHCA survival. Models were evaluated using Area Under the Receiver Operating Characteristic curve (AUROC) and features were analyzed using SHapley Additive exPansion (SHAP) values. RESULTS: Baseline results using CARES data achieved an AUROC of 84%. The final model utilizing community variables increased the AUROC to 88%. A SHAP analysis between high and low performing community area clusters showed the high performing cluster is positively impacted by good health related features and good community safety features positively impact the low performing cluster. CONCLUSION: Utilizing community variables helps predict neurologic outcomes with better performance than only CARES data. Future studies will use this model to perform simulations to identify interventions to improve OHCA survival.

A machine learning approach for modeling decisions in the out of hospital cardiac arrest care workflow.

BACKGROUND: A growing body of research has shown that machine learning (ML) can be a useful tool to predict how different variable combinations affect out-of-hospital cardiac arrest (OHCA) survival outcomes. However, there remain significant research gaps on the utilization of ML models for decision-making and their impact on survival outcomes. The purpose of this study was to develop ML models that effectively predict hospital's practice to perform coronary angiography (CA) in adult patients after OHCA and subsequent neurologic outcomes. METHODS: We utilized all (N = 2398) patients treated by the Chicago Fire Department Emergency Medical Services included in the Cardiac Arrest Registry to Enhance Survival (CARES) between 2013 and 2018 who survived to hospital admission to develop, test, and analyze ML models for decisions after return of spontaneous circulation (ROSC) and patient survival. ML classification models, including the Embedded Fully Convolutional Network (EFCN) model, were compared based on their ability to predict post-ROSC decisions and survival. RESULTS: The EFCN classification model achieved the best results across tested ML algorithms. The area under the receiver operating characteristic curve (AUROC) for CA and Survival were 0.908 and 0.896 respectively. Through cohort analyses, our model predicts that 18.3% (CI 16.4-20.2) of patients should receive a CA that did not originally, and 30.1% (CI 28.5-31.7) of these would experience improved survival outcomes. CONCLUSION: ML modeling effectively predicted hospital decisions and neurologic outcomes. ML modeling may serve as a quality improvement tool to inform system level OHCA policies and treatment protocols.

Implementing a Patient Tracking System in a Large EMS System.

Objective: Accurate tracking of patients poses a significant challenge to prehospital and hospital emergency medical providers in planned and unplanned events. Previous reports on patient tracking systems are limited primarily to descriptive reports of post incident reviews or simulated exercises. Our objective is to report our experience with implementing a patient barcode tracking system during various planned events within a large urban EMS system.Methods: In 2018, representatives from the Chicago Department of Public Health, Chicago Fire Department EMS, private EMS agencies, and 27 hospitals in the Chicago EMS System were trained on the use of a web-based patient tracking system using barcoded triage tags and wristbands to monitor triage category and hospital destination during an event. The tracking system was used on two planned operational days and three pre-planned mass gathering events. The primary outcome was the percent of patients initially scanned by EMS that were scanned by the hospital. Descriptive statistics were collected. Barriers to patient tracking system use were identified.Results: Each event was reviewed for the number of patients assigned a barcode identifier and scanned by EMS that were then scanned by the hospital. In the first planned operational day, 57% (359/622) of patients initially scanned by EMS were scanned by the hospital. In the second planned operational day, 88% (355/402) of EMS scanned patients were scanned by the hospital and 37% (133/355) were assigned a final disposition. At three city mass gathering events, there were 79% (50/63), 95% (190/199), and 82% (46/56) of EMS scanned patients also scanned by hospitals. Logistical and technological challenges were documented.Conclusions: Use of a web-based system with barcode identifiers successfully tracked patients from prehospital to hospital during planned operational days and mass gathering events. Percent of scanned patients increased after the first operational day and remained consistent in subsequent events. Limitations to the patient tracking system included logistical and technological barriers. Similar patient tracking systems may be implemented to assist with event management in other EMS systems.

Systems of Care for ST-Segment-Elevation Myocardial Infarction: A Policy Statement From the American Heart Association.

The introduction of Mission: Lifeline significantly increased timely access to percutaneous coronary intervention for patients with ST-segment-elevation myocardial infarction (STEMI). In the years since, morbidity and mortality rates have declined, and research has led to significant developments that have broadened our concept of the STEMI system of care. However, significant barriers and opportunities remain. From community education to 9-1-1 activation and emergency medical services triage and from emergency department and interfacility transfer protocols to postacute care, each critical juncture presents unique challenges for the optimal care of patients with STEMI. This policy statement sets forth recommendations for how the ideal STEMI system of care should be designed and implemented to ensure that patients with STEMI receive the best evidence-based care at each stage in their illness.

Prehospital Comprehensive Stroke Center vs Primary Stroke Center Triage in Patients With Suspected Large Vessel Occlusion Stroke.

Importance: Endovascular therapy (EVT) improves functional outcomes in acute ischemic stroke (AIS) with large vessel occlusion (LVO). Whether implementation of a regional prehospital transport policy for comprehensive stroke center triage increases use of EVT is uncertain. Objective: To evaluate the association of a regional prehospital transport policy that directly triages patients with suspected LVO stroke to the nearest comprehensive stroke center with rates of EVT. Design, Setting, and Participants: This retrospective, multicenter preimplementation-postimplementation study used an interrupted time series analysis to compare treatment rates before and after implementation in patients with AIS arriving at 15 primary stroke centers and 8 comprehensive stroke centers in Chicago, Illinois, via emergency medical services (EMS) transport from December 1, 2017, to May 31, 2019 (9 months before and after implementation in September 2018). Data were analyzed from December 1, 2017, to May 31, 2019. Interventions: Prehospital EMS transport policy to triage patients with suspected LVO stroke, using a 3-item stroke scale, to comprehensive stroke centers. Main Outcomes and Measures: Rates of EVT before and after implementation among EMS-transported patients within 6 hours of AIS onset. Results: Among 7709 patients with stroke, 663 (mean [SD] age, 68.5 [14.9] years; 342 women [51.6%] and 321 men [48.4%]; and 348 Black individuals [52.5%]) with AIS arrived within 6 hours of stroke onset by EMS transport: 310 of 2603 (11.9%) in the preimplementation period and 353 of 2637 (13.4%) in the postimplementation period. The EVT rate increased overall among all patients with AIS (preimplementation, 4.9% [95% CI, 4.1%-5.8%]; postimplementation, 7.4% [95% CI, 7.5%-8.5%]; P < .001) and among EMS-transported patients with AIS within 6 hours of onset (preimplementation, 4.8% [95% CI, 3.0%-7.8%]; postimplementation, 13.6% [95% CI, 10.4%-17.6%]; P < .001). On interrupted time series analysis among EMS-transported patients, the level change within 1 month of implementation was 7.15% (P = .04) with no slope change before (0.16%; P = .71) or after (0.08%; P = .89), which indicates a step rather than gradual change. No change in time to thrombolysis or rate of thrombolysis was observed (step change, 1.42%; P = .82). There were no differences in EVT rates in patients not arriving by EMS in the 6- to 24-hour window or by interhospital transfer or walk-in, irrespective of time window. Conclusions and Relevance: Implementation of a prehospital transport policy for comprehensive stroke center triage in Chicago was associated with a significant, rapid, and sustained increase in EVT rate for patients with AIS without deleterious associations with thrombolysis rates or times.

Retrospective Study of Midazolam Protocol for Prehospital Behavioral Emergencies.

INTRODUCTION: Agitated patients in the prehospital setting pose challenges for both patient care and emergency medical services (EMS) provider safety. Midazolam is frequently used to control agitation in the emergency department setting; however, limited data exist in the prehospital setting. We describe our experience treating patients with midazolam for behavioral emergencies in a large urban EMS system. We hypothesized that using midazolam for acute agitation leads to improved clinical conditions without causing significant clinical deterioration. METHODS: We performed a retrospective review of EMS patient care reports following implementation of a behavioral emergencies protocol in a large urban EMS system from February 2014-June 2016. For acute agitation, paramedics administered midazolam 1 milligram (mg) intravenous (IV), 5 mg intramuscular (IM), or 5 mg intranasal (IN). Results were analyzed using descriptive statistics, Levene's test for assessing variance among study groups, and t-test to evaluate effectiveness based on route. RESULTS: In total, midazolam was administered 294 times to 257 patients. Median age was 30 (interquartile range 24-42) years, and 66.5% were male. Doses administered were 1 mg (7.1%) and 5 mg (92.9%). Routes were IM (52.0%), IN (40.8%), and IV (7.1%). A second dose was administered to 37 patients. In the majority of administrations, midazolam improved the patient's condition (73.5%) with infrequent adverse events (3.4%). There was no significant difference between the effectiveness of IM and IN midazolam (71.0% vs 75.4%; p = 0.24). CONCLUSION: A midazolam protocol for prehospital agitation was associated with reduced agitation and a low rate of adverse events.

The utility of computed tomography to evaluate thoracic complications after cardiopulmonary resuscitation.

BACKGROUND: Cardiopulmonary resuscitation (CPR) in adults following non-traumatic out of hospital cardiac arrest (OHCA) can cause thoracic complications including rib fractures, sternal fractures, and pneumothorax. Post-CPR complication rates are poorly studied and the optimum imaging modality to detect these complications post-resuscitation has not been established. METHODS: We performed a retrospective review of adult patients transported to a single, urban, academic hospital following atraumatic OHCA between September 2015 and January 2020. Patients who achieved sustained return of spontaneous circulation (ROSC) and who underwent computed tomography (CT) imaging of the chest following radiographic chest x-ray were included in the analyses. Patient demographics and prehospital data were collected. Descriptive statistics and multivariate logistic regression analysis were performed. Sensitivity and specificity of chest x-ray for the detection of thoracic injury in this population were estimated. RESULTS: 786 non-traumatic OHCA patients were transported to the ED, 417 of whom obtained sustained ROSC and were admitted to the hospital (53%). 137 (32.9%) admitted patients underwent CT imaging of the chest in the ED. Of these imaged patients median age was 62 years old (IQR 53-70) with 54.0% female and 38.0% of patients having received bystander CPR. 40/137 (29.2%) patients had skeletal fractures noted on CT imaging and 12/137 (8.8%) had pneumothorax present on CT imaging. X-ray yielded a sensitivity of 7.5% for rib fracture and 50% for pneumothorax with a specificity of 100% for both. Logistic regression analysis revealed no significant association between age, sex, bystander CPR, or resuscitation length with thoracic fractures or pneumothorax. CONCLUSIONS: Complications from OHCA CPR were high with 29.2% of CT imaged patients having rib fractures and 8.8% having pneumothoraces. X-ray had poor sensitivity for these post-resuscitation complications. Post-CPR CT imaging of the chest should be considered for detecting post-CPR complications.

Cardiac Arrhythmia Following an Epileptic Seizure.

Sudden unexplained death in epilepsy (SUDEP) refers to a death in a patient with epilepsy that is not due to trauma, drowning, status epilepticus, or another apparent cause. Although the pathophysiology of SUDEP is incompletely understood, growing evidence supports the role of seizure-associated arrhythmias as a potential etiology. We present a unique case of a patient presenting with ventricular tachycardia shortly following a seizure, along with corresponding laboratory data. Awareness of high risk arrhythmias in seizure patients could lead to advances in understanding pathophysiology and treatment of this complication of seizure disorder and ultimately prevention of SUDEP.

Cincinnati Prehospital Stroke Scale Can Identify Large Vessel Occlusion Stroke.

OBJECTIVE: Accurate prehospital identification of patients with acute ischemic stroke (AIS) from large vessel occlusion (LVO) facilitates direct transport to hospitals that perform endovascular thrombectomy. We hypothesize that a cut-off score of the Cincinnati Prehospital Stroke Scale (CPSS), a simple assessment tool currently used by emergency medical services (EMS) providers, can be used to identify LVO. METHODS: Consecutively enrolled, confirmed AIS patients arriving via EMS between August 2012 and April 2014 at a high-volume stroke center in a large city with a single municipal EMS provider agency were identified in a prospective, single-center registry. Head and neck vessel imaging confirmed LVO. CPSS scores were abstracted from prehospital EMS records. Spearman's rank correlation, Wilcoxon rank-sum test, and Student's t-test were performed. Cohen's kappa was calculated between CPSS abstractors. The Youden index identified the optimal CPSS cut-off. Multivariate logistic regression controlling for age, sex, and race determined the odds ratio (OR) for LVO. RESULTS: Of 144 eligible patients, 138 (95.8%) had CPSS scores in the EMS record and were included for analysis. The median age was 69 (IQR 58-81) years. Vessel imaging was performed in 97.9% of patients at a median of 5.9 (IQR 3.6-10.2) hours from hospital arrival, and 43.7% had an LVO. Intravenous tissue plasminogen activator was administered to 29 patients, in whom 12 had no LVO on subsequent vessel imaging. The optimal CPSS cut-off predicting LVO was 3, with a Youden index of 0.29, sensitivity of 0.41, and specificity of 0.88. The adjusted OR for LVO with CPSS = 3 was 5.7 (95% CI 2.3-14.1). Among patients with CPSS = 3, 72.7% had an LVO, compared with 34.3% of patients with CPSS ≤ 2 (p < 0.0001). CONCLUSIONS: A CPSS score of 3 reliably identifies LVO in AIS patients. EMS providers may be able to use the CPSS, a simple, widely adopted prehospital stroke assessment tool, with a cut-off score to screen for patients with suspected LVO.

Identifying Key Words in 9-1-1 Calls for Stroke: A Mixed Methods Approach.

OBJECTIVES: Identifying stroke during a 9-1-1 call is critical to timely prehospital care. However, emergency medical dispatchers (EMDs) recognize stroke in less than half of 9-1-1 calls, potentially due to the words used by callers to communicate stroke signs and symptoms. We hypothesized that callers do not typically use words and phrases considered to be classical descriptors of stroke, such as focal neurologic deficits, but that a mixed-methods approach can identify words and phrases commonly used by 9-1-1 callers to describe acute stroke victims. METHODS: We performed a mixed-method, retrospective study of 9-1-1 call audio recordings for adult patients with confirmed stroke who were transported by ambulance in a large urban city. Content analysis, a qualitative methodology, and computational linguistics, a quantitative methodology, were used to identify key words and phrases used by 9-1-1 callers to describe acute stroke victims. Because a caller's level of emotional distress contributes to the communication during a 9-1-1 call, the Emotional Content and Cooperation Score was scored by a multidisciplinary team. RESULTS: A total of 110 9-1-1 calls, received between June and September 2013, were analyzed. EMDs recognized stroke in 48% of calls, and the emotional state of most callers (95%) was calm. In 77% of calls in which EMDs recognized stroke, callers specifically used the word "stroke"; however, the word "stroke" was used in only 38% of calls. Vague, non-specific words and phrases were used to describe stroke victims' symptoms in 55% of calls, and 45% of callers used distractor words and phrases suggestive of non-stroke emergencies. Focal neurologic symptoms were described in 39% of calls. Computational linguistics identified 9 key words that were more commonly used in calls where the EMD identified stroke. These words were concordant with terms identified through qualitative content analysis. CONCLUSIONS: Most 9-1-1 callers used vague, non-specific, or distractor words and phrases and infrequently provide classic stroke descriptions during 9-1-1 calls for stroke. Both qualitative and quantitative methodologies identified similar key words and phrases associated with accurate EMD stroke recognition. This study suggests that tools incorporating commonly used words and phrases could potentially improve EMD stroke recognition.

EMS Provider Perceptions on Termination of Resuscitation in a Large, Urban EMS System.

OBJECTIVE: Despite the value of out-of-hospital Termination of Resuscitation (TOR) and the scientific evidence in favor of this practice, TOR has not been uniformly adopted or consistently practiced in EMS systems. Previous focus group studies have identified multiple barriers to implementation of out of hospital TOR but existing literature on EMS provider perceptions is limited. We sought to identify EMS providers' perceived barriers to performing out-of-hospital TOR in a large urban EMS system. METHODS: The Chicago EMS System is a regional collaborative of EMS physicians, nurses and provider agencies, including the Chicago Fire Department (CFD), which provides exclusive emergency response for 9-1-1 calls in Chicago. CFD is an urban, fire-based EMS agency with a tiered response, with fire-fighter EMTs and paramedics providing initial care, and single role paramedics providing supplemental care and transport. A 2-page written survey was distributed to understand providers' experiences with managing OHCA and perceived barriers to TOR to inform subsequent improvements in protocol development and education. RESULTS: Of 3500 EMS providers that received the survey, 2309 were completed (66%). Survey respondent demographics were fire-fighter/EMTB (69%), fire-fighter/paramedic (14%), and single role paramedic (17%). The most frequent barrier to field TOR was scene safety (86%). The most common safety issue identified was family reaction to TOR (68%) and many providers felt threatened by family when trying to perform TOR (38%). Providers with a higher career numbers of OHCA were more likely to have felt threatened by the family (OR 6.70, 95% CI 2.99-15.00) and single role paramedics were more likely than FF/EMTBs to have felt threatened (OR 3.34, 95% CI 2.65-4.22). Barriers to delivering a death notification after TOR, include being uncomfortable or threatened with possible family reaction (52%) and family asking to continue the resuscitation (45%). There was lack of formal prior death notification training, the majority learned from colleagues through on the job training. CONCLUSIONS: Our study identifies scene safety, death notification delivery, and lack of formal training in death notification as barriers that EMS providers face while performing TOR in a large urban EMS system. These findings informed educational and operational initiatives to overcome the identified provider level issues and improve compliance with TOR policies.

Prehospital aspirin administration for acute coronary syndrome (ACS) in the USA: an EMS quality assessment using the NEMSIS 2011 database.

INTRODUCTION: National practice guidelines recommend early aspirin administration to reduce mortality in acute coronary syndrome (ACS). Although timely administration of aspirin has been shown to reduce mortality in ACS by 23%, prior regional Emergency Medical Service (EMS) data have shown inadequate prehospital administration of aspirin in patients with suspected cardiac ischaemia. OBJECTIVES: Using the National EMS Information System (NEMSIS) database, we sought to determine (1) the proportion of patients with suspected cardiac ischaemia who received aspirin and (2) patient and prehospital characteristics that independently predicted administration of aspirin. METHODS: Analysis of the 2011 NEMSIS database targeted patients aged ≥40 years with a paramedic primary impression of 'chest pain'. To identify patients with chest pain of suspected cardiac aetiology, we included those for whom an ECG or cardiac monitoring had been performed. Trauma-related chest pain and basic life support transports were excluded. The primary outcome was presence of aspirin administration. Patient (age, sex, race/ethnicity and insurance status) and regional characteristics where the EMS transport occurred were also obtained. Multivariate logistic regression was used to assess the independent association of patient and regional factors with aspirin administration for suspected cardiac ischaemia. RESULTS: Of the total 14,371,941 EMS incidents in the 2011 database, 198,231 patients met our inclusion criteria (1.3%). Of those, 45.4% received aspirin from the EMS provider. When compared with non-Hispanic white patients, several groups had greater odds of aspirin administration by EMS: non-Hispanic black patients (OR 1.49, 95% CI 1.44 to 1.55), non-Hispanic Asians (OR 1.62, 95% CI 1.21 to 2.18), Hispanics (OR 1.71, 95% CI 1.54 to 1.91) and other non-Hispanics (OR 1.27, 95% CI 1.07 to 1.51). Patients living in the Southern region of the USA (OR 0.59, 95% CI 0.57 to 0.62) and patients with governmental (federally administered such as Veteran's Health Care, but not Medicare or Medicaid) insurance (OR 0.67, 95% CI 0.57 to 0.78) had the lowest odds of receiving aspirin. Age and sex (OR 1.00, 95% CI 1.00 to 1.00) were not associated with aspirin administration. CONCLUSIONS: It is likely that prehospital aspirin administration for patients with suspected cardiac ischaemia remains low nationally and could be improved. Reasons for disparities among the various groups should be explored.

Translation of EMS: clinical practice and system oversight from core content study guide to best practices implementation in an Urban EMS system.

Since 2009, the seminal text in emergency medical services (EMS) medicine has been used to guide the academic development of the new subspecialty but direct application of the material into EMS oversight has not been previously described. The EMS/Disaster Medicine fellowship program at our institution scheduled a monthly meeting to systematically review the text and develop a study guide to assist the fellow and affiliated faculty in preparation for the board examination. In addition to the summary of chapter content, the review included an assessment of areas from each chapter subject where our EMS system did not exhibit recommended characteristics. A matrix was developed in the form of a gap analysis to include specific recommendations based on each perceived gap. Initial review and completion dates for each identified gap enable tracking and a responsible party. This matrix assisted the fellow with development of projects for EMS system improvement in addition to focusing and prioritizing the work of other interested physicians working in the system. By discussing expert recommendations in the setting of an actual EMS system, the faculty can teach the fellow how to approach system improvements based on prior experiences and current stakeholders. This collaborative environment facilitates system-based practice and practice-based learning, aligning with ACGME core competencies. Our educational model has demonstrated the success of translating the text into action items for EMS systems. This model may be useful in other systems and could contribute to the development of EMS system standards nationwide.

National trends in the utilization of emergency medical services for acute myocardial infarction and stroke.

INTRODUCTION: The emergency medical services (EMS) system plays a crucial role in the chain of survival for acute myocardial infarction (AMI) and stroke. While regional studies have shown underutilization of the 911 system for these time-sensitive conditions, national trends have not been studied. Our objective was to describe the national prevalence of EMS use for AMI and stroke, examine trends over a six-year period, and identify patient factors that may contribute to utilization. METHODS: Using the National Hospital Ambulatory Medical Care Survey-ED (NHAMCS) dataset from 2003-2009, we looked at patients with a discharge diagnosis of AMI or stroke who arrived to the emergency department (ED) by ambulance. We used a survey-weighted χ2 test for trend and logistic regression analysis. RESULTS: In the study, there were 442 actual AMI patients and 220 (49.8%) presented via EMS. There were 1,324 actual stroke patients and 666 (50.3%) presented via EMS. There was no significant change in EMS usage for AMI or stroke over the six-year period. Factors independently associated with EMS use for AMI and stroke included age (OR 1.21; 95% CI 1.12-1.31), Non-Hispanic black race (OR 1.72; 95% CI 1.16-2.29), and nursing home residence (OR 11.50; 95% CI 6.19-21.36). CONCLUSION: In a nationally representative sample of ED visits from 20003-2009, there were no trends of increasing EMS use for AMI and stroke. Efforts to improve access to care could focus on patient groups that underutilize the EMS system for such conditions.