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

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

Racial, Ethnic, and Socioeconomic Disparities in Out-of-Hospital Pain Management for Patients With Long Bone Fractures.

STUDY OBJECTIVE: To evaluate racial and ethnic disparities in out-of-hospital analgesic administration, accounting for the influence of clinical characteristics and community socioeconomic vulnerability, among a national cohort of patients with long bone fractures. METHODS: Using the 2019-2020 ESO Data Collaborative, we retrospectively analyzed emergency medical services (EMS) records for 9-1-1 advanced life support transport of adult patients diagnosed with long bone fractures at the emergency department. We calculated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for out-of-hospital analgesic administration by race and ethnicity, accounting for age, sex, insurance, fracture location, transport time, pain severity, and scene Social Vulnerability Index. We reviewed a random sample of EMS narratives without analgesic administration to identify whether other clinical factors or patient preferences could explain differences in analgesic administration by race and ethnicity. RESULTS: Among 35,711 patients transported by 400 EMS agencies, 81% were White, non-Hispanic, 10% were Black, non-Hispanic, and 7% were Hispanic. In crude analyses, Black, non-Hispanic patients with severe pain were less likely to receive analgesics compared with White, non-Hispanic patients (59% versus 72%; Risk Difference: -12.5%, 95% CI: -15.8% to -9.9%). After adjustment, Black, non-Hispanic patients remained less likely to receive analgesics compared with White, non-Hispanic patients (aOR:0.65, 95% CI:0.53 to 0.79). Narrative review identified similar rates of patients declining analgesics offered by EMS and analgesic contraindications across racial and ethnic groups. CONCLUSIONS: Among EMS patients with long bone fractures, Black, non-Hispanic patients were substantially less likely to receive out-of-hospital analgesics compared with White, non-Hispanic patients. These disparities were not explained by differences in clinical presentations, patient preferences, or community socioeconomic conditions.

Racial/Ethnic Disparities in Pain Treatment: Evidence From Oregon Emergency Medical Services Agencies.

BACKGROUND: Despite the critical role that Emergency Medical Services (EMS) provides in the health care system, racial/ethnic treatment disparities in EMS remain relatively unexamined. OBJECTIVE: To investigate racial/ethnic treatment disparities in pain assessment and pain medication administration in EMS. RESEARCH DESIGN: A retrospective analysis was performed on 25,732 EMS encounters from 2015 to 2017 recorded in the Oregon Emergency Medical Services Information System using multivariate logistic regression models to examine the role of patient race/ethnicity in pain assessment and pain medication administration among patients with a traumatic injury. RESULTS: Hispanic and Asian patients were less likely to receive a pain assessment procedure and all racial/ethnic patients were less likely to receive pain medications compared with white patients. In particular, regarding the adjusted likelihood of receiving a pain assessment procedure, Hispanic patients were 21% less likely [95% confidence interval (CI), 10%-30%; P<0.001], Asian patients were 31% less likely (95% CI, 16%-43%; P<0.001) when compared with white patients. Regarding the adjusted likelihood of receiving any pain medications, black patients were 32% less likely (95% CI, 21%-42%; P<0.001), Hispanic patients were 21% less likely (95% CI, 7%-32%; P<0.01), and Asian patients were 24% less likely (95% CI, 1%-41%; P<0.05) when compared with white patients. CONCLUSIONS: Racial/ethnic minorities were more likely to experience disadvantages in EMS treatment in Oregon. Hispanic and Asian patients who requested EMS services in Oregon for traumatic injuries were less likely to have their pain assessed and all racial/ethnicity patients were less likely to be treated with pain medications when compared with white patients.

Preliminary Findings of a Technology-Delivered Sexual Health Promotion Program for Black Men Who Have Sex With Men: Quasi-Experimental Outcome Study.

BACKGROUND: Human immunodeficiency virus (HIV) disproportionately affects black men who have sex with men (MSM), yet there are few evidence-based interventions specifically designed for black MSM communities. In response, the authors created Real Talk, a technology-delivered, sexual health program for black MSM. OBJECTIVE: The objective of our study was to determine whether Real Talk positively affected risk reduction intentions, disclosure practices, condom use, and overall risk reduction sexual practices. METHODS: The study used a quasi-experimental, 2-arm methodology. During the first session, participants completed a baseline assessment, used Real Talk (intervention condition) or reviewed 4 sexual health brochures (the standard of care control condition), and completed a 10-minute user-satisfaction survey. Six months later, participants from both conditions returned to complete the follow-up assessment. RESULTS: A total of 226 participants were enrolled in the study, and 144 completed the 6-month follow-up. Real Talk participants were more likely to disagree that they had intended in the last 6 months to bottom without a condom with a partner of unknown status (mean difference=-0.608, P=.02), have anal sex without a condom with a positive man who was on HIV medications (mean difference=-0.471, P=.055), have their partner pull out when bottoming with a partner of unknown HIV status (mean difference=-0.651, P=.03), and pull out when topping a partner of unknown status (mean difference=-0.644, P=.03). Real Talk participants were also significantly more likely to disagree with the statement "I will sometimes lie about my HIV status with people I am going to have sex with" (mean difference=-0.411, P=.04). In terms of attitudes toward HIV prevention, men in the control group were significantly more likely to agree that they had less concern about becoming HIV positive because of the availability of antiretroviral medications (mean difference=0.778, P=.03) and pre-exposure prophylaxis (PReP) (mean difference=0.658, P=.05). There were, however, no significant differences between Real Talk and control participants regarding actual condom use or other risk reduction strategies. CONCLUSIONS: Our findings suggest that Real Talk supports engagement on HIV prevention issues. The lack of behavior findings may relate to insufficient study power or the fact that a 2-hour, standalone intervention may be insufficient to motivate behavioral change. In conclusion, we argue that Real Talk's modular format facilitates its utilization within a broader array of prevention activities and may contribute to higher PReP utilization in black MSM communities.

Variability in the Treatment of Prehospital Hypoglycemia: A Structured Review of EMS Protocols in the United States.

BACKGROUND: In many industries, limiting variability in process has been associated with a reduction in errors. Hypoglycemia is a common prehospital diabetic emergency for which most EMS systems have a treatment protocol. OBJECTIVE: To examine the treatment variability for prehospital hypoglycemia within EMS protocols in the U.S. METHODS: EMS protocols were reviewed in a structured fashion from 2 sources: the website www.emsprotocols.org and through manual identification from the 50 largest populated cities in the U.S. Data was abstracted by trained investigators regarding the concentration of glucose recommended for the parenteral reversal of hypoglycemia, clinical treatment thresholds, dose recommendations, follow-up care, and non-transport policies. Descriptive statistics were used to summarize the findings. We also reviewed these EMS protocols for the protocol's effective date, the presence of a specific hypoglycemia patient non-transport policy, the use of dilutions of hypertonic dextrose for pediatric patients, glucagon use, and CBG or GCS for patient follow-up. RESULTS: Protocols were retrieved from 185 EMS agencies of a variety of sizes across the U.S. Seventy percent specified only D50 for the treatment of hypoglycemia in adult patients, 8% only D10, and 22% either D10 or D50. Most protocols (85%), which used D50, specified concentration dilutions for pediatric patients. The most frequently specified initial dose of glucose was 25 g of glucose for adults (73-78%), 0.5 g/kg for pediatric (70%), and 0.5 g/kg for neonates (45%). The median blood glucose level threshold for treatment was 60 mg/dl for patients of all ages, but the mean treatment threshold levels for adults, pediatric patients and neonates were statistically different (p < 0.0001). Nearly all protocols (97%) allowed for the use of glucagon in the absence of vascular access. Patient follow up with a repeat CBG was recommended in 32%, both CBG and GCS in 31%, GCS only in 4%, and no follow-up was specified in 33% of the protocols. A specific policy permitting the non-transport of select patients whose hypoglycemia had been corrected was noted in slightly less than half (49%) of the protocols. CONCLUSIONS: In the U.S., EMS protocols for the treatment of hypoglycemia vary significantly. Further studies are warranted to determine the factors underlying this variability and effects on patient outcomes.