Neighborhood Poverty and 9-1-1 Ambulance Response Time

Background: Are 9-1-1 ambulances relatively late to poorer neighborhoods? Studies suggesting so often rely on weak measures of neighborhood (e.g., postal zip code), limit the analysis to particular ambulance encounters (e.g., cardiac arrest responses), and do little to account for variations in dispatch priority or intervention severity. Methods: We merged EMS ambulance contact records in a single California county (n = 87,554) with tract-level data from the American Community Survey (n = 300). After calculating tract-level median ambulance response time (MART), we used ordinary least squares (OLS) regression to estimate a conditional average relationship between neighborhood poverty and MART and quantile regression to condition this relationship on 25th, 50th, and 75th percentiles of MART. We also specified each of these outcomes by five dispatch priorities and by three intervention severities. For each model, we estimated the associated changes in MART per 10 percentage point increase in tract-level poverty while adjusting for emergency department proximity, population density, and population size. Results: Our study produced three major findings. First, most of our tests suggested tract-level poverty was negatively associated with MART. Our baseline OLS model estimates that a 10 percentage point increase in tract-level poverty is associated with almost a 24 s decrease in MART (?23.55 s, 95% confidence interval [CI] ?33.13 to ?13.98). Results from our quantile regression models provided further evidence for this association. Second, we did not find evidence that ambulances are relatively late to poorer neighborhoods when specifying MART by dispatch priority. Third, we were also unable to identify a positive association between tract-level poverty and MART when we specified our outcomes by three intervention severities. Across each of our 36 models, tract-level poverty was either not significantly associated with MART or was negatively associated with MART by a magnitude smaller than a full minute per estimated 10 percentage point increase in poverty concentration. Conclusion: Our study challenges the commonly held assumption that ambulances are later to poor neighborhoods. We scrutinize our findings before cautiously considering their relevance for ambulance response time research and for ongoing conversations on the relationship between neighborhood poverty and prehospital care.     

Factors Related to the Sensitivity of Emergency Medical Service Impression of Stroke

Abstract

Objectives. To examine factors related to sensitivity of emergency medical services (EMS) stroke impression. Methods. We reviewed ambulance and hospital records of all patients transported to Long Island College Hospital between January 1, 2009 and January 1, 2011 by the hospital-based EMS with a discharge diagnosis of stroke or a confounding diagnosis, and compared EMS impression to hospital discharge diagnosis. We examined relationships between EMS diagnostic sensitivity and age, gender, ethnicity, NIH Stroke Scale (NIHSS), motor signs, aphasia, neglect, lesion side, circulation, stroke type, EMS provider level, and documented Cincinnati Pre-hospital Stroke Scale (CPSS) with contingency analysis and logistic regression. Results. Stroke was validated in 18% (56/310) of patients and 50% (28/56) of these were missed by EMS. EMS diagnostic sensitivity was 50% (95% CI: 36–64%), and was related to NIHSS quartile (p = 0.014), with higher sensitivities in 2nd (69%; 95% CI: 44–86%) and 3rd (75%; 95% CI: 47–91%) vs. 1st (20%; 95% CI: 7–45%) and 4th (45%; 95% CI: 21–72%) quartiles, motor signs (62 vs. 14%, p = 0.002), and documented CPSS (84 vs. 32%, p = 0.0002). EMS impression was independently related to NIHSS quartile (1st vs. 2nd adjusted OR = 9.61, 1.13–122.03, p = 0.038) and CPSS (adjusted OR = 12.58, 2.22–111.06, p = 0.003). Conclusion. Stroke was missed more frequently when CPSS was not documented, in patients without motor signs, and in patients with moderate–severe stroke. The sensitivity of prehospital screening for patients with moderate–severe stroke might be improved by including additional non-motor signs and by stressing indications for when screens should be performed.     

Emergency Medical Services Utilization Is Associated With Community Deprivation in Children

Background: Pediatric emergency medical services (EMS) utilization is costly and resource intensive; significant variation exists across large-scale geographies. Less is known about variation at smaller geographic levels where factors including lack of transportation, low health literacy, and decreased access to medical homes may be more relevant. Our objective was to determine whether pediatric EMS utilization varied across Hamilton County, Ohio, census tracts and whether such utilization was associated with socioeconomic deprivation. Methods: This was a retrospective analysis of children living in Hamilton County, Ohio, transported by EMS to the Cincinnati Children’s emergency department between July 1, 2014, and July 31, 2016. Participants’ addresses were assigned to census tracts and an EMS utilization rate and deprivation index were calculated for each. Pearson’s correlation coefficients evaluated relationships between tract-level EMS utilization and deprivation. Tract-level deprivation was used as a predictor in patient-level evaluations of acuity. Results: During the study period, there were 4,877 pediatric EMS transports from 219 of the 222 county census tracts. The county EMS utilization rate during the study period was 2.4 transports per 100 children (range 0.2–11). EMS utilization rates were positively correlated with increasing deprivation (r?=?0.72, 95% confidence interval [CI], 0.65–0.77). Deprivation was associated with lower illness severity at triage, fewer transports resulting in resuscitation suite use, and fewer transports resulting in hospitalizations (all p?<?0.05). Conclusions: EMS utilization varied substantially across census tracts in Hamilton County, Ohio. A deeper understanding into why certain socioeconomically deprived areas contribute to disproportionately high rates of EMS utilization could support development of targeted interventions to improve use.     

Path Analysis Modeling Indicates Free Transport Increases Ambulance Use for Minor Indications

Introduction. Clinically unnecessary ambulance transport is increasing, diverting limited resources from patients needing ambulance transport. It was anecdotally observed that inappropriate ambulance use increased after abolition of a direct patient cost for ambulance transport. Hypothesis. In July 2003, direct patient fees were abolished in favor of a universally applied ambulance levy, potentially leading to increased ambulance use by patients with low illness acuity andadmission rates. Methods. The influence of age, illness acuity, andneed for admission on ambulance use was assessed for 55,397 emergency department attendances in 2002 and2004. Ambulance users were compared with nonusers in both years andattendances for 2002 compared with 2004 using chi-square test for two groups. Logistic regression provided a multivariate model leading to ambulance use. Path analysis modeling to assess interrelationships between factors associated with ambulance use was developed. Results. Ambulance users in both years were older, had more acute illness, andhad greater need for admission compared with nonusers. The odds ratio (OR) of arrival by ambulance in 2004 compared with 2002 was 1.14 (95% confidence interval, [CI], 1.12 to 1.17). In 2002, ambulance users were older (OR, 1.42; 95% CI, 1.40 to 1.43), were more likely to need admission (OR, 2.28; 95% CI, 2.16 to 2.4) andhad higher illness acuity (OR, 2.02; 95% CI, 1.94 to 2.09). There was a negative correlation between 2004 andillness acuity. Conclusions. Ambulance use increased in 2004 after patient transport fees were abolished. Increased use was associated with decreased age, clinical acuity, andadmission need. Abolishing direct patient cost stimulates ambulance use, potentially including inappropriate transport. Path analysis to assess the effect of changed funding on ambulance use could be used to the influence of other locally relevant factors contributing to ambulance use.     

Trends in ambulance transports and costs among Medicare beneficiaries, 2007–2018

BackgroundThe primary purpose of this study was to evaluate trends in ambulance utilization and costs among Medicare beneficiaries from 2007 to 2018. Community characteristics associated with ambulance use and costs are also explored.MethodsAggregated county-level fee-for-service (FFS) Medicare beneficiary claims data from 2007 to 2018 were used to assess ambulance transports per 1000 FFS Medicare beneficiaries and standardized inflation-adjusted ambulance costs. Multivariable linear mixed models were used to quantify trends in ambulance utilization and costs and to control for confounders.ResultsA total of 37,675 county-years were included from 2007 to 2018. Ambulance transports per 1000 beneficiaries increased 15% from 299 (95% CI: 291.63, 307.30) to 345 (95% CI: 336.91, 353.10) from 2007 to 2018. Inflation-adjusted standardized per user costs exhibited an increasing (1.04, 95% CI: 1.04, 1.05), but non-linear relationship (0.996, 95% CI: 0.996, 0.996) over time with costs peaking in 2012. Indicators of lower socioeconomic status (SES) were associated with increases in both ambulance events and costs (p < .0001). A higher prevalence of Medicare beneficiaries utilizing Skilled Nursing Facilities was associated with increased levels of ambulance events per 1000 beneficiaries (95% CI: 8.06, 10.63). Rural location was associated with a 38% increase in ambulance costs (95% CI 1.30–1.47) compared to urban location.ConclusionsNumerous policy solutions have been proposed to address growing ambulance costs in the Medicare program. While ambulance transports and costs continue to increase, a bend in the ambulance cost curve is detected suggesting that one or more policies altered Medicare ambulance costs, although utilization has continued to grow linearly. Ambulance use and costs vary significantly with community-level factors. As policy makers consider how to address growing ambulance use and costs, targeting identified community-level factors associated with greater costs and utilization, and their root causes, may offer a targeted approach to addressing current trends.     

Clinical and Economic Factors Associated with Ambulance Use to the Emergency Department

Background: Concern about ambulance diversion and emergency department (ED) overcrowding has increased scrutiny of ambulance use. Knowledge is limited, however, about clinical and economic factors associated with ambulance use compared to other arrival methods. Objectives: To compare clinical and economic factors associated with different arrival methods at a large, urban, academic hospital ED. Methods: This was a retrospective, cross‐sectional study of all patients seen during 2001 (N= 80,209) at an urban academic hospital ED. Data were obtained from hospital clinical and financial records. Outcomes included acuity and severity level, primary complaint, medical diagnosis, disposition, payment, length of stay, costs, and mode of arrival (bus, car, air‐medical transport, walk‐in, or ambulance). Multivariate logistic regression identified independent factors associated with ambulance use. Results: In multivariate analysis, factors associated with ambulance use included: triage acuity A (resuscitation) (adjusted odds ratio [OR], 51.3; 95% confidence interval [CI] = 33.1 to 79.6) or B (emergent) (OR, 9.2; 95% CI = 6.1 to 13.7), Diagnosis Related Group severity level 4 (most severe) (OR, 1.4; 95% CI = 1.2 to 1.8), died (OR, 3.8; 95% CI = 1.5 to 9.0), hospital intensive care unit/operating room admission (OR, 1.9; 95% CI = 1.6 to 2.1), motor vehicle crash (OR, 7.1; 95% CI = 6.4 to 7.9), gunshot/stab wound (OR, 2.1; 95% CI = 1.5 to 2.8), fell 0–10 ft (OR, 2.0; 95% CI = 1.8 to 2.3). Medicaid Traditional (OR, 2.0; 95% CI = 1.4 to 2.4), Medicare Traditional (OR, 1.8; 95% CI = 1.7 to 2.1), arrived weekday midnight–8 AM (OR, 2.0; 95% CI = 1.8 to 2.1), and age ≥65 years (OR, 1.3; 95% CI = 1.2 to 1.5). Conclusions: Ambulance use was related to severity of injury or illness, age, arrival time, and payer status. Patients arriving by ambulance were more likely to be acutely sick and severely injured and had longer ED length of stay and higher average costs, but they were less likely to have private managed care or to leave the ED against medical advice, compared to patients arriving by independent means.     

Utilization of the electrocardiogram in the pediatric emergency department

ObjectiveReview pediatric electrocardiogram (ECG) result severity classification and describe the utilization of ECG testing, and rate of clinically significant results, in the pediatric emergency department (PED).MethodsThis was a review of patients ≤18 years who had an ECG performed in a tertiary children's hospital PED 2005–2017. Using established guidelines and expert consultation, ECG results were categorized: Class 0 = normal, Class I = mild abnormality (no cardiology follow-up), Class II = moderate abnormality (cardiology follow-up), Class III = severe abnormality (immediate intervention). Chi-square tests were used to examine differences between patients with clinically insignificant (Class 0/I) and clinically significant (Class II/III) results. Multivariable regression was used to examine factors associated with clinically significant results.Results16,147 unique PED encounters with ECG performed were included for analysis. The most common ECG indications were chest pain (32.5%), syncope (22.0%), arrhythmia (11.8%), toxicology/ingestion (9.4%), and seizure (5.7%). Overall, 12.7% (n = 2056) of ECGs had clinically significant (Class II/III) results, and only 2.0% (n = 325) had severe abnormality (Class III) that would require immediate intervention or cardiologist input. Factors associated with increased odds of clinically significant ECG were age ≤ 1 year (OR = 1.20, 95% CI: 1.02–1.41), male (OR = 1.33, 95% CI: 1.20–1.46), and indications of arrhythmia (OR = 1.84, 95% CI: 1.59–2.13), cardiac (OR = 2.57, 95% CI: 1.99–3.31), blank indication (OR = 1.52, 95% CI: 1.17–1.98), and electrolyte abnormality (OR = 1.42, 95% CI: 1.03–1.95).ConclusionsIn this study, we provided a valuable review of ECG result severity classification in the pediatric population. We found that chest pain and syncope represented over half of all ECGs performed. We found that clinically significant results are rare in the pediatric population at 12.7% of all ECGs performed, and very few (2.0%) have severe abnormalities that would require immediate intervention. Those with increased odds of a clinically significant ECG include young patients ≤1 year of age, male patients, and certain ECG indications.     

Patient Characteristics and Temporal Trends in Police Transport of Blunt Trauma Patients: A Multicenter Retrospective Cohort Study

Background: Police transport (PT) of penetrating trauma patients has the potential to decrease prehospital times for patients with life-threatening hemorrhage and is part of official policy in Philadelphia, Pennsylvania. We hypothesized that rates of PT of bluntly injured patients have increased over the past decade. Methods: We used Pennsylvania Trauma Outcomes Study registry data from 2006–15 to identify bluntly injured adult patients transported to all 8 trauma centers in Philadelphia. PT was compared to ambulance transport, excluding transfers, burn patients, and private transport. We compared demographics, mechanism, and injury outcomes between PT and ambulance transport patients and used multivariable logistic regression to identify independent predictors of PT. We also identified physiological indicators and injury patterns that might have benefitted from prehospital intervention by EMS. Results: Of 28 897 bluntly injured patients, 339 (1.2%) were transported by police and 28 558 (98.8%) by ambulance. Blunt trauma accounted for 11% of PT and penetrating trauma for 89%. PT patients were younger, more likely to be male, and more likely to be African American or Asian and were more often injured by assault or motor vehicle crash. There were no significant differences presenting physiology between PT and EMS patients. In multivariable logistic regression analysis, male sex (OR 1.89, 95%CI 1.40–2.55), African American race (OR 1.71 95%CI 1.34–2.18), and Asian race (OR 2.25, 95%CI 1.22–4.14) were independently associated with PT. Controlling for injury severity and physiology, there was no significant difference in mortality between PT and EMS. Overall, 64% of PT patients had a condition that might have benefited from prehospital intervention such as supplemental oxygen for brain injury or spine stabilization for vertebral fractures. Conclusions: PT affects a small minority of blunt trauma patients, and did not appear associated with higher mortality. However, PT patients included many who might have benefited from proven, prehospital intervention. Clinicians, EMS providers, and law enforcement should collaborate to optimize use of PT within the trauma system.     

Epinephrine use and outcomes in anaphylaxis patients transported by emergency medical services

Background

Anaphylaxis is a potentially life-threatening allergic reaction that may require emergency medical system (EMS) transport. Fatal anaphylaxis is associated with delayed epinephrine administration. Patient outcome data to assess appropriateness of EMS epinephrine administration are sparse.

Objectives

The objectives of this study are to (1) determine the frequency of epinephrine administration in EMS-transported patients with allergic complaints, (2) identify predictors of epinephrine administration, and (3) determine frequency of emergency department (ED) epinephrine administration after EMS transport.

Methods

A cohort study was conducted from over 5 years. A total of 59 187 EMS transports of an Advanced Life Support (ALS) ambulance service were studied.

Results

One hundred and three patient transports for allergic complaints were analyzed. Fifteen patients received EMS epinephrine, and epinephrine was recommended for 2 additional patients who refused, for a total of 17 (17%) patients for whom epinephrine was administered or recommended. Emergency medical system epinephrine administration or recommendation was associated with venom as a trigger (29% vs 8%; odds ratio [OR], 4.70; 95% confidence interval [CI], 1.28-17.22; P = .013), respiratory symptoms (88% vs 52%; OR, 6.83; 95% CI, 1.47-31.71; P = .006), and fulfillment of anaphylaxis diagnostic criteria (82% vs 49%; OR, 3.50; 95% CI, 0.94-13.2; P = .0498). Four (4%) patients received epinephrine after ED arrival.

Conclusion

Low rates of epinephrine administration were observed. The association of EMS administration of epinephrine with respiratory symptoms, fulfillment of anaphylaxis diagnostic criteria, and low rate of additional epinephrine administration in the ED suggest that ALS EMS administered epinephrine based on symptom severity. Additional studies of EMS anaphylaxis management including ED management and outcomes are needed.     

Flight Versus Ground Out-of-hospital Rapid Sequence Intubation Success: a Systematic Review and Meta-analysis

Introduction: Endotracheal intubation (ETI) is a critical procedure performed by both air medical and ground based emergency medical services (EMS). Previous work has suggested that ETI success rates are greater for air medical providers. However, air medical providers may have greater airway experience, enhanced airway education, and access to alternative ETI options such as rapid sequence intubation (RSI). We sought to analyze the impact of the type of EMS on RSI success. Methods: A systematic literature search of Medline, Embase, and the Cochrane Library was conducted and eligibility, data extraction, and assessment of risk of bias were assessed independently by two reviewers. A bias-adjusted meta-analysis using a quality-effects model was conducted for the primary outcomes of overall intubation success and first-pass intubation success. Results: Forty-nine studies were included in the meta-analysis. There was no difference in the overall success between flight and ground based EMS; 97% (95% CI 96–98) vs. 98% (95% CI 91–100), and no difference in first-pass success for flight compared to ground based RSI; 82% (95% CI 73–89) vs. 82% (95% CI 70–93). Compared to flight non-physicians, flight physicians have higher overall success 99% (95% CI 98–100) vs. 96% (95% CI 94–97) and first-pass success 89% (95% CI 77–98) vs. 71% (95% CI 57–84). Ground-based physicians and non-physicians have a similar overall success 98% (95% CI 88–100) vs. 98% (95% CI 95–100), but no analysis for physician ground first pass was possible. Conclusions: Both overall and first-pass success of RSI did not differ between flight and road based EMS. Flight physicians have a higher overall and first-pass success compared to flight non-physicians and all ground based EMS, but no such differences are seen for ground EMS. Our results suggest that ground EMS can use RSI with similar outcomes compared to their flight counterparts.     

Association Between Poor Sleep,Fatigue, and Safety Outcomes in Emergency Medical Services Providers

Abstract

Objective. To determine the association between poor sleep quality, fatigue, and self-reported safety outcomes among emergency medical services (EMS) workers. Methods. We used convenience sampling of EMS agencies and a cross-sectional survey design. We administered the 19-item Pittsburgh Sleep Quality Index (PSQI), 11-item Chalder Fatigue Questionnaire (CFQ), and 44-item EMS Safety Inventory (EMS-SI) to measure sleep quality, fatigue, and safety outcomes, respectively. We used a consensus process to develop the EMS-SI, which was designed to capture three composite measurements of EMS worker injury, medical errors and adverse events (AEs), and safety-compromising behaviors. We used hierarchical logistic regression to test the association between poor sleep quality, fatigue, and three composite measures of EMS worker safety outcomes. Results. We received 547 surveys from 30 EMS agencies (a 35.6% mean agency response rate). The mean PSQI score exceeded the benchmark for poor sleep (6.9, 95% confidence interval [CI] 6.6, 7.2). More than half of the respondents were classified as fatigued (55%, 95% CI 50.7, 59.3). Eighteen percent of the respondents reported an injury (17.8%, 95% CI 13.5, 22.1), 41% reported a medical error or AE (41.1%, 95% CI 36.8, 45.4), and 90% reported a safety-compromising behavior (89.6%, 95% CI 87, 92). After controlling for confounding, we identified 1.9 greater odds of injury (95% CI 1.1, 3.3), 2.2 greater odds of medical error or AE (95% CI 1.4, 3.3), and 3.6 greater odds of safety-compromising behavior (95% CI 1.5, 8.3) among fatigued respondents versus nonfatigued respondents. Conclusions. In this sample of EMS workers, poor sleep quality and fatigue are common. We provide preliminary evidence of an association between sleep quality, fatigue, and safety outcomes.     

Occupational Injuries and Exposures among Emergency Medical Services Workers

Objective: Emergency medical services (EMS) workers incur occupational injuries at a higher rate than the general worker population. This study describes the circumstances of occupational injuries and exposures among EMS workers to guide injury prevention efforts. Methods: The National Institute for Occupational Safety and Health collaborated with the National Highway Traffic Safety Administration to conduct a follow-back survey of injured EMS workers identified from a national sample of hospital emergency departments (EDs) from July 2010 through June 2014. The interviews captured demographic, employment, and injury event characteristics. The telephone interview data were weighted and are presented in the results as national estimates and rates. Results: Telephone interviews were completed by 572 EMS workers treated in EDs, resulting in a 74% cooperation rate among all EMS workers who were identified and successfully contacted. Study respondents represented 89,100 (95% CI 54,400–123,800) EMS workers who sought treatment in EDs over the four-year period. Two-thirds were male (59,900, 95% CI 35,200–84,600) and 42% were 18–29 years old (37,300, 95% CI 19,700–54,700). Three-quarters of the workers were full-time (66,800, 95% CI 39,800–93,800) and an additional 10% were part-time or on-call (9,300, 95% 4,900–13,700). Among career EMS workers, the injury rate was 8.6 per 100 full-time equivalent EMS workers (95% CI 5.3–11.8). Over half of all injured workers had less than ten years of work experience. Sprains and strains accounted for over 40% of all injuries (37,000, 95% CI 22,000–52,000). Body motion injuries were the leading event (24,900, 95% CI 14,900–35,000), with 90% (20,500, 95% CI 12,800–32,100) attributed to lifting, carrying, or transferring a patient and/or equipment. Exposures to harmful substances were the second leading event (24,400, 95% CI 11,700–37,100). Conclusion: New and enhanced efforts to prevent EMS worker injuries are needed, especially those aimed at preventing body motion injuries and exposures to harmful substances. EMS and public safety agencies should consider adopting and evaluating injury prevention measures to improve occupational safety and promote the health, performance, and retention of the EMS workforce.     

Contacts to general practice in the 12 months preceding a diagnosis of an abdominal cancer: a national register-based cohort study

ObjectiveTo compare the number of contacts to general practice across 11 types of abdominal cancer in the 12 months preceding a diagnosis.DesignNationwide register study.SettingDanish general practice.SubjectsForty-seven thousand eight hundred and ninety-eight patients diagnosed with oesophageal, gastric, colon, rectal, liver, gall bladder/biliary tract, pancreatic, endometrial, ovarian, kidney or bladder cancer in 2014–2018.Main outcome measuresMonthly contact rates and incidence rate ratios (IRRs) of daytime face-to-face, email and telephone consultations in general practice across different abdominal cancers. The analyses were conducted for each sex and adjusted for age, comorbidity, marital status and education.ResultsCompared to women with colon cancer, women with rectal cancer had the lowest number of contacts to general practice (IRR 12 months pre-diagnostic (IRR_–12)=0.86 (95% CI: 0.80–0.92); IRR 1 month pre-diagnostic (IRR_–1)=0.85 (95% CI: 0.81–0.89)), whereas women with liver (IRR_–12=1.23 (95% CI: 1.09–1.38); IRR_–1=1.11 (95% CI: 1.02–1.20)), pancreatic (IRR_–12=1.08 (95% CI: 1.01–1.16); IRR₁=1.52 (95% CI: 1.45–1.58)) and kidney cancer (IRR_–12=1.14 (95% CI: 1.05–1.23); IRR_–1=1.18 (95% CI: 1.12–1.24)) had the highest number of contacts. Men showed similar patterns. From seven months pre-diagnostic, an increase in contacts to general practice was seen in bladder cancer patients, particularly women, compared to colon cancer.ConclusionsUsing pre-diagnostic contact rates unveiled that liver, pancreatic, kidney and bladder cancers had a higher and more prolonged use of general practice. This may suggest missed opportunities of diagnosing cancer. Thus, pre-diagnostic contact rates may indicate symptoms and signs for cancer that need further research to ensure early cancer diagnosis.

Key points

• The majority of cancer patients attend their general practitioner (GP) before diagnosis; however, little is known about the use of general practice across different abdominal cancers.
• This study suggests that a potential exists to detect some abdominal cancers at an earlier point in time.
• The contact patterns in general practice seem to be shaped by the degree of diagnostic difficulty.
• GPs may need additional diagnostic opportunities to identify abdominal cancer in symptomatic patients.

     

Implementation of a Prehospital Protocol Change For Asthmatic Children

Background: Respiratory distress due to asthma is a common reason for pediatric emergency medical services (EMS) transports. Timely initiation of asthma treatment, including glucocorticoids, improves hospital outcomes. The impact of EMS-administered glucocorticoids on hospital-based outcomes for pediatric asthma patients is unknown. Objective: The objective of this study was to evaluate the effect of an evidence-based pediatric EMS asthma protocol update, inclusive of oral glucocorticoid administration, on time to hospital discharge. Methods: This was a retrospective cohort study of children (2–18 years) with an acute asthma exacerbation transported by an urban EMS system to 10 emergency departments over 2 years. The investigators implemented an EMS protocol update one year into the study period requiring glucocorticoid administration for all patients, with the major change being inclusion of oral dexamethasone (0.6 mg/kg, max. dose = 10 mg). Protocol implementation included mandatory paramedic training. Data was abstracted from linked prehospital and hospital records. Continuous data were compared before and after the protocol change with the Mann-Whitney test, and categorical data were compared with the Pearson χ² test. Results: During the study period, 482 asthmatic children met inclusion criteria. After the protocol change, patients were more likely to receive a prehospital glucocorticoid (11% vs. 18%, p = 0.02). Median total hospital time after the protocol change decreased from 6.1 hours (95% CI: 5.4–6.8) to 4.5 hours (95% CI: 4.2–4.8), p < 0.001. Total care time, defined as time from ambulance arrival to hospital discharge, also decreased [6.6 hours (95% CI: 5.8–7.3) vs. 5.2 hours (95% CI: 4.8–5.6), p = 0.01]. Overall, patients were less likely to be admitted to the hospital (30% vs. 21%, p = 0.02) after the change. Those with more severe exacerbations were less likely to be admitted to a critical care unit (82% vs. 44%, p = 0.02) after the change, rather than an acute care floor. Conclusions: Prehospital protocol change for asthmatic children is associated with shorter total hospital and total care times. This protocol change was also associated with decreased hospitalization rates and less need for critical care in those hospitalized. Further study is necessary to determine if other factors also contributed     

National Characteristics of Emergency Medical Services Responses for Older Adults in the United States

Objective: Older adults, those aged 65 and older, frequently require emergency care. However, only limited national data describe the Emergency Medical Services (EMS) care provided to older adults. We sought to determine the characteristics of EMS care provided to older adults in the United States. Methods: We used data from the 2014 National Emergency Medical Services Information System (NEMSIS), encompassing EMS response data from 46 States and territories. We excluded EMS responses for children <18 years, interfacility transports, intercepts, non-emergency medical transports, and standby responses. We defined older adults as age ≥65 years. We compared patient demographics (age, sex, race, primary payer), response characteristics (dispatch time, location type, time intervals), and clinical course (clinical impression, injury, procedures, medications) between older and younger adult EMS emergency 9-1-1 responses. Results: During the study period there were 20,212,245 EMS emergency responses. Among the 16,116,219 adult EMS responses, there were 6,569,064 (40.76%) older and 9,547,155 (59.24%) younger adults. Older EMS patients were more likely to be white and the EMS incident to be located in healthcare facilities (clinic, hospital, nursing home). Compared with younger patients, older EMS patients were more likely to present with syncope (5.68% vs. 3.40%; OR 1.71; CI: 1.71–1.72), cardiac arrest/rhythm disturbance (3.27% vs. 1.69%; OR 1.97; CI: 1.96–1.98), stroke (2.18% vs. 0.74%; OR 2.99; CI: 2.96–3.02) and shock (0.77% vs. 0.38%; OR 2.02; CI: 2.00–2.04). Common EMS interventions performed on older persons included intravenous access (32.02%), 12-lead ECG (14.37%), CPR (0.87%), and intubation (2.00%). The most common EMS drugs administered to older persons included epinephrine, atropine, furosemide, amiodarone, and albuterol or ipratropium. Conclusion: One of every three U.S. EMS emergency responses involves older adults. EMS personnel must be prepared to care for the older patient.     

Gender-related differences in intensive care: a multiple-center cohort study of therapeutic interventions and outcome in critically ill patients

OBJECTIVE: To determine whether gender-related differences exist in the provided level of care and outcome in a large cohort of critically ill patients. DESIGN: Prospective, observational cohort study with data collection from January 1, 1998, to December 31, 2000. SETTING: Thirty-one intensive care units in Austria. PATIENTS: A total of 25,998 adult patients, consecutively admitted to 31 intensive care units in Austria. INTERVENTIONS: We assessed severity of illness, level of provided care, and vital status at hospital discharge. MEASUREMENTS AND MAIN RESULTS: Of 25,998 patients, 58.3% were male and 41.7% were female. Hospital mortality rate was slightly higher in women (18.1%) than in men (17.2%), but severity of illness-adjusted mortality rate was not different. Men received an overall increased level of care and had a significantly higher probability of receiving invasive procedures, such as mechanical ventilation (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.16-1.28), single vasoactive medication (OR, 1.18; 95% CI, 1.12-1.24), multiple vasoactive medication (OR, 1.21; 95% CI, 1.15-1.28), intravenous replacement of large fluid losses (OR, 1.14; 95% CI, 1.08-1.20), central venous catheter (OR, 1.06; 95% CI, 1.01-1.12), peripheral arterial catheter (OR, 1.15; 95% CI, 1.10-1.22), pulmonary artery catheter (OR, 1.48; 95% CI, 1.34-1.62), renal replacement therapy (OR, 1.28; 95% CI, 1.16-1.42), and intracranial pressure measurement (OR, 1.34; 95% CI, 1.18-1.53). CONCLUSIONS: In a large cohort of critically ill patients, no differences in severity of illness-adjusted mortality rate between men and women were found. Despite a higher severity of illness in women, men received an increased level of care and underwent more invasive procedures. This different therapeutic approach in men did not translate into a better outcome.     

Health care utilization related to the introduction of designated GPs at care homes in Denmark: a register-based study

ObjectiveTo investigate the correlation between having designated general practitioners (GPs) in residential care homes and the residents’ number of contacts with primary care, number of hospital admissions and mortality.DesignA retrospective register-based longitudinal study.SettingForty-two care homes in Aarhus Municipality, Denmark.SubjectsA total of 2376 care home residents in the period from 1 September 2016 to 31 December 2018.Main outcome measuresWe used two models to calculate the incidence risk ratio (IRR) for primary care contacts, hospital admission or dying. Model 1 compared the residents’ risk time before with their risk time after implementation of the designated GP model. Model 2 included only risk time after implementation and was based on calculations of successful (rate ≥60%) implementation.ResultsWeighted by time at risk, the proportion of females across the two models ranged from 64% to 68%. The largest group was aged ‘85-94’ years. In Model 1, the mere implementation of the model did not correlate with changes in primary care contacts, hospital admissions, or mortality. Contrarily, in Model 2, residents living in care homes with successful implementation had fewer email contacts (IRR = 0.81, 95%CI: 0.68;0.96), fewer telephone contacts (IRR = 0.78, 95%CI: 0.68;0.90) and fewer hospital admissions (IRR = 0.85, 95%CI: 0.73;0.99), but more home visits (IRR = 1.70, 95%CI: 1.29;2.25) than residents living in care homes with lower implementation rates.ConclusionThe designated GP model seems promising, as a high implementation degree of the model correlated with a reduced the number of acute admissions, short-term admissions and readmissions. Future studies should focus on gaining deeper insight into the mechanisms of the designated GP model to further optimize the model.

Key points

• A new care model was introduced in Denmark in 2017, designating dedicated GPs to residential care homes for the elderly.
• Successful implementation correlated with significantly fewer hospital admissions, specifically for acute admissions, but also with fewer short-term admissions and readmissions.
• The implementation of the model correlated significantly with fewer e-mail and telephone contacts and with more home visits.
• Future studies should gain more insight into the mechanisms of the designated GP model to further optimize the model.

     

C HARACTERISTICS OF F IRE S TATION W ALK - IN P ATIENTS

Objective. To characterize the use of fire stations for walk-in health care and compare utilization patterns of fire stations in lower-income areas with those in higher-income areas. Methods. The study was a retrospective review of emergency medical services (EMS) medical forms of patients who presented directly to a fire station for medical care during a 12-month period. Results. During the study period, there were a total of 56,600 EMS calls by the studied fire department, with 155 visits by persons presenting to 19 fire stations in the 12 zip code areas. Of these, 131 were eligible for inclusion in our study. Of the 131 visits, 76 of 131 (58%) occurred in zip codes where more than 20% of residents lived below poverty level. Patients presenting to the fire station for medical care were disproportionately male, 84 of 131 (64%), aged 31-50 years, 61 of 131 (47%). Leading chief complaints were abrasion/laceration/hematoma, 20 of 131 (15%), shortness of breath, 18 of 131 (14%), loss of consciousness/syncope/dizziness/weakness, 17 of 131 (13%), musculoskeletal pain, 17 of 131 (13%), and chest pain, 14 of 131 (11%). Suicide, assault, alcohol, or substance intoxication (SAAD) was associated with 47 of 131 (36%) visits. Following evaluation at the fire station, 97 of 131 (82%) were transported by EMS; few patients were transported by private vehicle (n = 11) or did not need transport (n = 12). Conclusions. In the authors' EMS system, the use of fire stations for walk-in health occurs disproportionately in areas of poverty. SAAD features are present in more than one third of the visits.     

Spouse’s Diabetes Status and Incidence of Depression and Anxiety: An 18-Year Prospective Study

OBJECTIVEWe investigated the risk of depression and anxiety in people whose spouse did or did not have diabetes. We also examined associations between depression and anxiety and severity of spouse’s diabetes.RESEARCH DESIGN AND METHODSWe analyzed prospective self-reported data about diagnosed depression/anxiety and diabetes in cohabiting couples in the national Panel Study of Income Dynamics (PSID) during 1999–2017 (n = 13,500, 128,833 person-years of follow-up, median follow-up 8.1 years). We used Poisson models to estimate incidence and incidence rate ratios (IRRs) of depression/anxiety, according to spouse’s diabetes status overall and by severity of diabetes.RESULTSAge-, sex-, and race-adjusted incidence of depression/anxiety was 8.0/1,000 person-years (95% CI 6.5, 9.6) among those whose spouse had diabetes and 6.5/1,000 person-years (95% CI 6.0, 6.9) among those whose spouse did not have diabetes. Those whose spouse had diabetes had higher risk of depression/anxiety (IRR 1.24 [95% CI 1.01, 1.53]). Those whose spouse had diabetes-related limitations in daily activities (IRR 1.89 [95% CI 1.35, 2.67]) and diabetes combined with other chronic conditions (IRR 2.34 [95% CI 1.78, 3.09]) were more likely to develop depression/anxiety, while those whose spouse had diabetes with no limitations or additional chronic conditions had incidence of depression/anxiety similar to that of subjects whose spouses did not have diabetes.CONCLUSIONSPeople living with a spouse with diabetes are at higher risk of developing depression/anxiety than people whose spouse does not have diabetes; this risk is driven by the severity of the spouse’s diabetes. Strategies to address the impacts of diabetes on families need to be devised and tested.