Effect of Emergency Medical Service Use and Inter-hospital Transfer on Time to Percutaneous Coronary Intervention in Patients with ST Elevation Myocardial Infarction: A Multicenter Observational Study

Background: The 2013 ACCF/AHA guideline for the management of ST elevation myocardial infarction (STEMI) recommends that patients be transported by emergency medical services (EMS) directly to a percutaneous coronary intervention (PCI)-capable hospital. We examined the effects of EMS use according to inter-hospital transfer on time to PCI in STEMI patients. Methods: Adult patients diagnosed with STEMI from November 2007 to December 2012 with symptom onset less than 24 hours treated with primary PCI at 29 emergency departments (ED) were included. Patients with unknown information about important time variables, inter-hospital transfer and EMS use, and patients who already received PCI at another hospital were excluded. Patients were divided into groups according to EMS use and inter-hospital transfer: Group A (direct to final ED by EMS), Group B (transferred to final ED after EMS transport), Group C (direct to final ED not by EMS), and Group D (transferred to final ED after non-EMS transport). Symptom to balloon time less than 120 minutes was considered timely PCI. Multivariable logistic regression model adjusting for potential risk factors examined the relationship between the groups and timely PCI. Interactions between EMS use and inter-hospital transfer were also tested for the outcome. Results: A total of 5826 patients were analyzed in this study, of which 28.3% called for EMS and 50% were transferred to another hospital for PCI. Median symptom to balloon time was 216 minutes. Timely PCI was achieved in 20.3% of the patients. With the Group D as the reference, the adjusted odds ratio (AOR) with 95% confidence intervals (95% CI) for timely PCI was 5.78 (4.81–6.95) for Group A, 0.80 (0.53–1.20) for Group B, and 2.87 (2.39–3.44) for Group C. In the interaction model, the AOR (95% CI) of EMS use in nontransferred groups and transferred groups was 2.01(1.71–2.38) and 0.80(0.53–1.20). Conclusions: EMS use significantly increased the odds of timely primary PCI to patients directly transported to a primary PCI center, but not in patients transferred from another hospital. EMS systems that identify STEMI patients and transport them to PCI capable hospitals, and processes to expedite the transfer of patients between non-PCI and PCI hospitals need to be developed further.     

EMS blood collection from patients with acute chest pain reduces emergency department length of stay

BackgroundExpediting the measurement of serum troponin by leveraging EMS blood collection could reduce the diagnostic time for patients with acute chest pain and help address Emergency Department (ED) overcrowding. However, this practice has not been examined among an ED chest pain patient population in the United States.MethodsA prospective observational cohort study of adults with non-traumatic chest pain without ST-segment elevation myocardial infarction was conducted in three EMS agencies between 12/2016–4/2018. During transport, paramedics obtained a patient blood sample that was sent directly to the hospital core lab for troponin measurement. On ED arrival HEART Pathway assessments were completed by ED providers as part of standard care. ED providers were blinded to troponin results from EMS blood samples. To evaluate the potential impact on length of stay (LOS), the time difference between EMS blood draw and first clinical ED draw was calculated. To determine the safety of using troponin measures from EMS blood samples, the diagnostic performance of the HEART Pathway for 30-day major adverse cardiac events (MACE: composite of cardiac death, myocardial infarction (MI), coronary revascularization) was determined using EMS troponin plus arrival ED troponin and EMS troponin plus a serial 3-h ED troponin.ResultsThe use of EMS blood samples for troponin measures among 401 patients presenting with acute chest pain resulted in a mean potential reduction in LOS of 72.5 ± SD 35.7 min. MACE at 30 days occurred in 21.0% (84/401), with 1 cardiac death, 78 MIs, and 5 revascularizations without MI. Use of the HEART Pathway with EMS and ED arrival troponin measures yielded a NPV of 98.0% (95% CI: 89.6–100). NPV improved to 100% (95% CI: 92.9–100) when using the EMS and 3-h ED troponin measures.ConclusionsEMS blood collection used for core lab ED troponin measures could significantly reduce ED LOS and appears safe when integrated into the HEART Pathway.     

An Analysis of EMS and ED Detection of Stroke

Background and Purpose: Studies have shown a reduction in time-to-CT and improved process measures when EMS personnel notify the ED of a “stroke alert” from the field. However, there are few data on the accuracy of these EMS stroke alerts. The goal of this study was to examine diagnostic test performance of EMS and ED stroke alerts and related process measures. Methods: The EMS and ED records of all stroke alerts in a large tertiary ED from August 2013–January 2014 were examined and data abstracted by one trained investigator, with data accuracy confirmed by a second investigator for 15% of cases. Stroke alerts called by EMS prior to ED arrival were compared to stroke alerts called by ED physicians and nurses (for walk-in patients, and patients transported by EMS without EMS stroke alerts). Means ± SD, medians, unpaired t-tests (for continuous data), and two-tailed Fisher's exact tests (for categorical data) were used. Results: Of 260 consecutive stroke alerts, 129 were EMS stroke alerts, and 131 were ED stroke alerts (70 called by physicians, 61 by nurses). The mean NIH Stroke Scale was higher in the EMS group (8.1 ± 7.6 vs. 3.0 ± 5.0, p < 0.0001). The positive predictive value of EMS stroke alerts was 0.60 (78/129), alerts by ED nurses was 0.25 (15/61), and alerts by ED physicians was 0.31 (22/70). The PPV for EMS was better than for nurses or physicians (both p < 0.001), and more patients in the EMS group had final diagnoses of stroke (62/129 vs. 24/131, p < 0.001). The positive likelihood ratio was 1.53 for EMS personnel, 0.45 for physicians, and 0.77 for nurses. The mean time to order the CT (8.5 ± 7.1 min vs. 23.1 ± 18.2 min, p < 0.0001) and the mean ED length of stay (248 ± 116 min vs. 283 ± 128 min, p = 0.022) were shorter for the EMS stroke alert group. More EMS stroke alert patients received tPA (16/129 vs. 6/131, p = 0.027). Conclusions: EMS stroke alerts have better diagnostic test performance than stroke alerts by ED staff, likely due to higher NIH Stroke Scale scores (more obvious presentations) and are associated with better process measures. The fairly low PPV suggests room for improvement in prehospital stroke protocols.     

Impact of a Mass Gathering Alcohol Sobering Facility on Emergency Resources

Objective: Alcohol consumption has been implicated as an important factor driving the demand for medical care at mass gatherings. Patients exhibiting signs of possible alcohol intoxication are frequently diverted from traditional medical support facilities located within mass gathering events due to their disruptive behavior or need for prolonged observation. This conventional strategy can place additional stress on Emergency Medical Services (EMS) and Emergency Department (ED) resources. The purpose of this study was to determine if incorporation of an on-site alcohol sobering facility to supplement existing on-site medical support resources was associated with changes in EMS and ED resource utilization during an annual mass gathering. Methods: This retrospective observational study of a large, annual mass gathering included prospectively collected data from before and after the deployment of an on-site alcohol sobering facility. One year of EMS data along with 2 years of ED data from the pre-deployment time period were compared to 3 years of post-deployment data. The primary outcomes for this study were the number of EMS transports and ED visits. Results: Average single day event attendance was 176,116 during the 2012–13 time period before the ACS was deployed and 183,544 in the 3 years following. The odds of an EMS transport from the event to the ED decreased in the post-deployment period, OR 0.37 (95% CI = 0.16–0.86; p = 0.01). ED volume increased by 7.23% (p = 0.56) and ED LOS increased by 1.29% (p = 0.97) in the post-deployment period. Conclusion: This study reports on a unique strategy to improve resource utilization at large mass gatherings and the impact of this strategy on EMS and ED resource utilization. It appears that the addition of an on-site alcohol sobering facility to existing medical support services was associated with a significant decrease in EMS transports but no change in ED resource utilization. Further work is needed to determine if these findings can be reproduced at other mass gatherings.     

Do EMS Providers Accurately Ascertain Anticoagulant and Antiplatelet Use in Older Adults with Head Trauma?

Objective: Prehospital provider assessment of the use of anticoagulant or antiplatelet medications in older adults with head trauma is important. These patients are at increased risk for traumatic intracranial hemorrhage and therefore field triage guidelines recommend transporting these patients to centers capable of rapid evaluation and treatment. Our objective was to evaluate EMS ascertainment of anticoagulant and antiplatelet medication use in older adults with head trauma. Methods: A retrospective study of older adults with head trauma was conducted throughout Sacramento County. All 5 transporting EMS agencies and all 11 hospitals in the county were included in the study, which ran from January 2012 to December 2012. Patients ≥55 years who were transported to a hospital by EMS after head trauma were included. We excluded patients transferred between two facilities, patients with penetrating head trauma, prisoners, and patients with unmatched hospital data. Anticoagulant and antiplatelet use were categorized as: warfarin, direct oral anticoagulants (DOAC; dabigatran, rivaroxaban, and apixaban), aspirin, and other antiplatelet agents (e.g., clopidogrel and ticagrelor). We calculated the percent agreement and kappa statistic for binary variables between EMS and emergency department (ED)/hospital providers. A kappa statistic ≥0.60 was considered acceptable agreement. Results: After excluding 174 (7.6%) patients, 2,110 patients were included for analysis; median age was 73 years (interquartile range 62–85 years) and 1,259 (60%) were male. Per ED/hospital providers, the use of any anticoagulant or antiplatelet agent was identified in 595 (28.2%) patients. Kappa statistics between EMS and ED/hospital providers for the specific agents were: 0.76 (95% CI 0.71–0.82) for warfarin, 0.45 (95% CI 0.19–0.71) for DOAC agents, 0.33 (95% CI 0.28–0.39) for aspirin, and 0.51 (95% CI 0.42–0.60) for other antiplatelet agents. Conclusions: The use of antiplatelet or anticoagulant medications in older adults who are transported by EMS for head trauma is common. EMS and ED/hospital providers have acceptable agreement with preinjury warfarin use but not with DOAC, aspirin, and other antiplatelet use.     

Burden of Emergency Medical Services Usage by Dialysis Patients

Background: Patients receiving chronic dialysis often require emergent and inpatient care; however, only a minimal amount is known about their out-of-hospital/inter-hospital use of Emergency Medical Services (EMS). The purpose of this study was to describe the utilization of EMS in a cohort of dialysis patients. Methods: We analyzed a cohort of adult (≥18 years) chronic dialysis patients within the Nova Scotia Health Authority Central Zone Renal Program who initiated chronic dialysis between January 1, 2009 and June 30, 2013 (last follow up July 1, 2015). Dialysis patient data was linked to regional EMS data. Requests for EMS, including encounter type, day of the week, and patient characteristics were described. Results: The cohort consisted of 468 patients of whom 79% (N = 361) had an EMS encounter. There were a total of 8,774 EMS encounters for the entire cohort. Patients who had an EMS encounter tended to be older (64 ± 14 years), compared to those without an encounter (55 ± 16 years, P < 0.001) and also had a higher burden of comorbidity. Transfers (including those between facilities) accounted for 89% of all encounters (N = 7,826), followed by emergency department (ED) transports (N = 749, 9%). Overall, 79% of all non-transfers underwent transport to the ED. For patients receiving thrice weekly in-center hemodialysis, the highest EMS utilization for ED transport occurred on the first hemodialysis day after the long dialysis break (22%, P < 0.01). The lowest proportion of ED transports occurred on the day after hemodialysis day 3. Conclusion: Utilization of EMS services by dialysis patients is considerable, particularly for transfers. This highlights a potential area to be targeted for reducing resource utilization. Calls requiring transport to the ED occurred most often on Mondays and Tuesdays, the day after the long-dialysis break, and may represent a time of heightened risk for in-center hemodialysis patients.     

Interactive Effect between On-Scene Hypoxia and Hypotension on Hospital Mortality and Disability in Severe Trauma

Background: It is unclear whether effect size of the hypoxia is different on in-hospital mortality and disability according to hypotension status in the field. Methods: Adult severe trauma (ST) patients during 2012–13 who were treated by emergency medical services (EMS) and had abnormal revised trauma scores in the field or who had positive trauma triage criteria were analyzed. Exposure was hypoxia (<94%) measured by EMS. End points were hospital mortality and disability defined as a Glasgow Outcome Scale that decreased by 2 points or more. Multivariable logistic regression with interaction model between hypoxia and hypotension was used for outcomes to calculate the adjusted odds ratios (AOR) with 95% confidence intervals (95% CIs) after adjusting for potential confounders. Results: A total of 17,406 EMS-ST patients were analyzed. Of those, 2,598 (14.9%) died, and 3,292 (21.5%) were considered disabled at discharge. The total hypoxia group showed higher mortality and disability indices (35.7 and 51.2%) than the non-hypoxia group (10.7 and 15.9%) (each p-value < 0.0001). The AOR of hypoxia was 2.15 (1.92–2.40) for mortality and was 1.97 (1.75–2.21) for disability. In the interaction model, AORs for mortality by hypoxia in the hypotensive and non-hypotensive groups were 2.66 (2.32–3.04) and 1.74 (1.61–1.87), respectively (P < 0.0001 for interaction). The AORs for disability in the hypotensive and non-hypotensive groups were 2.17 (1.87–2.53) and 1.55 (1.42–1.69), respectively (P < 0.0001 for interaction). Conclusions: The effect of hypoxia was much greater in the hypotensive group than in the non-hypotensive group both in terms of mortality and disability.     

Validation of field assessment stroke triage for emergency destination for prehospital use in a rural EMS system

BackgroundField Assessment Stroke Triage for Emergency Destination (FAST-ED) is a simple and accurate prehospital stroke severity scale that has been shown to have comparable accuracy to the gold standard National Institutes of Health Stroke Scale (NIHSS) but requires further field validation for use by emergency medical services (EMS), particularly in rural systems. FAST-ED scores ≥4 are considered high probability for large vessel occlusion (LVO) strokes, while scores <4 are low to moderate probability for LVO. The objective of this study was to assess inter-rater reliability of the EMS FAST-ED (EMS) score to the emergency department FAST-ED (ED-MD) scores.MethodsEMS calculated FAST-ED scores prior to transport to the emergency department (ED) on patients with a positive prehospital stroke screen. EDMD calculated FAST-ED scores for the same patients upon arrival to the ED. Interrater reliability and test characteristics were calculated.ResultsA total of 95 patients were included in this study and 14 were subsequently diagnosed with an LVO. EMS assigned 34 patients (35.8%) a FAST-ED score of ≥4. EDMD assigned 25 patients (26.3%) a FAST-ED score of ≥4. Using the clinical cut-points of FAST-ED scores <4 and ≥ 4, a linearly weighted Cohen's kappa coefficient showed moderate interrater reliability when comparing EMS and EDMD scores (k_w 0.44, 95% CI 0.25–0.63). At ≥4, EMS FAST-ED scores had a sensitivity 0.48, specificity 0.75, PPV 0.62, NPV 0.62 for predicting an LVO, while EDMD FAST-ED scores had a sensitivity 0.36, specificity 0.82, PPV 0.64, NPV 0.60. Comparable receiver operator curve area under the curve values were obtained.ConclusionsEMS and EDMD FAST-ED scores were moderately comparable in a rural EMS system. Similar NPVs compared to EDMD suggest the use of FAST-ED as an appropriate screening tool for EMS to predict the probability of LVO in the prehospital setting and make destination determinations regarding primary transport to a thrombectomy-capable stroke center.     

Ability of the Physiologic Criteria of the Field Triage Guidelines to Identify Children Who Need the Resources of a Trauma Center

Background: There is limited research on how well the American College of Surgeons/Center for Disease Control and Prevention Guidelines for Field Triage of Injured Patients assist EMS providers in identifying children who need the resources of a trauma center. Objective: To determine the accuracy of the Physiologic Criteria (Step 1) of the Field Triage Guidelines in identifying injured children who need the resources of a trauma center. Methods: EMS providers who transported injured children 15 years and younger to pediatric trauma centers in 3 mid-sized cities were interviewed regarding patient demographics and the presence or absence of each of the Field Triage Guidelines criteria. Children were considered to have needed a trauma center if they had non-orthopedic surgery within 24 hours, ICU admission, or died. This data was obtained through a structured hospital record review. The over- and under-triage rates and positive likelihood ratios (+LR) were calculated for the overall Physiologic Criteria and each individual criterion. Results: Interviews were conducted for 5,610 pediatric patients; outcome data were available for 5,594 (99.7%): 5% of all patients needed the resources of a trauma center and 19% met the physiologic criteria. Using the physiologic criteria alone, 51% of children who needed a trauma center would have been under-triaged and 18% would have been over-triaged (+LR 2.8, 95% CI 2.4–3.2). Glasgow Coma Score (GCS) < 14 had a +LR of 14.3 (95% CI 11.2–18.3), with EMS not obtaining a GCS in 4% of cases. 54% of those with an EMS GCS < 14 had an initial ED GCS < 14. Abnormal respiratory rate (RR) had a +LR of 2.2 (95% CI 1.8–2.6), with EMS not obtaining a RR in 5% of cases. 41% of those with an abnormal EMS RR had an abnormal initial ED RR. Systolic blood pressure (SBP) < 90 had a +LR of 3.5 (95% CI 2.5–5.1), with EMS not obtaining a SBP in 20% of cases. SBP was not obtained for 79% of children <1 year, 46% 1–4 years, 7% 5–9 years, and 2% 10–15 years. A total of 19% of those with an EMS SBP < 90 had an initial ED SBP < 90. Conclusions: The Physiologic Criteria are a moderate predictor of trauma center need for children. Missing or inaccurate vital signs may be limiting the predictive value of the Physiologic Criteria.     

Scene time interval and good neurological recovery in out-of-hospital cardiac arrest

Objectives

It is unclear whether scene time interval (STI) is associated with better neurological recovery in the emergency medical service (EMS) system with intermediate service level.

Comparison of children receiving emergent sepsis care by mode of arrival

ObjectiveTo determine if differences in patient characteristics, treatments, and outcomes exist between children with sepsis who arrive by emergency medical services (EMS) versus their own mode of transport (self-transport).MethodsRetrospective cohort study of patients who presented to the Emergency Department (ED) of two large children's hospitals and treated for sepsis from November 2013 to June 2017. Presentation, ED treatment, and outcomes, primarily time to first bolus and first parental antibiotic, were compared between those transported via EMS versus patients who were self-transported.ResultsOf the 1813 children treated in the ED for sepsis, 1452 were self-transported and 361 were transported via EMS. The EMS group were more frequently male, of black race, and publicly insured than the self-transport group. The EMS group was more likely to have a critical triage category, receive initial care in the resuscitation suite (51.9 vs. 22%), have hypotension at ED presentation (14.4 vs. 5.4%), lactate >2.0 mmol/L (60.6 vs. 40.8%), vasoactive agents initiated in the ED (8.9 vs. 4.9%), and to be intubated in the ED (14.4 vs. 2.8%). The median time to first IV fluid bolus was faster in the EMS group (36 vs. 57 min). Using Cox LASSO to adjust for potential covariates, time to fluids remained faster for the EMS group (HR 1.26, 95% CI 1.12, 1.42). Time to antibiotics, ICU LOS, 3- or 30-day mortality rates did not differ, yet median hospital LOS was significantly longer in those transported by EMS versus self-transported (6.5 vs. 5.3 days).ConclusionsChildren with sepsis transported by EMS are a sicker population of children than those self-transported on arrival and had longer hospital stays. EMS transport was associated with earlier in-hospital fluid resuscitation but no difference in time to first antibiotic. Improved prehospital recognition and care is needed to promote adherence to both prehospital and hospital-based sepsis resuscitation benchmarks.     

Effect of opioid analgesics on emergency department length of stay among low back pain patients in the United States

ObjectivesThe objective of this study was to compare emergency department (ED) length of stay (LOS) between patients treated with opioid analgesia versus non-opioid analgesia for low back pain (LBP) in the ED.MethodsWe conducted a secondary analysis of National Hospital Ambulatory Medical Care Survey (NHAMCS) data (2014–2015). Adults (age ≥18 years) who presented to the ED with a reason for visit or primary diagnosis of LBP were included in the final study sample. Patient visits were categorized into two groups based on whether they received opioid analgesia (with or without non-opioid analgesia) or non-opioid analgesia only in the ED. The primary outcome measure was ED LOS, which was log-transformed (as ED LOS was not normally distributed) for analysis. A multivariable linear regression analysis was used to evaluate the association between opioid use and ED LOS.ResultsThe study sample consisted of a national estimate of approximately 8.6 million ED visits for LBP (during 2014–2015), of which 60.1% received opioids and 39.9% received non-opioids only. The geometric mean ED LOS for patient visits who received opioids was longer than patient visits who received non-opioids (142 versus 92 min, respectively; p < 0.001). After adjusting for confounders in the multivariable analysis, patient visits that received opioids had a significantly longer ED LOS (coefficient 0.25; 95% CI 0.11 to 0.38; p < 0.001).ConclusionsIn a nationally representative sample of patient visits to ED due to LBP in the US, use of opioids in the ED was associated with an increased ED LOS.     

Significant changes in emergency department length of stay and case mix over eight years at a large Swedish University Hospital

ObjectiveDescribe the longitudinal development of crowding and patient/emergency department (ED) characteristics at a Swedish University Hospital.MethodsA retrospective longitudinal registry study based on all ED visits with adult patients during 2009–2016 (N = 1,063,806). Patient characteristics and measures of ED crowding (ED occupancy ratio, length-of-stay [LOS], patients/clinician’s ratios) were extracted from the hospital’s electronic health record. Non-parametric analyses were conducted.ResultsThe proportion of unstable patients (triage level 1–2) increased while the proportion of admitted patients decreased. All crowding variables were stable, except for LOS, which increased by 9 min/visit/year (95% CI: 8.8–9.1). LOS for visits by patients ≥ 80 years increased more compared to those 18–79 (248 min vs. 190 min, p < 0.001). Unstable patients increased their median LOS compared to stable patients (triage level 3–5). LOS for discharged patients increased with an average of 7.7 min/year (95% CI: 7.5–7.9) compared to 15.5 min/year (95% CI: 15.2–15.8) for those being admitted.ConclusionFewer admissions, despite an increase of unstable patients, is likely related to lack of in-hospital beds and contributes to ED crowding. The increase in median ED LOS, especially for patients in the subgroups unstable, ≥80 years and admitted to in-hospital care reflects this problem.     

Effect of hypoxia on mortality and disability in traumatic brain injury according to shock status: A cross-sectional analysis

ObjectivesThis study aimed to test the association between hypoxia level and outcomes according to shock status in traumatic brain injury (TBI) patients.MethodsAdult TBI patients transported by emergency medical services in 10 provinces were enrolled. Hypoxia was a main exposure; three groups by oxygen saturation (SaO2, non-hypoxia (≥94%), mild hypoxia (90 ≤ SaO2 < 94%)), and severe hypoxia (<90%). Shock status (<systolic blood pressure 90 mmHg) was an interactive exposure. The outcomes were hospital mortality and worsened disability (a 2-point increase of Glasgow Outcome Scale). Multivariable logistic regression was used to calculate the adjusted odds (AORs) with 95% Confidence intervals (CIs).ResultsOf the 6125 patients, the mortality/disability rates were 49.4%/69.0% in severe hypoxia, 30.7%/46.9% in mild hypoxia, and 18.5%/27.5% in normoxia (p < 0.0001). Mortality/disability rates were 47.1%/57.1% in shock status and 20.5%/31.4% in non-shock status (p < 0.0001). AORs (95% CIs) for worsened disability/mortality compared with normoxia (reference) were 3.23 (2.47–4.21)/2.24 (1.70–2.96) in patients with severe hypoxia and 2.11 (1.63–2.74)/1.84 (1.39–2.45) in those with mild hypoxia. AORs (95% CIs) for worsened disability/mortality was 1.58 (1.20–2.09)/1.33 (1.01–1.76) by severe hypoxia than normoxia in patient with only non-shock status in the interaction analysis.ConclusionsThere was a trend toward worsened outcomes with mild and severe hypoxia in patient with and without shock, however, the only met statistical significance for patients with both severe hypoxia and non-shock status.     

Can Prehospital Personnel Accurately Triage Patients for Large Vessel Occlusion Strokes?

BackgroundThe Field Assessment Stroke Triage for Emergency Destination (FAST-ED) score was developed in the hospital setting to be used in the prehospital setting. It has been shown to have higher predictive value than comparable stroke scales, including the National Institutes of Health Stroke Scale, for identifying large vessel occlusion strokes.ObjectiveWe sought to determine whether prehospital FAST-ED scores are comparable with FAST-ED scores determined by emergency physicians.MethodsEmergency Medical Services (EMS) personnel were trained to calculate a FAST-ED score for any patient suspected of having a stroke in the field. When the patient arrived at our ED, an emergency physician generated a FAST-ED score.ResultsOne hundred and thirty-five patients were studied and large vessel occlusions were detected in 23.7%. There was no significant difference between median FAST-ED scores from EMS personnel (3; interquartile range [IQR] 1–5) and emergency physician (2; IQR 1–6). The difference between paired scores was not significantly different from 0 (median of paired differences was 0). In addition, prehospital FAST-ED scores were significantly and positively correlated with physician FAST-ED scores (r² = 0.26). Comparable receiver operator curve area under the curve values were obtained for EMS FAST-ED (0.727; 95% confidence interval [CI] 0.638–0.816) and ED FAST-ED (0.769; 95% CI 0.669–0.868).ConclusionsThe findings validate that prehospital FAST-ED scores are comparable in predictive value to FAST-ED scores calculated in the ED for prediction of large vessel occlusion strokes.     

Time to first defibrillation and survival outcomes of out-of-hospital cardiac arrest with refractory ventricular fibrillation

IntroductionTimely defibrillation is associated with increased survival in out-of-hospital cardiac arrest (OHCA) cases. This study aimed to determine whether the time to first defibrillation was associated with good neurological outcomes in OHCA patients with refractory ventricular fibrillation.MethodsBystander-witnessed adult OHCA patients with presumed cardiac etiology who presented with ventricular fibrillation and received ≥2 successive prehospital defibrillations from emergency medical services between 2013 and 2018 were included. The times from collapse to first defibrillation were categorized into Group 1 (0–5 min), Group 2 (6–10 min), Group 3 (11–15 min), and Group 4 (16–60 min). The primary outcome was a good neurological recovery (cerebral performance category 1–2). Multivariable logistic regression analysis was performed to calculate the adjusted odd ratios (AORs) and 95% confidence intervals (CIs) for outcomes according to time group (Group 1 as the reference) and per 1-min delay.ResultsThe study included 5753 patients, with overall rates of 34.4% for survival to discharge and 27.2% for good neurological recovery. The median number of prehospital defibrillations was 3 (interquartile range 2–5). Relative to Group 1, the AORs for good neurological recovery were 0.58 in Group 2 (95% CI: 0.41–0.82), 0.42 in Group 3 (95% CI: 0.29–0.60), and 0.19 in Group 4 (95% CI: 0.13–0.29). When time from collapse to first EMS defibrillation was analyzed as a continuous variable, each 1-min delay was associated with a significant decrease in the likelihood of good neurological recovery (AOR: 0.93, 95% CI: 0.91–0.94).ConclusionsA short time from collapse to first defibrillation was associated with good neurological recovery among patients with OHCA and refractory ventricular fibrillation. This result suggests that a failed first shock still has a positive effect if it is delivered quickly.     

U SE OF E MERGENCY M EDICAL S ERVICES FOR S USPECTED A CUTE C ARDIAC I SCHEMIA AMONG D EMOGRAPHIC AND C LINICAL P ATIENT S UBGROUPS : T HE REACT T RIAL

Objective. Barriers to the use of emergency medical services (EMS) and patient delay in seeking care can limit the receipt or effectiveness of reperfusion therapies and the availability of prehospital emergency cardiac care. The Rapid Early Action for Coronary Treatment (REACT) trial was designed to determine the impact of a community intervention on use of EMS among demographic and clinical subgroups of patients with suspected acute cardiac ischemia. Methods. A randomized controlled community trial was conducted in 20 pair-matched communities in the United States. One community from each pair received an 18-month, multicomponent community education program. Data were collected at 44 participating hospitals during a four-month baseline period and throughout the 18-month trial, using medical record abstracts to collect information on mode of transport to the hospital and other sociodemographic and clinical variables. Eligible patients were persons aged ≥30 years presenting with chest pain or discomfort to emergency departments (EDs) who were admitted and discharged with a cardiac-related diagnoses (ICD 410-414, 427-429, 440, 786.9). Results. The net change in the odds of EMS use was an increase of 34% in intervention compared with control communities [adjusted odds ratio (OR) 1.34, 95% CI 1.07–1.67]. We observed greater increases in the odds of EMS use among patients who had chronic or other cardiac diagnoses (adjusted OR 1.53, 95% CI 1.18–1.99, and adjusted OR 1.52, 95% CI 1.17–1.97, respectively) than in those diagnosed as having acute ischemia (adjusted OR 1.14, 95% CI 0.91-1.44). We observed greater increases in odds of EMS use in those who were retired (adjusted OR 1.62, 95% CI 1.29–2.04) or had systolic blood pressure (SBP) at or below 160?mm Hg upon presentation to the ED (adjusted OR 1.55, 95% CI 1.26–1.91 for SBP 100-160 mm Hg; 1.61, 95% CI 0.88–2.97 for SBP <100?mm Hg). Conclusions. The REACT trial demonstrated a significant impact on the use of EMS among patients admitted to the hospital for suspected acute myocardial infarction, with greater increases among patients with chronic or other cardiac ICD-9 discharge diagnoses, those presenting with lower SBP, and retired persons.     

One-way-street revisited: Streamlined admission of critically-ill trauma patients

IntroductionEmergency department (ED) crowding is associated with increased mortality and delays in care. We developed a rapid admission pathway targeting critically-ill trauma patients in the ED. This study investigates the sustainability of the pathway, as well as its effectiveness in times of increased ED crowding.Materials & methodsThis was a retrospective cohort study assessing the admission of critically-ill trauma patients with and without the use of a rapid admission pathway from 2013 to 2018. We accessed demographic and clinical data from trauma registry data and ED capacity logs. Statistical analyses included univariate and multivariate testing.ResultsA total of 1700 patients were included. Of this cohort, 434 patients were admitted using the rapid admission pathway, whereas 1266 were admitted using the traditional pathway. In bivariate analysis, mean ED LOS was 1.54 h (95% Confidence Interval [CI]: 1.41, 1.66) with the rapid pathway, compared with 5.88 h (95% CI: 5.64, 6.12) with the traditional pathway (p < 0.01). We found no statistically significant relationship between rapid admission pathway use and survival to hospital discharge. During times of increased crowding, rapid pathway use continued to be associated with reduction in ED LOS (p < 0.01). The reduction in ED LOS was sustained when comparing initial results (2013–2014) to recent data (2015–2018).ConclusionThis study found that a streamlined process to admit critically-ill trauma patients is sustainable and associated with reduction in ED LOS. As ED crowding remains pervasive, these findings support restructured care processes to limit prolonged ED boarding times for critically-ill patients.