A nationwide prehospital stroke survey

Objectives. To identify deficiencies in stroke knowledge among prehospital providers. Methods. A nationwide multiple-choice survey was sent to 689 paramedics (EMT-Ps) and 294 advanced EMTs (EMT-Is) from a random selection of the National Registry of Emergency Medical Technicians database. Of the 23 questions, five addressed demographic information, four quantity of training, five general knowledge, and seven management, and two open-ended questions addressed the signs, symptoms, and risk factors of stroke. The EMT-P and EMT-I answers were compared using chi-square analysis or Fisher's exact test. Results. Of the 355 (36%) respondents, 256 (72%) were EMT-Ps and 99 (28%) were EMT-Is. Virtually all the EMT-Ps (99%) and EMT-Is (98%) knew that a stroke injures the brain, but only 199 (78%) of the EMT-Ps and 47 (47%) of the EMT-Is correctly defined a transient ischemic attack (TIA) (p < 0.001). Slurred speech, weakness/paralysis, and altered mental status were the three most commonly cited symptoms of stroke by both groups. The EMT-Ps were more likely to recognize that dextrose is potentially harmful to stroke patients [EMT-P = 216 (85%), EMT-I = 71 (72%), p = 0.0051; 169 (66%) of the EMT-Ps and 75 (76%) of the EMT-Is felt that elevated blood pressures should be lowered in the prehospital setting. Only 93 (36%) of the EMT-Ps and 22 (22%) of the EMT-Is knew that tissue plasminogen activator (PA) must be given within three hours of symptom onset (p = 0.01). Conclusion. Most EMS providers are knowledgeable about the symptoms of stroke but are unaware of the therapeutic window for thrombolysis and the recommended avoidance of prehospital blood pressure reduction. In addition, further education is needed regarding TIAs.     

Use of resuscitation skills by paramedics caring for critically injured children in oregon

Objectives. 1) To perform a statewide analysis of the frequency of major pediatric trauma cases and the use of resuscitation skills by paramedics (EMT-Ps). 2) To determine whether EMT-Ps use resuscitation skills less frequently for injured children than for older patients.

Methods. Study Design: Retrospective, database analysis of major trauma cases. Setting and Population: 1995 statewide trauma registry data for patients with EMT-P scene care.

Observations. The database included patient demographics, field vital signs, field procedures [e.g., intravenous (IV) line placement, chest compressions, needle thoracostomy, endotracheal intubation], field medication, and vital signs at ED presentation. Data Analysis: Patients aged ≤ 12 years (“pediatric”) were compared with those aged >12 years (“older”). Analyses of patients with tachycardia, hypotension, and obtundation were performed using χ² analysis (α = 0.05).

Results. Of 3,502 trauma patients managed by an EMT-P, only 297 (8%) were aged ≤ 12 years. Fewer pediatric patients (18%) than adults (27%) had an injury severity scale score ≤ 16, p < 0.005. The frequency of most resuscitation skills and the administration of medications were not statistically different between patient groups. However, IVs were four times more likely to be placed in adults (76%) than in pediatric patients (42%), p < 0.001. Subanalyses indicated fewer pediatric patients with tachycardia (p = 0.02) or hypotension (p = 0.02) received an IV, compared with adults who had similar physiologic parameters. Obtunded patients were equally likely to receive endotracheal intubation, although the procedure was rarely used (20%).

Conclusions. EMT-Ps infrequently manage seriously injured children. IVs are less frequently placed in pediatric trauma patients, even in the setting of physiologic abnormalities. The contributions of these field procedures to patient outcomes should be evaluated further.     

Vital signs records omissions on prehospital patient encounter forms

INTRODUCTION: A reported in-field, prospective evaluation of 227 prehospital patient assessments by advanced life support (ALS) emergency medical technicians (EMTs) found a frequent failure to measure vital signs. The objective of this retrospective review was to report the omission frequency of vital signs found in a centralized emergency medical services (EMS) data collection system. METHODS: The EMS database contained information from 90,480 optically scanned, prehospital patient encounter forms. Each record identified EMT skill levels, response times, dispatch type, vital signs, medical and trauma information, treatment, and patient disposition. Records for 1989 and 1990 were collected from 92 rural EMS providers who responded to emergency medical and trauma events. RESULTS: Of 90,480 emergency responses, 14,129 (15.6%) were false alarms, deceased, or canceled without vital patient contact. Valid encounters were documented for 76,351 (84.4%) patient contacts. Systolic blood pressure measurements were not recorded for 13,262 (17.4%) patients. Diastolic blood pressure was not recorded for 14,272 (18.7%) patients. A pulse record was not recorded for 12,125 (15.9%) patients. A ventilatory rate was absent in 12,958 (17.0%) patient records. CONCLUSION: This study found a frequent failure by non-metropolitan basic life support (BLS) and advanced life support (ALS) EMTs to record vital signs on prehospital emergency patient encounter forms. It supports a previous report of direct in-field observations of ALS EMTs failing to measure vital signs during patient assessment. The impact of vital sign omissions upon individual patient care can be assessed only by receiving medical control physicians. In the absence of effective emergency physician networking, the statewide magnitude of the problem among BLS and ALS EMTs has not been recognized as a system issue.     

Factors Associated with Emergency Medical Services Scope of Practice for Acute Cardiovascular Events

Abstract

Objectives. To examine prehospital emergency medical services (EMS) scope of practice for acute cardiovascular events and characteristics that may affect scope of practice; and to describe variations in EMS scope of practice for these events and the characteristics associated with that variability. Methods. In 2008, we conducted a telephone survey of 1,939 eligible EMS providers in nine states to measure EMS agency characteristics, medical director involvement, and 18 interventions authorized for prehospital care of acute cardiovascular events by three levels of emergency medical technician (EMT) personnel. Results. A total of 1,292 providers responded to the survey, for a response rate of 67%. EMS scope of practice interventions varied by EMT personnel level, with the proportion of authorized interventions increasing as expected from EMT-Basic to EMT-Paramedic. Seven of eight statistically significant associations indicated that EMS agencies in urban settings were less likely to authorize interventions (odds ratios <0.7) for any level of EMS personnel. Based on the subset of six statistically significant associations, fire department–based EMS agencies were two to three times more likely to authorize interventions for EMT-Intermediate personnel. Volunteer EMS agencies were more than twice as likely as nonvolunteer agencies to authorize interventions for EMT-Basic and EMT-Intermediate personnel but were less likely to authorize any one of the 11 interventions for EMT-Paramedics. Greater medical director involvement was associated with greater likelihood of authorization of seven of the 18 interventions for EMT-Basic and EMT-Paramedic personnel but had no association with EMT-Intermediate personnel. Conclusions. We noted statistically significant variations in scope of practice by rural vs. urban setting, medical director involvement, and type of EMS service (fire department–based/non–fire department–based; volunteer/paid). These variations highlight local differences in the composition and capacity of EMS providers and offer important information for the transition towards the implementation of a national scope of practice model.     

Scene Transport of Pediatric Patients Injured at Winter Resorts

Objective. To examine the characteristics of pediatric patients (age ≤16 years) injured at winter resort scenes andtransported by helicopter emergency medical services (HEMS) or ground EMS (GEMS) ambulance services to regional trauma centers. Methods. Between 1997 and2001, a total of 119 patients (GEMS = 69; HEMS = 50) were identified from trauma registries andHEMS transport records. Demographic data, initial vital signs, hospital interventions, anddischarge status of the two groups were examined. Results. The distributions of gender, initial vital signs, Injury Severity Score (ISS; either ≤ or > 15), intensive care unit (ICU) length of stay (LOS), total hospital LOS, andhome discharge status were similar between the two groups (p ≥ 0.05). Patients transported by HEMS were older (14 ± 2 vs. 10 ± 4, p < 0.001), less likely to be admitted to the hospital (73% vs. 98.5%; p < 0.001), andmore likely to have multiple injuries [13 (27%) vs. 8 (11.6%), p ≤ 0.032]. The GEMS patients had a higher rate of isolated extremity [33 (80.5%) vs. 8 (19.5%)] andthoracoabdominal [11 (73.3%) vs. 4 (26.7%)] injuries. The high orthopedic injury rate in the GEMS patients contributed to a higher rate of surgery in this group (45% vs. 24%, p ≤ 0.028). Regardless of transport mode, patients requiring immediate interventions (intubation, chest tube placement, or blood product administration) had either a depressed level of consciousness (GCS = 12) on emergency department arrival or thoracoabdominal injuries. No deaths were recorded. Conclusions. Patients transported by HEMS andGEMS had similar hospital characteristics but different injury patterns. A prospective study examining the initial triage of pediatric patients injured at winter resorts would help to determine which subset of patients are best served by HEMS transport.     

C AN B ASIC L IFE S UPPORT P ERSONNEL S AFELY D ETERMINE THAT A DVANCED L IFE S UPPORT I S N OT N EEDED ?

Objective. To determine whether firefighter/emergency medical technicians-basic (FF/EMT-Bs) staffing basic life support (BLS) ambulances in a two-tiered emergency medical services (EMS) system can safely determine when advanced life support (ALS) is not needed. Methods. This was a prospective, observational study conducted in two academic emergency departments (EDs) receiving patients from a large urban fire-based EMS system. Runs were studied to which ALS and BLS ambulances were simultaneously dispatched, with the patient transported by the BLS unit. Prospectively established criteria for potential need for ALS were used to determine whether the FF/EMT-B's decision to cancel the ALS unit was safe, and simple outcomes (admission rate, length of stay, mortality) were examined. In the system studied, BLS crews may cancel responding ALS units at their discretion; there are no protocols or medical criteria for cancellation. Results. A convenience sample of 69 cases was collected. In 52 cases (75%), the BLS providers indicated that they cancelled the responding ALS unit because they did not feel ALS was needed. Of these, 40 (77%) met study criteria for ALS: 39 had potentially serious chief complaints, nine had abnormal vital signs, and ten had physical exam findings that warranted ALS. Forty-five (87%) received an intervention immediately upon ED arrival that could have been provided in the field by an ALS unit, and 16 (31%) were admitted, with a median length of stay of 3.3 days (range 1.1–73.4 days). One patient died. Conclusion. Firefighter/EMT-Bs, working without protocols or medical criteria, cannot always safely determine which patients may require ALS intervention.     

E DUCATION OF P ARAMEDICS R EGARDING A SPIRIN U SE

Objective. Paramedics (EMT-Ps) often care for patients having an acute myocardial infarction (AMI). The benefit of early administration of aspirin in AMI is well established. This study was undertaken to determine whether EMT-Ps are able to retain information regarding the use of aspirin in AMI after a standard didactic session. Methods. The EMT-Ps from a suburban EMS system with an annual call volume of 4,000 were given a 12-question test regarding the out-of-hospital use of aspirin in AMI. They then received a 30-minute lecture about the use of aspirin in the out-of-hospital venue. Aspirin was then put into the treatment protocols for AMI. Three months after the educational session, a follow-up test was administered. A paired, two-tailed t-test was used to compare pretest and posttest scores with a p ≤ 0.05 for statistical significance. Results. The study was completed by 22 of 25 EMT-Ps. The scores on the pretest ranged from 50% to 100% correct, with an average score of 83%. The posttest scores ranged from 83% to 100%, with an average score of 94% (p = 0.002). The questions missed on the posttest were regarding: 1) the length of the effects of aspirin, 2) the bronchospastic effects of aspirin, and 3) the recently instituted indications for its out-of-hospital use. All paramedics correctly identified the contraindications to aspirin use. Conclusion. These results suggest that EMT-Ps can retain information regarding the out-of-hospital use of aspirin for AMI after a standard didactic session. Further study is needed to determine how this information is clinically applicable.     

Potential Utility of a Miniature Electrocardiographic Device in the Medical Support of Law Enforcement Tactical Teams

Abstract

Objectives. To determine which mode of completing a survey yields the highest response rate among emergency medical services (EMS) providers, examine rural and urban differences, and determine the completeness of questions by mode of response. Methods. A random sample of EMS providers was mailed one of the following: 1) a paper survey, with instructions to return it via the enclosed self-addressed, stamped envelope; 2) a letter, with instructions to complete the survey at the provided URL (Web address); or 3) a paper survey with a self-addressed, stamped envelope and a URL, with the option of choosing the mode of response. We compared response rates based on the three different modes. We conducted analysis of the number of skipped multiple-choice and open-ended questions by mode and content analysis of the open-ended questions. Results. The paper-only option resulted in the highest response rate (40.4%, p = 0.003) compared with the response rates from Web-only and choice of mode. Overall, rural EMS providers responded at a higher rate than urban EMS providers (40.3% vs. 31.6%, respectively [p = 0.0002]). Web respondents were more likely to complete all the open-ended questions (p = 0.003). Almost a fourth (22.8%) of the paper respondents skipped multiple-choice questions. There was a pattern of more complete responses for open-ended questions among the Web-based participants, but this was not significant (p = 0.17). Conclusion. EMS providers seem to prefer a more traditional mode (paper) when responding to a survey. Rural providers are more likely to respond. Mode of response influences the number of skipped questions but does not impact the quality of open-ended answers.     

Outcomes of cardiac arrest in the nursing home: Destiny or futility?

Objective. To compare EMS system characteristics and outcomes between nursing home (NH) patients and out-of-hospital cardiac arrest (OHCA) patients whose arrests occurred in a residence (home).

Design. Prospective cohort study reviewing OHCA from July 1989 to December 1993. Variables were age, witnessed arrest, response intervals, automated external defibrillator (AED) use, and arrest rhythms. Outcomes were hospital admission and discharge. Pearson chi-square was used for analysis.

Setting. Suburban EMS system.

Subjects. Patients ≥ 19 years old with arrest of presumed cardiac cause, with locations at home or at a NH.

Results. 2,348 total arrests were complete for analysis, 182 at a NH and 2,166 at home. BLS and ALS response intervals were shorter for the NH patients. The NH patients were more likely to receive CPR on collapse, were older (73.1 vs 67.5 years, p < 0.001), were less likely to have had an AED used (9.9% vs 30.0%, p < 0.001), and were more likely to have an arrest bradyasystolic rhythm (74.7% vs 51.5%, p < 0.001). They were less likely to survive to hospital admission (10.4% vs 18.5%, p < 0.006) and discharge (0.0% vs 5.6%, p < 0.001).

Conclusion. During this four-and-a-half-year study period, no NH patient survived, even though % CPR was increased. Arrest rhythm is an important factor in this finding. EMS initial care for ventricular tachycardia/fibrillation NH patients, with less application of AEDs, was identified. This different response may adversely contribute to dismal NH outcome.     

F EW E MERGENCY M EDICAL S ERVICES P ATIENTS WITH L OWER-EXTREMITY F RACTURES R ECEIVE P REHOSPITAL A NALGESIA

Previous literature has identified prehospital pain management as an important emergency medical services (EMS) function, and few patients transported by EMS with musculoskeletal injuries receive prehospital analgesia (PA). Objectives. 1) To describe the frequency with which EMS patients with lower-extremity and hip fracture receive prehospital and emergency department (ED) analgesia; 2) to describe EMS and patient factors that may affect administration of PA to these patients; and 3) to describe the time interval between EMS and ED medication administrations. Methods. This was a four-month (April to July 2000) retrospective study of patients with a final hospital diagnosis of hip or lower-extremity fracture who were transported by EMS to a single suburban community hospital. Data including patient demographics, fracture type, EMS response, and treatment characteristics were abstracted from review of EMS and ED records. Patients who had ankle fractures, had multiple traumatic injuries, were under the age of 18 years, or did not have fractures were excluded. Results. One hundred twenty-four patients met inclusion criteria. A basic life support (BLS)-only response was provided to 20 (16.0%). Another 38 (38.4%) received an advanced life support (ALS) response and were triaged to BLS transport. Of all the patients, 22 (18.3%) received PA. Patients who received PA were younger (64.0 vs. 77.3 years, p < 0.001) and more likely to have a lower-extremity fracture other than a hip fracture (31.8% vs. 10.7%, p < 0.004). Of all patients, 113 (91.1%) received ED analgesia. Patients received analgesia from EMS almost 2.0 hours sooner that in the ED (mean 28.4 ± 36 min vs. 146 ± 74 min after EMS scene arrival, p < 0.001). Conclusion. A minority of the study group received PA. Older patients and patients with hip fracture are less likely to receive PA. It is unclear whether current EMS system design may adversely impact administration of PA. Further work is needed to clarify whether patient need or EMS practice patterns result in low rates of PA.     

Recognition of Stroke by EMS is Associated with Improvement in Emergency Department Quality Measures

Objective: Hospital arrival via Emergency Medical Services (EMS) and EMS prenotification are associated with faster evaluation and treatment of stroke. We sought to determine the impact of diagnostic accuracy by prehospital providers on emergency department quality measures. Methods: A retrospective study was performed of patients presenting via EMS between September 2009 and December 2012 with a discharge diagnosis of transient ischemic attack (TIA), ischemic stroke (IS), or intracerebral hemorrhage (ICH). Hospital and EMS databases were used to determine EMS impression, prehospital and in-hospital time intervals, EMS prenotification, NIH stroke scale (NIHSS), symptom duration, and thrombolysis rate. Results: 399 cases were identified: 14.5% TIA, 67.2% IS, and 18.3% ICH. EMS providers correctly recognized 57.6% of cases. Compared to cases missed by EMS, correctly recognized cases had longer median on-scene time (17 vs. 15 min, p = 0.01) but shorter transport times (12 vs. 15 min, p = 0.001). Cases correctly recognized by EMS were associated with shorter door-to-physician time (4 vs. 11 min, p < 0.001) and shorter door-to-CT time (23 vs. 48 min, p < 0.001). These findings were independent of age, NIHSS, symptom duration, and EMS prenotification. Patients with ischemic stroke correctly recognized by EMS were more likely to receive thrombolytic therapy, independent of age, NIHSS, symptom duration both with and without prenotification. Conclusion: Recognition of stroke by EMS providers was independently associated with faster door-to-physician time, faster door-to-CT time, and greater odds of receiving thrombolysis. Quality initiatives to improve EMS recognition of stroke have the potential to improve hospital-based quality of stroke care.     

Videographic Assessment of the Quality of EMS to ED Handoff Communication During Pediatric Resuscitations

Background: The National Association of Emergency Medical Services (EMS) Physicians emphasizes the importance of high quality communication between EMS providers and emergency department (ED) staff for providing safe, effective care. The Joint Commission has identified ineffective handoff communication as a contributing factor in 80% of serious medical errors. The quality of handoff communication from EMS to ED teams for critically ill pediatric patients needs further exploration.

Objective: This study assessed the quality of handoff communication between EMS and ED staff during pediatric medical resuscitations.

Methods/Design: We conducted a retrospective review of video recordings of pediatric patients who required critical care (“resuscitation”) in the ED between January 2014 and February 2016 at a Level 1 pediatric trauma center. Handoff quality between EMS and emergency department teams was assessed for completeness, timeliness, and efficiency. Institutional review board approval was obtained.

Results: Sixty-eight resuscitations were reviewed; 28% presented in cardiac arrest, requiring cardiopulmonary resuscitation (CPR). Completeness of information communicated was variable and included chief complaint (88%), prehospital interventions (81%), physical exam findings (63%), medical history (59%), age (56%), and weight (20%). Completeness of specific vital sign reporting included: respiratory rate (53%), heart rate (43%), oxygen saturation (39%), and blood pressure (31%). Timeliness of communication included median patient handoff and report times of 50?seconds [IQR 30,74] and 108?seconds [IQR 62,252], respectively. Inefficient communication occurred in 87% of handoffs, including interruptions by ED staff (51%), questions from the ED physician team leader asking for information already communicated (40%), and questions by ED physician team leader requesting information not yet communicated (65%). When comparing non-CPR to CPR cases, only timeliness of patient handoff was significantly different for those patients receiving prehospital CPR.

Conclusion: Handoff communication between EMS and ED teams during pediatric resuscitation was frequently incomplete and inefficient. Future educational and quality improvement interventions could aim to improve the quality of handoff communication for this patient population.     

Pediatric Use of Emergency Medical Services: The Role of Chronic Illnesses and Behavioral Health Problems

Objective: The increasing use of prehospital emergency medical services (EMS) and its contribution to rising emergency department use and healthcare costs point to the need for better understanding factors associated with EMS use to inform preventive interventions. Understanding patient factors associated with pediatric use of EMS will inform pediatric-specific intervention. We examined pediatric patient demographic and health factors associated with one-time and repeat use of EMS. Methods: We reviewed data from Baltimore City Fire Department EMS patient records over a 23-month period (2008–10) for patients under 21 years of age (n = 24,760). Repeat use was defined as involvement in more than one EMS incident during the observation period. Analyses compared demographics of EMS users to the city population and demographics and health problems of repeat and one-time EMS users. Health comparisons were conducted at the patient and incident levels of analysis. Results: Repeat users (n = 1,931) accounted for 9.0% of pediatric users and 20.8% of pediatric incidents, and were over-represented among the 18–20 year age group and among females. While trauma accounted for approximately one-quarter of incidents, repeat versus one-time users had a lower proportion of trauma-related incidents (7.2% vs. 26.7%) and higher proportion of medical-related incidents (92.6% vs. 71.4%), including higher proportions of incidents related to asthma, seizures, and obstetric/gynecologic issues. In patient-level analysis, based on provider or patient reports, greater proportions of repeat compared to one-time users had asthma, behavioral health problems (mental, conduct and substance use problems), seizures, and diabetes. Conclusions: Chronic somatic conditions and behavioral health problems appear to contribute to a large proportion of the repeat pediatric use of this EMS system. Interventions may be needed to engage repeat users in primary care and behavioral health services, to train EMS providers on the recognition and management of behavioral health emergencies, and to improve family care and self-management of pediatric asthma and other chronic conditions.     

Determinants of Pediatric EMS Utilization in Children with High-Acuity Conditions

Background: Underutilization of emergency medical services (EMS) for children with high-acuity conditions is poorly understood. Our objective was to identify differences in demographic factors and describe caregivers' knowledge, beliefs, and attitudes regarding EMS utilization for children with high-acuity conditions. Design/Methods: This was a mixed-methods study of children with high acuity conditions, defined as requiring immediate medical or surgical intervention and intensive care admission, over a one year period. Demographic data were collected through a retrospective chart review. Qualitative analysis of semi-structured interviews from a purposive sample of caregivers was conducted until thematic saturation was achieved. Results: Three hundred seventy-four charts were reviewed; 19 caregivers were interviewed (17 in-person, 2 via telephone). The 232 (62%) children not arriving by EMS tended to be younger (1.58 years vs. 2.31 years, p = 0.02), privately insured (30% vs. 19%, p = 0.04), and lived further from the hospital (16.80 miles vs. 12.45 miles, p = 0.001). Patient gender, ethnicity, comorbidities and caregiver language were not associated with EMS underutilization. Immediate invasive medical interventions were more often required for EMS utilizers (85% vs. 60%, p < 0.001). EMS utilizers were more likely to require intubation (78% vs. 47%, p < 0.001) and cardiopulmonary resuscitation (CPR) (26% vs. 2%, p < 0.001), and had shorter hospital stays (4.70 vs. 8.16 days; p-value < 0.001). Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Caretakers expected EMS would provide timely, safe transportation that expedited medical care and emotional support. Medical knowledge and prior experience with EMS influenced decision-making about arrival mode. Timeliness, cost, socioeconomic and demographic characteristics, loss of autonomy, and the logistics of EMS activation and transport were the most commonly reported barriers. Conclusions: Young age, private insurance status, and greater distance from the hospital were associated with EMS underutilization. Understanding caregiver expectations, knowledge, and perceived barriers may have important implications for the use of EMS for children. These findings reveal opportunities for improved public education on EMS systems to enhance appropriate EMS utilization for children with high acuity conditions.     

Emergency Medical Services Provider Experiences of Hospice Care

Background: Growing numbers of emergency medical services (EMS) providers respond to patients who receive hospice care. The objective of this investigation was to assess the knowledge, attitudes, and experiences of EMS providers in the care of patients enrolled in hospice care. Methods: We conducted a survey study of EMS providers regarding hospice care. We collected quantitative and qualitative data on EMS provider's knowledge, attitudes, and experiences in responding to the care needs of patients in hospice care. We used Chi-squared tests to compare EMS provider's responses by credential (Emergency Medical Technician [EMT] vs. Paramedic) and years of experience (0–5 vs. 5+). We conducted a thematic analysis to examine open-ended responses to qualitative questions. Results: Of the 182 EMS providers who completed the survey (100% response rate), 84.1% had cared for a hospice patient one or more times. Respondents included 86 (47.3%) EMTs with Intermediate and Advanced training and 96 (52.7%) Paramedics. Respondent's years of experience ranged from 0–10+ years, with 99 (54.3%) providers having 0–5 years of experience and 83 (45.7%) providers having 5+ years of experience. There were no significant differences between EMTs and Paramedics in their knowledge of the care of these patients, nor were there significant differences (p < 0.05) between those with 0–5 and 5+ years of experience. Furthermore, 53 (29.1%) EMS providers reported receiving formal education on the care of hospice patients. A total of 36% respondents felt that patients in hospice care required a DNR order. In EMS providers' open-ended responses on challenges in responding to the care needs of hospice patients, common themes were family-related challenges, and the need for more education. Conclusion: While the majority of EMS providers have responded to patients enrolled in hospice care, few providers received formal training on how to care for this population. EMS providers have expressed a need for a formal curriculum on the care of the patient receiving hospice.