Measuring quality and effectiveness of prehospital ems

Introduction. In today's health care environment, the demand for objective comparative information about the performance of health care organizations and providers has created a need for data-driven evaluation processes. In response, national organizations and federal agencies have established quality indicators, created tools to measure performance according to those indicators, and issued report cards for individual providers, as well as health care organizations. Purpose. Emergency medical services (EMS) systems are no different from other health care systems in the need for objective comparative system information to assist government officials at all levels in establishing relevant policy, selecting appropriate system design, and monitoring system quality and effectiveness. Governmental decision makers, payers, and consumers are demanding objective evidence that they are receiving value and quality for the cost of EMS. EMS systems administrators also require objective feedback about performance that can be used internally to support improvement efforts and externally to demonstrate accountability to the public and other stakeholders. To date, there are few validated indicators of effectiveness and quality in EMS systems. Moreover, most potential indicators have not been studied for use in systemwide evaluation. As a result, there are no universally accepted methods of measurement. The following paper examines traditional efforts to assure quality in EMS systems, while assessing the need to go beyond the traditional to establish measurable indicators of system quality. Valid and measurable indicators will provide a basis for establishing benchmarks of performance. In the future, these benchmarks will facilitate comparisons of a system with itself, as well as with other systems.     

Procedures Performed by Emergency Medical Services in the United States

Emergency medical services (EMS) must provide a wide range of care for patients in the out-of-hospital setting. Although previous work has detailed that EMS providers rarely perform certain procedures, (e.g., endotracheal intubation) there are limited data detailing the frequency of procedures across the breadth of EMS providers’ scope of practice. We sought to characterize procedures performed by EMS in the United States. We conducted an analysis of the 2011 National Emergency Medical Services Information System (NEMSIS) research data set, encompassing EMS emergency response data from 40 states and two territories. From these data, we report the number and incidence of EMS procedures. We also characterize procedures performed. There were 14,371,941 submitted EMS responses, of which 7,680,559 had complete information on procedures performed on adults. Of these, 4,206,360 EMS responses had procedures performed totaling 11,407,396 procedures. The most common procedures performed were peripheral venous access (28.4%), cardiac monitoring (16.1%) pulse oximetry (13.5%), and blood glucose analysis (10.4%). Procedures were performed most often in patients with traumatic injury (20.0%) followed by chest pain/discomfort (14.0%). Critical procedures (cardioversion, defibrillation, endotracheal intubation, etc.) were infrequently performed (n = 277,785, 2.4%). These data highlight the frequency with which EMS providers perform procedures across the United States. This may help to guide future EMS training and education efforts by highlighting the relative frequency and infrequency of specific procedures.     

The field instructor program: quality control of prehospital care, the first step

Orientation and evaluation of the new paramedic employee are areas that are frequently overlooked or not performed in a consistent manner. In order to evaluate skills of new employees in a standardized fashion and provide a formal structured orientation, the field instructor program was instituted. Since 1978, 78 people have gone through the program. Sixty-nine (88.5%) successfully completed the course. All of those released in “poor standing” were subsequently dismissed from the paramedic division because of poor medical performance. This program has provided orientation of new paramedics and identified those with serious deficiencies in their practice.     

Evaluation of Physiologic Alterations during Prehospital Paramedic-Performed Rapid Sequence Intubation

Objective: Physiologic alterations during rapid sequence intubation (RSI) have been studied in several emergency airway management settings, but few data exist to describe physiologic alterations during prehospital RSI performed by ground-based paramedics. To address this evidence gap and provide guidance for future quality improvement initiatives in our EMS system, we collected electronic monitoring data to evaluate peri-intubation vital signs changes occurring during prehospital RSI. Methods: Electronic patient monitor data files from cases in which paramedic RSI was attempted were prospectively collected over a 15-month study period to supplement the standard EMS patient care documentation. Cases were analyzed to identify peri-intubation changes in oxygen saturation, heart rate, and blood pressure. Results: Data from 134 RSI cases were available for analysis. Paramedic-assigned prehospital diagnostic impression categories included neurologic (42%), respiratory (26%), toxicologic (22%), trauma (9%), and cardiac (1%). The overall intubation success rate (95%) and first-attempt success rate (82%) did not differ across diagnostic impression categories. Peri-intubation desaturation (SpO₂ decrease to below 90%) occurred in 43% of cases, and 70% of desaturation episodes occurred on first-attempt success. The incidence of desaturation varied among patient categories, with a respiratory diagnostic impression associated with more frequent, more severe, and more prolonged desaturations, as well as a higher incidence of accompanying cardiovascular instability. Bradycardia (HR decrease to below 60 bpm) occurred in 13% of cases, and 60% of bradycardia episodes occurred on first-attempt success. Hypotension (systolic blood pressure decrease to below 90 mmHg) occurred in 7% of cases, and 63% of hypotension episodes occurred on first-attempt success. Peri-intubation cardiac arrest occurred in 2 cases, one of which was on first-attempt success. Only 11% of desaturations and no instances of bradycardia were reflected in the standard EMS patient care documentation. Conclusions: In this study, the majority of peri-intubation physiologic alterations occurred on first-attempt success, highlighting that first-attempt success is an incomplete and potentially deceptive measure of intubation quality. Supplementing the standard patient care documentation with electronic monitoring data can identify unrecognized physiologic instability during prehospital RSI and provide valuable guidance for quality improvement interventions.     

The Accuracy of Predicting Cardiac Arrest by Emergency Medical Services Dispatchers: The Calling Party Effect

OBJECTIVES: To analyze the accuracy of paramedic emergency medical services (EMS) dispatchers in predicting cardiac arrest and to assess the effect of the caller party on dispatcher accuracy in an advanced life support, public utility model EMS system, with greater than 90,000 calls and greater than 60,000 transports per year. METHODS: This was a retrospective analysis from January 1, 2000, through June 30, 2000, of 911 calls with dispatcher-assigned presumptive patient condition (PPC) or field diagnosis of cardiac arrest. Sensitivity and positive predictive value (PPV) of the PPC code for cardiac arrest by calling parties were calculated. Homogeneity of sensitivity and PPV of the PPC code for cardiac arrest by calling parties was studied with chi-square analysis. Relevant proportions, relative risk ratios, and associated 95% confidence intervals (95% CIs) were calculated. Student's t-test was used to compare quality assurance scores between calling parties. RESULTS: There were 506 patients included in the study. Overall sensitivity for dispatcher-assigned PPC of cardiac arrest was 68.3% (95% CI = 63.3% to 73.0%) with a PPV of 65.0% (95% CI = 60.0% to 69.7%). There was a significant difference in the PPV for the EMS dispatcher diagnosis of cardiac arrest depending on the type of caller (chi(2) = 17.34, p < 0.001). CONCLUSIONS: A higher level of medical training may improve dispatch accuracy for predicting cardiac arrest. The type of calling party influenced the PPV of dispatcher-assigned condition.     

Evaluation of a new ems asthma protocol in new york city: A preliminary report

Background. In July 1996, the New York City (NYC) regional EMS implemented a new protocol whereby EMS personnel in the prehospital setting could administer 125 mg of intravenous methylprednisolone to asthma patients as one of their medical options following telephone consultation with a medical control physician. Objective. To determine whether this protocol had any effect on hospital admission rates or the emergency department (ED) length of stay. Methods. This retrospective chart review focused on the 219 (of 603 total) patients who arrived to the ED by ambulance over a two-year period whose ED diagnosis was asthma. There were 81 patient encounters in year 1, and 138 in year 2. Eleven of the year 2 group received prehospital steroids. The study took place at an urban 911 receiving, Level 2 ED. Results. Of the group who received prehospital steroids, none resulted in hospital admission. Due to the small sample size in the steroid-receiving group, the differences in these admission rates are not yet significant. No differences were detected in the ED length of stay between the two patient groups (157 vs 160 minutes in year 2, p = 0.9). Conclusion. The differences in admission rates suggested by this study suggest a simple yet potentially powerful tool for improving patient outcome in the treatment of asthma.     

Physician medical direction of ems education programs: Policy resource and education paper

Abstract

Objectives. To compare the effectiveness of intravenous morphine, intranasal (IN) fentanyl, and inhaled methoxyflurane for managing moderate to severe pain in pediatric patients in the out-of-hospital setting. Methods. We conducted a retrospective comparative study of 3,312 pediatric patients aged between 5 and 15 years who had moderate to severe pain (pain score ≥5) and who received intravenous morphine, IN fentanyl, or inhaled methoxyflurane, either alone or in combination, between January 1, 2004, and November 30, 2006. Multivariate logistic regression was used to analyze data extracted from a clinical database containing routinely entered information from patient health care records. The primary outcome measure was effective analgesia, defined as a reduction in pain severity of ≥30% of initial pain score using an 11-point verbal numeric rating scale. Results. Effective analgesia was achieved in 82.5% of cases overall. All analgesic agents were effective in the majority of patients (87.5%, 89.5%, and 78.3% for morphine, fentanyl, and methoxyflurane, respectively). There was evidence that methoxyflurane was less effective than both morphine (odds ratio [OR] 0.52; 95% confidence interval [CI] 0.36–0.74) and fentanyl (OR 0.43; 95% CI 0.29–0.62; p < 0.0001). There was no clinical or statistical evidence of difference in the effectiveness of fentanyl and morphine in this population (OR 1.22; 95% CI 0.74–2.01). There was no evidence that combination analgesia was better than either fentanyl or morphine alone. Conclusion. Intranasal fentanyl and intravenous morphine are equally effective analgesic agents in pediatric patients with moderate to severe acute pain in the out-of-hospital setting. Methoxyflurane is less effective in comparison with both morphine and fentanyl, but is an effective analgesic in the majority of children.     

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.     

Impact of ems education on emergency medicine ability and career choices of medical students

Objective. To determine whether a course in emergency medical services (EMS) impacts on the perceived ability of medical students to render care in emergencies such as choking and cardiac arrest, and affects their choice of emergency medicine as a career. Methods. An eight-question pre- and postcourse survey was given to first- and second-year medical students. The elective course lasted a semester (four months) and dealt with prehospital emergency care, including ambulance rides and helicopter observation. Surveys were collected over a period of seven semesters. The eight-question survey assessed the student's experience, interest, and perceived competence. Precourse and postcourse results were compared using a chi-square with p < 0.05 considered significant. Results. Two hundred ten students enrolled in the EMS course. A total of 384 surveys were completed, 190 precourse and 194 postcourse surveys. Eighty-three students (44%) had a family member in the medical profession, five students (2.6%) had experience as an EMT or EMT-P, and 67 students (35%) had worked in any capacity in an ED. There was a statistically significant positive shift in the responses to both questions relating to self-perceived competency (p < 0.01). Thirty-eight students (20%) precourse and 58 students (30%) postcourse were interested in emergency medicine as a career (p = 0.03). Conclusion. A course in EMS has significant impact on the perceived ability and career choice of medical students. Further study of an EMS curriculum design is needed to determine what information is critical to medical students' education and valuable in their career choice decisions.     

Legislative and regulatory description of ems medical direction: A survey of states

Objective. To assess regulatory trends in EMS medical direction by examining state EMS legislation and regulations, and legal qualifications for medical direction.

Methods. A two-page survey was mailed to all 50 state EMS directors, with a repeat mailing to nonresponders and telephone follow-up as needed. Copies of EMS legislation and regulations were requested to assist in the interpretation of answers to survey questions. The questions focused on two physician roles in the oversight of the practice of paramedics: off-line ALS service medical director (ASMD) and on-line medical command (OLMC).

Results. Thirty-nine surveys were returned (78%). Only one state (IL) requires that ASMDs be board-certified in emergency medicine. Thirteen others (33%) permit physicians with primary care specialization or various ACLS/ATLS certifications to serve as ASMDs. Twenty-two states (56%) require only that the ASMD be a physician; three states (8%) have no requirements at all. Eight states (21%) have no requirements for personnel providing OLMC, and another 25 (64%) require only physician licensure. Six states (15%) require various ACLS/ATLS certifications. Several states do not differentiate between the two physician roles. Twenty-four states (62%) provide some type of Good Samaritan protection for medical direction, but in two of these only unpaid medical directors are protected.

Conclusions. There is tremendous variation in regulatory requirements for physician participation in EMS medical direction activities at the ALS level. Few states have specific training or background requirements for the provision of OLMC, and a requirement for board certification in emergency medicine is the exception, not the rule.     

Estimating the Probability of Passing the National Paramedic Certification Examination

Objectives:  It is hypothesized that student and program characteristics will influence the probability of passing the national paramedic certification exam. The objective of this study was to utilize student and program characteristics to build a statistical model to determine the probability of success on the cognitive portion of the national paramedic certification exam.
Methods:  The study population for this analysis consisted of graduates attempting the National Registry of Emergency Medical Technicians (NREMT) paramedic written examination from January 1, 2002, through December 31, 2002. To be included in this analysis, graduates must have been first-time testers and have completed a survey attached to the exam. Independent variables analyzed reflected program and student characteristics derived from the survey questions and the NREMT application. A multivariable logistic regression model was fit to the outcome (pass/fail) of the examination.
Results:  Complete demographic and survey data were available for 5,208 (86.8%) individuals. The final multivariable logistic regression model included nine independent variables. There were two programmatic characteristics (national accreditation and instructor qualification), six student characteristics (high school class rank, years of education, required for employment, age, race, and gender), and one graduate characteristic (elapsed time since course completion) that had a significant effect on the probability of passing the examination.
Conclusions:  National program accreditation, lead instructor qualifications, student educational background, and student demographics are all significantly associated with the probability of success on the national paramedic certification examination. This model can be used by program directors, paramedic program instructors, and prospective paramedic students to maximize the probability of attaining national paramedic certification.     

Emergency Medical Services Fellowship in the United States of America

Travelling outside Australia to undertake further training in an area of subspecialty interest is both interesting and beneficial to the advancement of the individual and our specialty. In the United States of America, such formal training following completion of specialist qualification in emergency medicine is referred to as ‘Fellowship’ training. While other authors have discussed the general areas of overseas work and emergency medicine Fellowships, this paper specifically addresses the area of prehospital care, known in the United States as ‘emergency medical services’. Although there are significant differences in prehospital care between the United States and Australia, a great deal of what can be learned from undertaking a Fellowship in prehospital care in the United States is locally applicable. A typical curriculum is outlined, and the steps in selecting and arranging such a programme are discussed. Some potential pitfalls are also mentioned. Given the paucity of formal training in prehospital care in this country, such fellowship programmes are an excellent means of obtaining a very solid understanding of this important aspect of emergency medicine.     

Coordination of the ems system: An organizational theory approach

Emergency medical services (EMS) systems include autonomous organizations with high degrees of interdependence. The need to coordinate system participants has long been recognized but seldom achieved. This can be explained by organizational theory—specifically, the study of the relationships among organizations. Existing models identify the total system's functions, but fail to explain roles and relationships among the system's participants. Coordination among organizations is more difficult than coordination within an organization because of lack of an authority structure. The EMS system can be described as “a functionally interdependent system,” consisting of multiple autonomous organizations with high degrees of interdependence in their technical functions. Communities have five potential management approaches, varying according to their aggressiveness. These are laissez-faire, where even voluntary coordination efforts are not tried; voluntary cooperation efforts, such as coordinating councils; external planning agencies without regulatory control; “framework organizations” with regulatory control over the system participants; and bureaucratization, placing the system participants within a single organizational hierarchy. The “multicratic organization” is a model for management of multiorganizational systems. A “system lead agency” plans joint activities and manages relationships among system participants in the way that the management of a uniorganization integrates departments. A lead agency is usually a unit of government or organized pursuant to government action, but a managed care organization can also fill this role. In extreme application of the model, the system is viewed as a framework and temporary modules are attached. Their interests are limited, as needed, to optimize the entire system. The lead agency sets policies affecting relationships of modules and policies crossing organizational boundaries.     

Loss of Paramedic Availability in an Urban Emergency Medical Services System during a Severe Acute Respiratory Syndrome Outbreak

OBJECTIVES: To describe the loss of paramedic availability to Toronto Emergency Medical Services during a biphasic (SARS-1 and SARS-2) outbreak of severe acute respiratory syndrome (SARS). METHODS: During the SARS outbreak, a dedicated paramedic surveillance and quarantine program was developed. The authors determined the number of paramedics on quarantine each day, the type of quarantine (either home quarantine [HQ] or work quarantine [WQ]), and the development of SARS-like symptoms. RESULTS: During the SARS outbreak, there were five cases of probable SARS and three cases of suspect SARS. SARS-1 lasted 30 days, during which 234 paramedics were placed on HQ. The total number of HQ days was 1,615. During the five peak days of SARS-1, the total number of HQ days was 664. SARS-2 lasted 18 days, during which 292 paramedics were placed on either HQ or WQ, for a combined number of quarantine days of 1,637. During the five peak days of SARS-2, the combined number of quarantine days was 910. Of these, paramedics were available for duty on 708 days (78%) due to the WQ program. The primary reason for quarantine was unprotected exposure to a health care institution experiencing a SARS outbreak. Under quarantine, SARS-like symptoms developed in 68 paramedics, including cough (53 [78%]), myalgia (33 [48%]), fatigue (30 [44%]), headache (29 [43%]), fever (11 [16%]), and shortness of breath (7 [10%]). CONCLUSIONS: Paramedics were among the health care workers who developed SARS. During SARS-2, WQ optimized the number of days on which paramedics were available for duty. Many paramedics developed SARS-like symptoms without being diagnosed as having SARS. A dedicated paramedic surveillance and quarantine program provided a useful means to manage the paramedic resource during the SARS outbreak.     

The effect of simple interventions on paramedic aspirin administration rates

Objective

To determine the baseline rate of aspirin administration by paramedics and to assess the effect of two interventions (protocol change and brief educational intervention) on that rate.

Methods

The advanced life support transport provider's clinical database was retrospectively queried to identify calls involving adult patients with chest pain or paramedic impression of suspected cardiac event (possible acute coronary syndrome [ACS]). The study includes data from January 1, 1999, to June 30, 2002, which was divided into three distinct periods. Period 1 was the baseline, period 2 was after the protocol change intervention, and period 3 was after the brief educational intervention. The chest pain protocol indicates patients with chest pain should be treated with aspirin.

Results

During period 1, 548 of 3,635 (15.1%) patients with possible ACS received aspirin. During period 2, 1,941 of 7,236 (26.8%) patients with possible ACS received aspirin (χ² p<0.0001; odds ratio [OR] = 2.06; 95% confidence interval [CI] = 1.86-2.29). During period 3, 749 of 2,026 (37%) patients with possible ACS received aspirin (χ² p<0.0001; OR = 1.60; 95% CI = 1.44-1.78). Comparing period 1 with period 3, after both interventions, there was a 22% absolute improvement in aspirin administration rates (χ² p<0.0001; OR = 3.30; 95% CI = 2.91-3.76).

Conclusion

Aspirin is underutilized in treating patients with suspected ACS. Two brief interventions can lead to modest increases in aspirin administration rates. Even after these interventions, aspirin administration rates remain low.     

Use of ems for seriously ill children in the office: A survey of primary care physicians

Objectives. To describe how primary care physicians (PCPs) transport seriously ill children from their offices to emergency departments (EDs). Methods. The authors conducted a mail survey of PCPs in upstate New York. Results. The response rate was 60% (119/199). Sixty-six percent (79/119) of the physicians had transferred at least one child from their office to an ED via EMS. Forty-five percent (53/119) had encountered a case of suspected epiglottitis in the office. EMS was used to send 45% (24/53) of suspected epiglottitis cases to the ED, while 40% (21/53) transferred children with possible epiglottitis via family auto. Similarly, the family's auto was used to transport 26% (6/23) of the patients with suspected foreign body aspiration, 46% (32/70) with severe asthma, 59% (30/51) with severe dehydration, and 37% (14/38) with suspected meningococcemia. In contrast, the family's auto was never used for patients with active seizures. The physicians denied that they would call EMS more often if transport time were shorter (58%) or if costs were less (64%). Sixty percent of the PCPs were not sure whether EMS personnel are skilled in pediatric emergencies. Conclusion. The PCPs often failed to call EMS for seriously ill children seen in the office and, instead, used the family's auto for emergency transportation. In this survey, transport time and cost were not barriers to use of EMS. The physicians expressed a lack of confidence in EMS providers' pediatric skills. Targeting educational programs to PCPs that highlight 1) the availability, training, and skill of EMS personnel and 2) the medicolegal risks of family transportation may result in more appropriate use of EMS for children.     

Undergraduate paramedicine students' experiences of feedback during clinical placement on-road: A scoping review

Feedback on performance enhances student confidence and clinical skills and promotes safe clinical practice. Experiences of feedback are well documented across many health disciplines; however, less is known about paramedicine students' experiences of feedback on-road in an emergency ambulance. The aim of this scoping review was to identify what is known about paramedicine students' experiences of feedback during clinical placement on-road in an emergency ambulance. A review of studies between 2000 and 2021 was undertaken, guided by the Joanna Briggs Institute Methodology for JBI Scoping Reviews and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. Databases included CINAHL, EMBASE, EBSCO, MEDLINE, Web of Science, Cochrane, ERIC (ProQuest), ProQuest (Nursing and Allied Health), Trove, and Open Accessd Theses and Dissertations. Three studies were identified. Feedback is valued by paramedicine students; however, it can be personal and destructive in nature. Paramedics are enthusiastic and supportive and provide clear feedback. Paramedics face challenges supervising students and may lack preparation to provide feedback. There is limited evidence on paramedicine students’ experiences of feedback during clinical placement. Further exploration is needed to gain further understanding.     

Evaluation of the Uptake of a Prehospital Cardiac Arrest Termination of Resuscitation Rule

BackgroundPrevious research has focused on creation and validation of a basic life support rule for termination of resuscitation (TOR) in nontraumatic out-of-hospital cardiac arrest (OHCA) to identify patients who will not be successfully resuscitated or will not have a favorable outcome. Although now widely implemented, translational research regarding in-field compliance with TOR criteria and barriers to use is scarce.ObjectivesThis project aimed to assess compliance rates, barriers to use, and effect on ambulance transport rates after implementing TOR criteria for OHCA.MethodsRetrospective chart review of patients ≥ 18 years with OHCA. Data from regional Emergency Medical Services agencies were collected to determine TOR rule compliance for patients meeting criteria, barriers to use, and effect of a TOR rule on ambulance transport.ResultsThere were 552 patients with OHCAs identified. Ninety-one patients met TOR criteria, with paramedics requesting TOR in 81 (89%) cases and physicians granting requests in 65 (80.2%) cases. Perceived barriers to TOR compliance included distraught families, nearby advanced-care paramedics, and unusual circumstances. Reasons for physician refusal of TOR requests included hospital proximity, patient not receiving epinephrine, and poor communication connection to paramedics. Total high priority transports decreased 15.6% after implementation of a TOR rule.ConclusionsThe study found high compliance after implementation of a TOR rule and identified potentially addressable barriers to TOR use. Appropriate application of a TOR rule led to reduction in high-priority ambulance transports, potentially reducing futile use of health care resources and risk of ambulance motor vehicle collisions.     

The Epidemiology of Emergency Medical Services Use by Older Adults: An Analysis of the National Hospital Ambulatory Medical Care Survey

Objectives To characterize older adult emergency department (ED) visits arriving by emergency medical services (EMS) and to identify factors associated with those patient visits.
Methods A secondary analysis of the ED component of the 1997–2000 National Hospital Ambulatory Medical Care Survey using logistic regression analyses was conducted. The dependent variable was the modes of arrival (EMS vs. not EMS) to the ED. Independent variables were grouped into four domains: demographic, clinical, system, and service characteristics.
Results Between 1997 and 2000, 38% of EMS responses were for patients aged 65 years and older. During that period, 62.2 million older adult ED patient visits occurred; 38% arrived via EMS. The average rate of EMS utilization by older adults was 167/1,000 population per year, more than four times the rate for younger patients (39/1,000 population). Fifty-three percent of EMS responses with transport to an ED for older adults resulted in hospital admission. Factors found to be associated with EMS mode of arrival included demographic (older age and urban residence), clinical (need for more rapid care and circulatory system illnesses), and service (need for procedures).
Conclusions Older adults account for a large proportion of EMS responses and use EMS at a disproportionately high rate. As the older adult population grows, EMS systems must prepare for the increased volume of older adults by making changes in training, operations, and equipment.