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.     

Characterization of Children with Septic Shock Cared for by Emergency Medical Services

Objective: To inform the future development of a pediatric prehospital sepsis tool, we sought to 1) describe the characteristics, emergent care, and outcomes for children with septic shock who are transported by emergency medicine services (EMS) and compare them to those self-transported; and 2) determine the EMS capture rate of common sepsis screening parameters and the concordance between the parameters documented in the EMS record and in the emergency department (ED) record. Methods: This is a retrospective cohort study of children ages 0 through 21 years who presented to a pediatric ED with septic shock between 11/2013 and 06/2016. Data, collected by electronic and manual chart review of EMS and ED records, included demographics, initial vital signs in both EMS and ED records, ED triage level, site of initial ED care, ED disposition, ED therapeutic interventions, outcomes, and times associated with processes. Potential screening parameters were dichotomized as normal vs. abnormal based on age-dependent normative data. Results: Of the children with septic shock treated in our ED, 19.3% arrived via EMS. These children as compared to those self-transported were more likely (i.e., p?<?0.05) to be male, have public insurance, receive initial care in the ED resuscitation suite, be hypotensive on arrival, receive their first ED fluid bolus sooner (33 vs. 58?minutes), receive vasoactive agents, be mechanically ventilated in the first 24?hours, and have slightly longer length of hospital stays. Both groups had similar times to antibiotics. While poor outcomes were rare, the 3- and 30-day mortalities were similar for both groups. EMS capture rates were highest for heart rate and respiratory rate and lowest for temperature, glucose, and blood pressure. Interrater reliability was highest for heart rate. Conclusions: Children presenting to the ED with septic shock transported by EMS represent a critically ill subset of modest proportions. Realization of a sepsis screening tool for this vulnerable population will require both creation of a tool containing a limited subset of objective parameters along with processes to ensure capture.     

Prevalence of Depression and Cognitive Impairment in Older Adult Emergency Medical Services Patients

Abstract

Objectives. To characterize the proportion of older adult emergency department (ED) patients with depression or cognitive impairment. To compare the prevalences of depression or cognitive impairment among ED patients arriving via emergency medical services (EMS) and those arriving via other modes. Methods. Community-dwelling older adults (age ≥60 years) presenting to an academic medical center ED were interviewed. Participants provided demographic and clinical information, and were evaluated for depression and cognitive impairment. Subjects arriving via EMS were compared with those arriving via other modes using the chi-square test, t-test, and the Wilcoxon rank sum test, where appropriate. Results. Consent was obtained from 1,342 eligible older adults; 695 (52%%) arrived via EMS. The median age for those arriving via EMS was 74 years (interquartile range 65, 82), 52%% were female, and 81%% were white. Fifteen percent of EMS patients had moderate or greater depression, as compared with 14%% of patients arriving via other modes (p == 0.52). Thirteen percent of the EMS patients had cognitive impairment, as compared with 8%% of those arriving via other modes (p < 0.01). The depressed EMS patients frequently reported a history of depression (47%%) and taking antidepressants (51%%). The cognitively impaired EMS patients infrequently reported a history of dementia (16%%) and taking medications for dementia (14%%). Conclusions. In this cohort of community-dwelling older adult ED patients, depression and cognitive impairment were common. As compared with ED patients arriving by other transport means, patients arriving via EMS had a similar prevalence of depression but an increased prevalence of cognitive impairment. Screening for depression and cognitive impairment by EMS providers may have value, but needs further investigation.     

Utilization of Intravenous Catheters by Prehospital Providers during Pediatric Transports

Introduction: Prehospital intravenous (IV) access in children may be difficult and time-consuming. Emergency Medical Service (EMS) protocols often dictate IV placement; however, some IV catheters may not be needed. The scene and transport time associated with attempting IV access in children is unknown. The objective of this study is to examine differences in scene and transport times associated with prehospital IV catheter attempt and utilization patterns of these catheters during pediatric prehospital encounters. Methods: Three non-blinded investigators abstracted EMS and hospital records of children 0–18 years of age transported by EMS to a pediatric emergency department (ED). We compared patients in which prehospital IV access was attempted to those with no documented attempt. Our primary outcome was scene time. Secondary outcomes include utilization of the IV catheter in the prehospital and ED settings and a determination of whether the catheter was indicated based on a priori established criteria (prehospital IV medication administration, hypotension, GCS < 13, and ICU admission). Results: We reviewed 1,138 records, 545 meeting inclusion criteria. IV catheter placement was attempted in 27% (n = 149) with success in 77% (n = 111). There was no difference in the presence of hypotension or median GCS between groups. Mean scene time (12.5 vs. 11.8 minutes) and transport time (16.9 vs. 14.6 minutes) were similar. Prehospital IV medications were given in 38.7% (43/111). One patient received a prehospital IV medication with no alternative route of administration. Among patients with a prehospital IV attempt, 31% (46/149) received IV medications in the ED and 23% (34/396) received IV fluids in the ED. Mean time to use of the IV in the ED was 70 minutes after arrival. Patients with prehospital IV attempt were more likely to receive IV medication within 30 minutes of ED arrival (39.1% vs. 19.0%, p = 0.04). Overall, 34.2% of IV attempts were indicated. Conclusions: Prehospital IV catheter placement in children is not associated with an increase in scene or transport time. Prehospital IV catheters were used in approximately one-third of patients. Further study is needed to determine which children may benefit most from IV access in the prehospital setting.     

Accuracy of Paramedic Broselow Tape Use in the Prehospital Setting

Introduction. Previous literature has documented that prehospital 12-lead electrocardiography (ECG) decreases the time to reperfusion in patients with an acute ST-segment elevation myocardial infarction (STEMI). Objective. To compare time to ECG, time to angioplasty suite (laboratory), andtime to reperfusion in emergency medical services (EMS) STEMI patients, who received care through three different processes. Methods. The setting was a large suburban community teaching hospital with emergency department (ED)-initiated single-page acute myocardial infarction (AMI) team activation for STEMI patients. The population was STEMI patients transported by EMS from January 2003 to October 2005. Not all EMS agencies had prehospital 12-lead ECG capability. Paramedics interpret andverbally report clinical assessment andECG findings via radio. The AMI team is activated at the discretion of the emergency physician 1) before patient arrival to the ED based on EMS assessment, 2) after ED evaluation with EMS ECG, or 3) after ED evaluation andED ECG. Time intervals were calculated from ED arrival. To assess the impact of interventions on performance targets, we also report the proportion of patients who arrived in laboratory within 60 minutes andreperfusion within 90 minutes of arrival. Parametric andnonparametric statistics are used for analysis. Results. During the study period, there were 164 STEMI patients transported by EMS; mean age was 66.1 years, and56% were male. Of these, 93 (56.7%) had an EMS ECG and31 (33%) had AMI team activation before ED arrival. Mean time to laboratory for all patients was 49.8 ± 34.4 minutes andtime to reperfusion was 93.2 +/? 34.5 min. Patients with prearrival activation were transported to laboratory sooner (mean, 24.3 vs. 53. 4 minutes; p < 0.001) andreceived reperfusion sooner than all other patients (mean, 70.4 vs. 96.3 minutes; p = 0.007). More prearrival activation patients met performance targets to laboratory (96.7% vs. 73.7%; p = 0.009) andreperfusion (85.2% vs. 51.0%; p = 0.003). There was no difference in time to laboratory or to reperfusion for patients who received EMS ECG but no prearrival activation compared with those who received EMS transport alone. Conclusions. A minority of patients with EMS ECGs had prearrival AMI team activation. EMS ECGs combined with systems that activate hospital resources, but not EMS ECGs alone, decrease time to laboratory andreperfusion.     

Preferences for EMS Transport andPediatric Emergency Department Care

Objectives. To characterize the reasons pediatric emergency department (PED), patients access emergency medical services (EMS) for transport to the pediatric ED. To describe the acceptability of other modes of transport andalternative sites of care. Methods. We included a convenience sample of the responsible adults accompanying pediatric patients who arrived via EMS to the PED of an academic medical center. We administered a survey to evaluate why they chose EMS andtheir feelings about alternative modes of transport (e.g., medical van, taxi) or alternative sites of care (e.g., urgent care center, primary care physician's office, or getting an appointment within 24 hours). Results. One hundred thirthy-eight surveys were completed. Pediatric patients averaged eight years of age. Trauma (44%) andseizures (17%) were the chief complaints. The primary reasons for EMS use were perceived medical necessity (54%) andsecurity of transport by EMS (17%). Only transport by EMS was found to be acceptable. The responsible adults expressed acceptance of the PED (median = 7, 1 = not acceptable, 7 = very acceptable) as a destination, more than their child's primary care doctor's (median = 4), urgent care centers (median = 3), or no transport anda physician appointment within 24 hours (median = 1). Conclusions. Adults access the EMS system for children because of concerns regarding the acuity of illness andfor the security of EMS transport. They were generally uninterested in transport by any mode other than EMS. However, they would accept transport to alternative sites for immediate care.     

Interfacility transports by emergency medical services in the United States: Estimates from the National Hospital Ambulatory Medical Care Survey

ObjectiveTo describe characteristics of encounters in U.S. emergency departments (EDs) brought by interfacility transport by emergency medical services (EMS) from other EDs or urgent care settings.MethodsWe performed a cross-sectional study of the National Hospital Ambulatory Medical Care Survey, a multistage probability survey of nonfederal of visits to U.S. EDS. We evaluated patients who were brought to the ED as an interfacility transport by EMS from another ED or urgent care setting between 2014 and 2017. We report demographics, clinical characteristics and treatment factors of ED encounters brought interfacility transport and assessed factors associated with discharge from the receiving ED.ResultsOf 562.9 million ED encounters during the assessed period, 4.5 million were brought by interfacility transport by EMS (1.1 million per year). This represented 0.8% (95% CI 0.6–1.0%) of all ED encounters and 5.3% (95% CI 4.4–6.3%) of ED encounters transported by EMS. Most encounters brought by interfacility transport were adults (85%) who were publicly insured (62%). 39% had at least one abnormal vital sign. Most encounters received diagnostic testing (84%) and were seen within 30 min of presentation (61%). 54% were admitted, and 36% were discharged from the ED. Encounters without chronic complex conditions and with normal triage vital signs were associated with ED discharge (p < 0.01).DiscussionInterfacility transports between EDs transported by EMS account for <1% of ED encounters in the U.S. Nearly 40% of such encounters are ultimately discharged. Further research is needed to identify a low-risk cohort among patients in need of secondary transport.     

P REHOSPITAL R APID-SEQUENCE I NTUBATION

Prehospital pain management has become an important emergency medical services (EMS) patient care issue. Objectives. To describe the frequency of EMS andemergency department (ED) analgesic administration to injured children; to describe factors associated with the administration of analgesia by EMS; andto assess whether children with lower-extremity fractures receive analgesia as frequently as do adults with similar injuries. Methods. This was a retrospective study of children (age < 21 years) who were transported by EMS between January 2000 andJune 2002 andhad a final hospital diagnosis of extremity fractures or burns. Secondarily, children with lower-extremity fractures were compared with a cohort of EMS-transported adults with similar injuries andtransported during the same study period. Receipt of andtime of parenteral analgesia were recorded. Results. Seventy-three children met the inclusion criteria. The mean (range) age of this sample was 12.4 (0.9–21) years, with only four patients aged < 5 years. A majority of the patients were male (49/73, 67.1%) andsustained femur (20/73, 27.4%) or tibia/fibula (26/73, 35.6%) fractures. Few pediatric patients received prehospital analgesia (16/73, 21.9%), while a majority received analgesia in the ED (58/73, 79.4%). Prehospital analgesia was associated with earlier patient treatment than that administered in the ED (22.3 ± 5.9 min vs. 88.3 ± 38.2 min). Comparing children (n = 33) with adults (n = 76) with similar lower-extremity fractures, a small insignificant difference was found in the rate of prehospital analgesia between children andadults (7/33, 21.2%, vs. 20/56, 26.3%). Conclusion. Few pediatric patients receive prehospital analgesia, although most ultimately received ED analgesia. Few factors were identified that could be associated with EMS oligoanalgesia. No difference was found between children andadults in the rates of EMS analgesia.     

Pediatric Behavioral Health-Related EMS Encounters: A Statewide Analysis

Objectives: Pediatric behavioral health disorders and related emergency department visits are increasing, but effects on emergency medical services (EMS) are unknown. This study’s objective was to describe the statewide epidemiology of pediatric behavioral health-related EMS encounters in Florida, including mental health and substance use. Methods: This analysis is a retrospective study of pediatric behavioral health-related EMS encounters from Florida’s statewide EMS Tracking and Reporting Systems Database from 2011 to 2016. Demographic, clinical, EMS, and geographic characteristics are described. We also compared characteristics between patients who did and did not receive an acute EMS behavioral/psychiatric intervention. Results: There were 22,254 pediatric behavioral health-related EMS encounters during the study period, one-quarter of which were noted to have suspected or confirmed ingestion/substance use. The median age was 16 and the majority of patients were female and white. A total of 946 patients (4%) had an acute EMS behavioral/psychiatric intervention. EMS scene, ED turnaround, and total EMS time were significantly longer for intervention patients. Of the 14 counties in the top quartile of percentages of intervention patients, 7 were rural, 10 did not have any hospitals with child/adolescent psychiatric services, and 7 did not have any child psychiatrists. Conclusions: Pediatric behavioral-health related EMS encounters had a significant proportion of suspected ingestions/substance use, and we found disproportionate effects on rural agencies. Increases in EMS resource utilization (including longer EMS times) occurred in certain settings with limited behavioral health infrastructure. Those findings suggest an opportunity for community paramedicine to alleviate EMS utilization and decrease the frequency of pediatric behavioral health emergencies.     

Time Delays in Accessing Stroke Care in the Emergency Department

OBJECTIVE: To delineate components of delay within the hospital ED for patients presenting with symptoms of stroke. METHODS: A prospective registry of patients presenting to the ED with signs or symptoms of stroke was established at a university hospital from July 1995 to March 1996. The ED arrival time, time to being seen by an emergency physician (EP), time to CT scan, and time to neurology consultation were obtained by medical record review. RESULTS: The median delay (interquartile range) from ED arrival to being seen by an EP for the 170 eligible subjects was 0.42 (0.20-0.75) hours. The median delay to CT scan was 1.88 hours (1.25-2.67) and the median delay to neurology consultation was 2.42 hours (1.50-3.48). Age, race, sex, and hospital discharge diagnosis had little influence on delay. Subjects arriving by emergency medical services (EMS) had a significantly shorter time to being seen by an EP (0.33 vs 0.50 hours) when compared with those who arrived by other means. Time to CT scan was shorter by 0.5 hours for patients arriving by EMS as well. These differences persisted when stratified by out-of-hospital delay times. CONCLUSIONS: These data suggest that arriving by EMS is associated with shorter times to being seen by an EP and receiving a CT scan. The influence of EMS on delays associated with rapid medical care of stroke patients reaches beyond the out-of-hospital transport phase.     

Factors associated with destination of pediatric EMS transports

ObjectivePediatric patients comprise 13% of emergency medical services (EMS) transports, and most are transported to general emergency departments (ED). EMS transport destination policies may guide when to transport patients to a children's hospital, especially for medical complaints. Factors that influence EMS providers ‘decisions about where to transport children are unknown.Our objective was to evaluate the factors associated with pediatric EMS transports to children's hospitals for medical complaints.MethodsWe performed a cross-sectional study of a large, urban EMS system over a 12-month period for all transports of patients 0–17 years old. We electronically queried the EMS database for demographic data, medical presentation and management, comorbidities, and documented reasons for choosing destination. Distances to the destination hospital and nearest children's and community hospital (if not the transport destination) were calculated. Univariate and multiple logistic regression analyses were conducted to determine the association between independent variables and the transport destination.ResultsWe identified 10,065 patients, of which 6982 (69%) were for medical complaints. Of these medical complaints, 3518 (50.4%) were transported to a children's hospital ED. Factors associated with transport to a children's hospital include ALS transport, greater transport distance, protocol determination, developmental delay, or altered consciousness. Factors associated with transport to general EDs were older age, unknown insurance status, lower income, greater distance to children's or community hospital, destination determined by closest facility or diversion, abnormal respiratory rate or blood glucose, psychiatric primary impression, or communication barriers present.ConclusionsWe found that younger patient age, EMS protocol requirements, and paramedic scene response may influence pediatric patient transport to both children's and community hospitals. Socioeconomic factors, ED proximity, diversion status, respiratory rate, chief complaints, and communication barriers may also be contributing factors. Further studies are needed to determine the generalizability of these findings to other EMS systems.     

Emergency Medical Services Bypass of the Closest Facility for Pediatric Patients

Objectives: Pediatric specialty care is increasingly regionalized. It is unknown how regionalization affects emergency medical services (EMS) providers’ destination decisions for non-trauma pediatric patients. We sought to characterize the rates of bypass of the closest facility, and destination facilities’ levels of pediatric care in three diverse EMS agencies.

Methods: This is a one-year retrospective study of non-trauma pediatric patients less than 18 years of age transported by three EMS agencies (Baltimore City, Prince George’s County, and Queen Anne’s County) in 2016. A priori, a bypass was defined as transport to a facility more than 2?km farther than the distance to the closest facility. We calculated rates of bypass and categorized destination and closest facilities by their pediatric service availability using publicly available information. EMS transport distance and time were also compared for bypass and closest facility patients.

Results: The three EMS agencies in 2016 transported a total of 12,258 non-trauma pediatric patients, of whom 11,945 (97%) were successfully geocoded. Overall 43% (n?=?5,087) of patients bypassed the nearest facility, of which 87% (n?=?4,439) were transported to a facility with higher-level pediatric care than the closest facility. Both bypass rates and destination facility pediatric levels differed between agencies. Bypasses had significantly longer transport times and distances as compared to closest facility transports (p?<?0.001). For non-trauma pediatric bypasses alone, an additional 41,494 kilometers traveled, and 979?hours of EMS transport time was attributable to bypassing the closest facility.

Conclusions: This study reveals a high rate of pediatric bypass for non-trauma patients in three diverse EMS agencies. Bypass results in increased EMS resource utilization through longer transport time and distance. For non-trauma pediatric patients for whom there is little destination guidance, further work is required to determine bypass’ effects on patient outcomes.     

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.     

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.     

Ambulance use by high-acuity patients in a pediatric ED

The objective of this study was to analyze ambulance usage by highest acuity patients as compared with all patients in a suburban pediatric hospital ED. A 1-year retrospective records analysis was conducted of all highest acuity patients (those patients triaged as emergent or critical or admitted to the intensive care unit). A total of 245 patients made 270 high-acuity visits to the ED in 1995. Thirty-one (13%) of the high-acuity patients arrived via ambulance; the rest arrived via private vehicle. The 31 high-acuity patients constituted 8% of the total number of patients arriving by ambulance. There was no significant difference in ambulance usage between insurance groups in the high-acuity patients. Only high-acuity patients with neurologic symptoms (primarily seizures) had a greater relative use of EMS transportation, with 39% of these patients arriving via ambulance (odds ratio 6.6, 95% confidence interval 2.6,16.6). High-acuity patients account for the minority of total ambulance usage in our ED.     

Pediatric Prehospital Refusal of Medical Assistance: Association with Suspected Abuse or Neglect

Introduction: Unlike adult refusal of medical assistance (RMA), pediatric refusal is not initiated by the patient. This lack of autonomy may permit neglect by the guardian through denial of necessary treatment. The purpose of the current study was to determine whether pediatric RMA was associated with suspected abuse or neglect (SAN). Methods: This was a retrospective single EMS agency cross-sectional analysis of calls between January 1, 2011 and December 31, 2015 for patients <18 years of age resulting in RMA. Age- and complaint-matched control groups were generated from transported patients during the same time period. Recidivism was defined as 2 or more episodes of RMA involving a single patient during the study period. Results: A total of 241 calls for service resulted in RMA during the study period, representing 12.7% of all pediatric calls. Information regarding SAN was available for 202 calls. Recidivism was noted in 8 patients (17 calls for service), resulting in 185 unique patients. Twenty-one RMA patients (11.4%) were identified as SAN. No difference in SAN status was noted between RMA patients and age-matched controls (21 vs. 24, p = 0.75) and complaint-matched controls (21 vs. 26, p = 0.53). No SAN was identified in the 8 recidivist patients when compared with the 177 non-recidivist patients (0 vs. 21, p = 0.60). Conclusions: Pediatric SAN patients are not uncommon users of EMS in our service area. Neither RMA nor recidivist RMA was associated with the presence of SAN within our patient population.     

Child and Provider Restraints in Ambulances: Knowledge, Opinions, and Behaviors of Emergency Medical Services Providers

Background: Approximately 16,000 children are transported by ambulances each day, and there are an estimated 4,500 ambulance crashes each year. Information about emergency medical services (EMS) provider knowledge, opinions, and behaviors regarding occupant restraint is lacking. Objectives: To measure the knowledge, opinions, and behaviors of EMS personnel regarding child and provider restraint use in ambulances. Methods: A survey was given to all EMS providers in two large ambulance‐service organizations and in a hospital‐based pediatric ambulance service in a midsized urban area. Results: A total of 302 EMS providers were surveyed, for a return rate of 67.7%. Nearly half were involved in an ambulance crash at least once; of those, 7.6% were injured and 1% had patients in their care injured. The majority (91%) reported some training in child‐restraint use in ambulances, and half reported that they know a lot or very much about securing a critically ill child for transport. However, 30% did not identify the correct method of transport for a stable 2‐year‐old, and 40% did not choose the correct method of securing a child seat to the ambulance cot. Securing a child seat to the cot was viewed by 81% to not take too much time from patient care, and 63% did not view caring for a child in a car seat as difficult. Although 80% of providers regularly transported children in a car seat, 23% transported them on an adult's lap at least sometimes. Specialized pediatric‐transport providers were more likely to report safe pediatric and occupant restraint practices than were community EMS providers. Pediatric restraint behaviors were not associated with years of service or history of a crash. Two thirds of respondents reported not wearing their seatbelt on the squad bench while treating patients, and half believe that wearing a seatbelt interferes with patient care. A total of 95% report wearing seatbelts in the front seat of the ambulance. Provider seatbelt use in the patient compartment was not associated with years of service, with number of crashes, or with reporting correct use of pediatric restraints. Conclusions: This study indicates that the frequency of crashes in ambulances, and therefore the potential for injury, may be underappreciated. Current restraint practices of some of the study group are outside recommendations and may be placing at risk some children who are being transported by ambulances. This problem is complicated by the relative infrequency of pediatric ambulance transports compared with adults. Improved equipment and education may help providers safely transport pediatric patients. In addition, providers are risking their own safety by not wearing seatbelts in the rear ambulance compartment. Improved equipment may help alleviate this risk and allow providers to take care of patients safely.     

Morbidity and Mortality Associated with Prehospital “Lift-assist” Calls

Introduction: When an individual requires assistance with mobilization, emergency medical services (EMS) may be called. If a patient does not receive treatment on scene and is not transported to hospital, these are referred to as “Lift Assist” (LA) calls. It is possible this need for assistance represents a subtle onset of a disease process or decline in function. Without recognition or treatment, the patient may be at risk for recurrent falls, repeat EMS visits or worsening illness. Objective: To examine the 14-day morbidity and mortality associated with LA calls and determine factors that are associated with increased risk of these outcomes. Methods: All LA calls from a single EMS agency were collected over a one year study period (January–December 2013). Calls were linked with hospital records to determine if LA patients had a subsequent visit to the emergency department (ED), admission, or death within 14 days of the LA call. Logistic regression analyses were completed to determine factors predicting ED visit or hospital admission within 14 days of the LA call. Results: Of 42,055 EMS calls, 804 (1.9%) were LAs. These calls were for 414 individuals; 298 (72%) patients had 1 LA, and 116 (28%) patients had >1 LA call. There were 169 (21%) ED visits, 93 (11.6%) hospital admissions and 9 (1.1%) deaths within 14 days of a LA call. Patient age (p = 0.025) significantly predicted ED visit. Patient age (p = 0.006) and an Ambulance Call Record missing at least 1 vital sign (p = 0.038) significantly predicted hospital admission. Conclusions: LA calls are associated with short-term morbidity and mortality. Patient age was found to be associated with these outcomes. These calls may be early indicators of problems requiring comprehensive medical evaluation and thus further factors associated with poor outcomes should be determined.