STREMS: A Smart Real-Time Solution toward Enhancing EMS Prehospital Quality

Cost-Effectiveness Analysis of Potential Improvements to Emergency Medical Services for Victims of Out-of-Hospital Cardiac Arrest

The recommendations for electrical therapies described in this section are designed to improve survival from SCA and life-threatening arrhythmias. Whenever defibrillation is attempted, rescuers must coordinate high-quality CPR with defibrillation to minimize interruptions in chest compressions and to ensure immediate resumption of chest compressions after shock delivery. The high first-shock efficacy of newer biphasic defibrillators led to the recommendation of single shocks plus immediate CPR instead of 3-shock sequences that were recommended prior to 2005 to treat VF. Further data are needed to refine recommendations for energy levels for defibrillation and cardioversion using biphasic waveforms.

Effectiveness of Emergency Medical Services for Victims of Out-of-Hospital Cardiac Arrest: A Metaanalysis

93 Patients With Sickle Cell Disease Pain Crises Are Often Undertreated in the Out-of-Hospital Setting: A Multi-Agency Cohort Study

263 Does Failure to Activate Stroke Resources from the Out-of-Hospital Setting Delay Stroke Recognition by Emergency Department Staff?

Ensuring the effectiveness of community-wide emergency cardiac care

Introduction: In Japan, emergency medical service (EMS) providers are prohibited from cardiopulmonary resuscitation (CPR) termination in the field and must transport all out-of-hospital cardiac arrest (OHCA) patients to a hospital, regardless of the return of spontaneous circulation (ROSC). We previously developed a termination of resuscitation (TOR) rule for emergency department physicians (ED-TOR) treating OHCA patients using data from the All-Japan Utstein Registry between 2005 and 2009, when CPR was performed according to the 2005 guidelines. The ED-TOR rule recommends CPR termination when patients in the emergency department meet all of the following criteria: initial unshockable rhythm, arrest unwitnessed by bystanders and no prehospital ROSC. Hypothesis: We aimed to validate the ED-TOR rule using more recent data, where CPR was performed according to the 2010 and 2015 guidelines, comparing the relevance of the ED-TOR rule with the universal basic life support TOR (BLS-TOR) rule, which consists of the following criteria: no prehospital ROSC, unwitnessed arrest by EMS providers and no shock received. Methods: We analysed 552,554 OHCA patients (age ≥ 18 years) treated by EMS providers. OHCA patients witnessed by EMS providers were excluded. Data were obtained from a prospectively recorded All-Japan Utstein Registry from 2013 to 2017. The study endpoints were specificity and a positive predictive value (PPV) for predicting 1-month mortality after OHCA with the ED-TOR and BLS-TOR rules. Results: The overall 1-month survival rate was 4.3% (23,733/552,554). The proportions of OHCA patients who fulfilled the ED-TOR and BLS-TOR criteria were 59.6% and 83.8%, respectively. The specificity and PPV of the ED-TOR and BLS-TOR rules for predicting 1-month mortality were 93.2% (95% confidence interval [CI], 92.8%-93.5%) and 99.5% (95% CI, 99.5%-99.5%) and 82.6% (95% CI, 82.1%-83.1%) and 99.1% (95% CI, 99.1%-99.1%), respectively. Conclusions: The ED-TOR rule was successfully validated using more recent data from a Japanese registry where CPR was performed according to the 2010 and 2015 guidelines. The ED-TOR rule was slightly superior to the BLS-TOR rule in Japanese EMS systems showing high specificity and PPV for predicting 1-month mortality.

Survey of nationally registered emergency medical services providers: Pediatric education

196 Comparing Response Times, Intensity of Care and Outcomes between Private versus Municipal Emergency Medical Services Systems

Creating an ideal system of care to address the care forpatients with ST-elevation myocardial infarction (STEMI) iscomplex from both the system’s and patient/family’s perspec-tives. In general, this care is unlike most other hospital care.It typically involves very fast and complex decision makingand, often, sudden transportation to another facility forpercutaneous coronary intervention (PCI). All of this occurswith a potentially critically ill patient and at a time when thefamily is often not immediately available. In this report, weaddress key perspectives from the patient and public point ofview of the current system of care for STEMI patients andhighlight the barriers and gaps that must be addressed by anideal system of care (Table 1).

Background. Occupational injuries are an important source of morbidity for emergency medical services (EMS) providers. Previous work has shown that employee perceptions of an organization's commitment to safety (i.e., safety climate) correlate with adherence to safe practices. Objective. To assess the association between perceived safety climate and compliance with safety procedures in an urban EMS system with >100,000 calls/year. Methods. EMS providers were issued a self-administered survey that included questions on demographics, years of experience, perceived safety climate, and adherence to safety procedures. Safety climate was assessed with a 20-item validated instrument. Adherence to safety procedures was assessed with a nine-item list of safety behaviors. Strict adherence to safety procedures was defined as endorsing “agree” or “strongly agree” on 80% of items. The effect of safety climate on compliance with safe practices was estimated using multiple logistic regression. Results. One hundred ninety-six of 221 providers (89%) completed surveys; 74% were male; the median age was 36–40 years; and the median amount of experience was 8 years. One hundred twenty-seven of 196 respondents (65%) reported strict adherence to safe work practice. Factor analysis confirmed the original six-factor grouping of questions; frequent safety-related feedback/training was significantly associated with safe practices (odds ratio [OR] = 2.14, 95% confidence interval [CI] = 1.01–4.51). Conclusion. EMS workers perceiving a high degree of perceived safety climate was associated with twofold greater odds of self-reported level of strict adherence to safe work practices. Frequent safety-related feedback/training was the one dimension of safety climate that had the strongest association with adherence to safe workplace behaviors.

Many colleges and universities appear to exist in relative isolation from community-based emergency medical services (EMS) systems. In response, some have developed their own EMS systems. To determine the extent of this phenomenon and to delineate the characteristics of these systems. Questionnaires were mailed to 1,503 colleges/universities in the United States and Canada. The questionnaire asked whether the institution had an EMS system and included 19 questions about the characteristics of the system. A total of 919 (61%) responses were received. Of the institutions responding, 234 (25%) had an EMS system and 31 (3.4%) were considering starting a system. Characteristics of the systems were as follows: 1) Types of patients-the two most common call types were medical and trauma/surgical; 134 (57%) reported one-fourth of calls to be medical and 91 (39%) reported one-fourth of calls to be trauma/surgical. 2) Type of service-133 (57%) services transport patients; 195 (83%) respond only to the campus or other university property; the remainder also respond to the community; and 135 (58%) function all year. 3) Dispatch-178 (76%) are dispatched by the campus police, although most services are dispatched by several sources; 46 (20%) use 9-1-1. 4) Personnel-two systems (0.85%) exclusively employ paramedics; 141 systems (60%) have at least one emergency medical technician; the remainder use emergency care attendants and first-aid providers; 118 (50%) have medical directors, of these 76 (64%) are student health physicians and 21 (18%) are community physicians. 5) Demographic Information-The majority of the campus-based EMS systems exist on small campuses in urban areas. A significant number of colleges/universities have EMS systems and one-half transport patients. However, the level of training of the personnel and medical direction may be below the standard for the EMS systems in the communities in which these campus-based systems exist.

Background. On July 12, 2010, Boston Medical Center (BMC), the busiest emergency department (ED) in Massachusetts, with more than 100,000 adult patient visits per year, consolidated its two fully functional EDs into one. In preparation for this consolidation, BMC implemented systems changes to mitigate potential negative effects on both BMC and emergency medical services (EMS) providers, including Boston Emergency Medical Services (Boston EMS), the provider of 9-1-1 EMS to the City of Boston. Objective. To examine the impact of the closure of an ED on an urban EMS system in a setting where ambulance diversion is not allowed. Methods. We performed a before-and-after study that examined the effects of an ED closure on BMC and Boston EMS. We examined ED and Boston EMS volumes and ambulance turnaround intervals from June 1, 2010, to July 11, 2010 (preclosure) as compared with July 12, 2010, to August 26, 2010 (postclosure). Mean ED and Boston EMS volumes and Boston EMS turnaround intervals were calculated in four-hour shifts. We used multivariate analysis to analyze electronic medical systems data from BMC and Boston EMS and linear regression. We used autoregressive integrated moving average (ARIMA) models to determine the effect of the ED closure on turnaround intervals, ED volumes, and transport volumes. All analyses were adjusted for shift, ED volume, day of the week, and citywide EMS transport volumes. Results. After ED closure, there was a statistically significant increase of 0.89 minutes (p = 0.02) in the mean EMS turnaround intervals. Additionally, the total ED volume decreased by 3.67 visits per shift (p < 0.001). The ratio of patients transported by Boston EMS to BMC remained unchanged (p = 0.11) for two weeks before and two weeks after the closure. Conclusions. The closure of one ED resulted in a statistically significant increase in turnaround intervals and a significant decrease in ED volume independent of EMS volumes. In the absence of ambulance diversion, ratios of EMS turnaround intervals and EMS volumes according to hospital destination can be used as alternatives to ambulance diversion times to examine the effects of system-level changes such as closure of an ED on an urban EMS system. Key words: emergency department; EMS system; closure; impact; consolidation

Many state and local emergency medical services (EMS) systems may wish to modify provider levels and their scope of practice to align their systems with the recommendations of the National Emergency Medical Services Education and Practice Blueprint. To determine any changes that may be needed in a typical EMS system, the knowledge and skills of EMS providers in one rural area of North Carolina were compared with the knowledge and skills recommended in the National Emergency Medical Services Education and Practice Blueprint. A survey listing 175 items of patient care-oriented knowledge and skills described in the National Emergency Medical Services Education and Practice Blueprint was developed. EMS providers from five rural eastern North Carolina counties were asked to identify on the survey those items of knowledge and skills they believed they possessed. The skills and knowledge selected by the respondents at the five different North Carolina levels of certification were compared with the knowledge and skills listed for comparable provider levels delineated by the National Emergency Medical Services Education and Practice Blueprint. The proportions of the recommended skills reported to be possessed by the respondents were compared to determine which North Carolina certification levels best correlate with the Blueprint. One hundred forty-five EMS providers completed the survey. The proportion of recommended skills and knowledge reported to be possessed by Emergency Medical Technicians (EMTs) ranked significantly lower than did the skills and knowledge reported to be possessed by respondents at other levels in five of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Defibrillator-level personnel ranked lower than did those reported to be possessed by respondents at other levels in seven of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Intermediates ranked lower than did those reported to be possessed by respondents at other levels in nine of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Advanced Intermediates ranked lower than were the skills and knowledge reported to be possessed by respondents at other levels in two of the 10 Blueprint elements. Finally, the proportion of recommended skills and knowledge reported to be possessed by EMT-Paramedics ranked lower than were those reported to be possessed by respondents at other levels in one of the 10 Blueprint elements. In North Carolina, combining the EMT and EMT-Defibrillator levels and eliminating the EMT-Intermediate level would create three levels of certification, which would be more consistent with levels recommended by the Blueprint. The results of this study should be considered in any effort to revise the levels of EMS certification in North Carolina and in planning the training curricula for bridging those levels. Other states may require similar action to align with the National Emergency Medical Services Education and Practice Blueprint.

Emergency Medical Services (EMS) providers, capable of rapidly delivering life-prolonging interventions, are often first to respond to acute health concerns for older adults in the United States. Prior work has shown a preference among many people with dementia for comfort-focused care near end-of-life. People with dementia frequently use EMS; however, little is known about communication surrounding treatment preferences during EMS response for this group. We conducted a qualitative content analysis of EMS incident reports for older adults with dementia transported to two urban academic hospitals (2011-2021). We identified eligible patients in the hospital electronic health record applying the following criteria: age ≥ 65, diagnosis code indicating dementia, assessment by EMS, hospitalization between 2011 and 2021, and National Early Warning Score ≥ 7 indicating critical illness. We characterized the frequency and content of documented patient treatment preferences in EMS incident reports and identified barriers and facilitators to communication about treatment preferences or goal-concordant care. We reviewed incident reports for 171 patients with a median age of 82 (IQR 12) years. About half (51%) of the patients were residing in nursing homes. A minority (23%) of the patients were described as able to communicate needs, and only 24% had a family member or friend present at the time of EMS assessment. Treatment preferences were mentioned in 27% of the reports. EMS providers documented barriers to communication or delivery of goal-concordant care in nursing home settings that included difficulty obtaining information from professional caregivers, receiving secondhand information, and variable role expectations. Goal-concordant care was facilitated in these settings when EMS providers spoke directly with patients' family members by telephone. EMS providers treating critically ill older adults with dementia face challenges that may hinder their ability to elicit treatment preferences, in particular when responding to calls from professional caregivers. Direct communication with surrogate decision-makers may facilitate goal-concordant care.