Association of Ambulance Diversion Policy on EMS Transport and Ambulance Patient Offload Times: A Comparison of Three Strategies.

OBJECTIVES: Despite limited supporting data, hospitals continue to apply ambulance diversion (AD). Thus, we examined the impact of three different diversion policies on diversion hours, transport time (TT; leaving scene to arrival at the hospital), and ambulance patient offload time (APOT; arrival at the hospital to patient turnover to hospital staff) for 9-1-1 transports in a 22-hospital county Emergency Medical Services (EMS) system. METHODS: This retrospective study evaluated metrics during periods of three AD policies, each 27 days long: hospital-initiated (Period 1), complete suspension (Period 2), and County EMS-initiated (Period 3). We described the median transports and diversion hours, and compared the daily average and daily 90th percentile TT and APOT during the three study periods. RESULTS: Over the study period, there were 50,992 total transports in the county; Period 3 had fewer median transports per day than Period 1 (581 vs 623, p < 0.001), while Period 2 was similar to Period 1 (606 vs 623, p = 0.108). Median average daily diversion hours decreased from 98.1 h during Period 1 to zero hours during both Periods 2 (p < 0.001) and 3 (p < 0.001). Median daily average TT decreased from 18.3 min in Period 1 to 16.9 min in both Periods 2 (p < 0.001) and 3 (p < 0.001). Median daily 90th percentile TT showed a similar decrease from 30.2 min in Period 1 to 27.5 in Period 2 (p < 0.001), and to 28.1 in Period 3 (p = 0.001). Median average daily APOT was 26.0 min during Period 1, similar at 25.2 min during Period 2 (p = 0.826) and decreased to 20.4 min during Period 3 (p < 0.001). The median daily 90th percentile APOT was 53.9 min during Period 1, similar at 51.7 min during Period 2 (p = 0.553) and decreased to 40.3 min during Period 3 (p < 0.001). CONCLUSIONS: Compared to hospital-initiated AD, enacting no AD or County EMS-initiated AD was associated with less diversion time; TT and APOT showed statistically significant improvement without hospital-initiated AD but were of unclear clinical significance. EMS-initiated AD was difficult to interpret as that period had significantly fewer transports. EMS systems should consider these findings when developing strategies to improve TT, APOT, and system use of diversion.

Emergency Medical Responses at US Immigration and Customs Enforcement Detention Centers in California.

Importance: Knowledge of medical care in US Immigration and Customs Enforcement (ICE) detention centers is limited. Reviews show high rates of preventable deaths while in detention due to substandard medical care within detention centers. Objective: To describe characteristics of medical emergencies at ICE detention centers in California. Design, Setting, and Participants: This cross-sectional study analyzed emergency medical services (EMS)-reported medical emergencies activated through 911 from January 1, 2018, to December 31, 2022, at 3 of the 5 ICE detention centers in California: Adelanto ICE Processing Center, Imperial Regional Detention Facility, and Otay Mesa Detention Center. Exposure: Medical services requiring 911 activation. Main Outcomes and Measures: Data included the number of EMS-reported medical emergencies; ICE-reported medical emergencies; patient age and sex; and medical data in the EMS report, including primary symptom, EMS provider (emergency medical technician or paramedic) impression, vital signs, and interventions performed, using descriptive statistics. Results: In this analysis of 3 detention centers with a mean daily census of 775 (range, 504-1001) individuals per center, there was a median of 68 (IQR, 10-88) EMS-reported emergencies per center per year for a total of 1224 emergencies. The EMS-reported emergencies involved 881 males (72%) and 338 females (28%) with a median age of 39.0 (IQR 30.0-49.0) years. The ratios of female-to-male EMS-reported emergencies were 0.51 (95% CI, 0.31-0.87) at Adelanto, 0.86 (95% CI, 0.31-2.43) at Imperial, and 1.60 (95% CI, 1.40-1.83) at Otay Mesa. Pregnancy-related emergencies accounted for 12.4% (42 of 338) of emergencies in females. A total of 357 individuals (29.2%) had at least 1 abnormal vital sign during their EMS encounter. Psychiatric emergencies comprised 48 EMS responses (3.9%), despite higher rates of ICE-reported psychiatric-related complaints. The median number of monthly EMS-reported emergencies across all 3 centers was 3 (IQR, 0-9) vs 4 ICE-reported emergencies (IQR, 1-15). Conclusions and Relevance: In this study of medical emergencies at 3 of 5 ICE detention facilities in California, there were discrepancies in EMS vs ICE reported emergencies. The data suggested that vulnerable populations, such as pregnant women, had an increased number of medical emergencies, while individuals with psychiatric emergencies accounted for fewer reported emergencies. Based on these findings, emergency medical care provision in ICE detention centers requires increased transparency to ensure appropriate delivery of care.

Pediatric respiratory distress: California out-of-hospital protocols and evidence-based recommendations.

OBJECTIVES: Prehospital protocols vary across local emergency medical service (EMS) agencies in California. We sought to develop evidence-based recommendations for the out-of-hospital evaluation and treatment of pediatric respiratory distress, and we evaluated the protocols for pediatric respiratory distress used by the 33 California local EMS agencies. METHODS: Evidence-based recommendations were developed through an extensive literature review of the current evidence regarding out-of-hospital treatment of pediatric patients with respiratory distress. The authors compared the pediatric respiratory distress protocols of each of the 33 California local EMS agencies with the evidence-based recommendations. Our focus was on the treatment of 3 main pediatric respiratory complaints by presentation: stridor (croup), wheezing < 24 months (bronchiolitis), and wheezing > 24 months (asthma). RESULTS: Protocols across the 33 California local EMS agencies varied widely. Stridor (croup) had the highest protocol variability of the 3 presentations we evaluated, with no treatment having uniform use among all agencies. Only 3 (9.1%) of the local EMS agencies differentiated wheezing in children < 24 months of age, referencing this as possible bronchiolitis. All local EMS agencies included albuterol and epinephrine (intravenous/intramuscular) in their pediatric wheezing (asthma) treatment protocols. The least common treatments for wheezing (asthma) included nebulized epinephrine (3/33) and magnesium (2/33). No agencies included steroids in their treatment protocols (0/33). CONCLUSION: Protocols for pediatric respiratory distress vary widely across the state of California, especially among those for stridor (croup) and wheezing in < 24 months (bronchiolitis). The evidence-based recommendations that we present for the prehospital treatment of these conditions may be useful for EMS medical directors tasked with creating and revising these protocols.

Epidemiology of Prehospital Care at the San Diego (USA) - Tijuana (Mexico) International Border Crossing.

Introduction: San Diego has one of the busiest international land border crossings in the world. The epidemiology of prehospital care at the San Diego (California, USA)-Tijuana (Baja California, Mexico) border crossings are previously unreported. Investigators sought to describe prehospital care provided at the San Diego border crossings. Methods: This was a cross-sectional, retrospective data collection from April 2014 to March 2017 evaluating prehospital provider (PHP) contacts at 2 international border crossing addresses in San Diego. The 9-1-1 dispatch center and first response were provided by a single municipal fire agency with ambulance transportation provided by a contracting private agency. Patient dispatch data and electronic patient care records were queried for patient demographics, PHP arrival time, incident complaint, assessment narrative, and treatments provided. Natural language processing techniques were applied to map the narrative to the National Library of Medicine's Unified Medical Language System. Descriptive analysis was performed in the R software program. Results: A total of 6,261 PHP patient contacts were made at the 2 border crossings during the study period. 87% of the calls were at the San Ysidro border crossing compared to 13% at Otay Mesa. The population, composed of 50.8% males, had ages ranging from 0 days-103 years old, with a median age of 45 years old. There were 606 (9.7%) pediatric patients (<18 years) and 1,416 (22.6%) geriatric patients (>65 years). The top 3 incident complaints were respiratory distress (830, 10.8%), blunt trauma (827, 10.7%), and abdominal pain (814, 10.6%); and, the top 3 medications provided were oxygen (481, 7.7%), normal saline (393, 6.3%), and ondansetron (352, 5.6%). Conclusion: This was the first study of PHP assessment and care at the San Diego-Tijuana border crossings. We found a large diversity in patient ages. Respiratory distress and blunt trauma were the most frequent complaints and oxygen was the most frequent medication. The busiest day of the week was Sunday, and the busiest month of the year was July. Our newly described findings may assist EMS agencies with optimizing staff, equipment, and training at international border crossings.

Osteopathic Cranial Manipulative Medicine and the Blood-Brain Barrier: A Mechanistic Approach to Alzheimer Prevention.

Recent studies have demonstrated that blood-brain barrier (BBB) dysfunction may be implicated in the pathogenesis of Alzheimer disease, thus establishing a link between disease manifestation and compromised neurovasculature. The authors identify relationships between Alzheimer disease and BBB breakdown, the response of the BBB to increased cerebral blood flow and shear stress, and the impact of osteopathic cranial manipulative medicine on cerebrovascular hemodynamics. They propose and review a rationale for future research to evaluate osteopathic cranial manipulative medicine as a preventive treatment for patients with illnesses of neurovascular origin.

Pertussis: The Identify, Isolate, Inform Tool Applied to a Re-emerging Respiratory Illness.

Pertussis, commonly referred to as "whooping cough," is a highly contagious acute respiratory infection that has exhibited cyclical outbreaks throughout the last century. Although vaccines have provided some immunity, many populations, including infants and pregnant women, remain at risk for serious illness. Through the use of the novel "Identify, Isolate, Inform" (3I) tool, emergency department (ED) providers can readily recognize key symptoms of the disease and risk factors for exposure, thus curbing its transmission through early initiation of antimicrobial therapy and post-exposure prophylaxis. The three classic stages of pertussis include an initial catarrhal stage, characterized by nonspecific upper respiratory infection symptoms, which may advance to the paroxysmal stage, revealing the distinctive "whooping cough." This cough can persist for weeks to months leading into the convalescent stage. Household contacts of patients with suspected pertussis or other asymptomatic, high-risk populations (infants, pregnant women in their third trimester, and childcare workers) may benefit from post-exposure prophylactic therapy. The Pertussis 3I tool can also alert healthcare professionals to the proper respiratory droplet precautions during contact with a symptomatic patient, as well as isolation practices until antimicrobial treatment is in progress. ED personnel should then inform local public health departments of any suspected cases. All of these actions will ultimately aid public health in controlling the incidence of pertussis cases, thus ensuring the protection of the general public from this re-emerging respiratory illness.

Percutaneous mitral valve repair: A new treatment for mitral regurgitation.

Mitral valve disease affects more than 4 million people in the United States. The gold standard of treatment in these patients is surgical repair or replacement of the valve with a prosthesis. The MitraClip (Abbott Vascular, Menlo Park, CA) is a new technology, which offers an alternative to open surgical repair or replacement via a minimally invasive route. We present an evidence-based clinical update that provides an overview of this technology as it relates to managing patients with significant mitral regurgitation. This review article is particularly useful to noninterventional cardiologists and interventional cardiologists who will be managing patients with this novel technology in increased volumes over the next decade but who do not perform this procedure.

Exploring prayer as a spiritual modality.

BACKGROUND: What does it mean to focus on the spiritual in occupational therapy? What interventions would qualify as spiritual modalities? This paper attempts to define the boundaries of what may be considered legitimate uses of spirituality in occupational therapy by using the example of prayer. PURPOSE: The purpose of this paper was to provide an in-depth analysis of the use of prayer in practice. METHOD: Medical and allied health journals were searched using the terms spirituality, spirit, religion, and prayer. Identified articles were synthesized to identify potential advantages and disadvantages of using prayer in therapy. FINDINGS: Prayer can be considered an appropriate occupational therapy intervention so long as four questions can be answered positively. IMPLICATIONS: To answer these questions, guidelines are provided that will lead the therapist through a decision making process to determine the appropriateness of incorporating prayer into any clinical situation.