Disparities in Prehospital Non-Traumatic Pain Management.

Introduction: While prior research has identified racial disparities in prehospital analgesia for traumatic pain, little is known about non-traumatic pain. Using a national prehospital dataset, we sought to evaluate for racial and ethnic disparities in analgesia given by EMS for non-traumatic pain.Methods: We analyzed the 2018 and 2019 data from the ESO Data Collaborative, a collection of de-identified prehospital electronic health records from nearly 1,300 participating EMS agencies in the US. We included all transported, adult, non-traumatic encounters with a primary or secondary impression of a pain complaint, and we stratified encounters based on race and ethnicity as recorded by the EMS clinicians. We performed a mixed model analysis, modeling EMS agency as a random intercept and adjusting for age, sex, pain location, level of service, location of incident, and highest pain score. With non-Hispanic White patients as the reference group, we then evaluated the association between race/ethnicity and receiving any pain medication (acetaminophen, non-steroidal anti-inflammatories, or opioids), receiving opioid pain medication, and receiving pain medication within 20 minutes of EMS arrival.Results: We included 1,035,486 patients; 67.5% non-Hispanic White, 26.8% Black, 4.9% Hispanic, 0.5% Asian, 0.1% Native Hawaiian or Other Pacific Islander, and 0.2% American Indian or Alaska Native patients. 4.7% of patients received pain medications. Compared to White patients (5.1%), Black patients were less likely to receive pain medication (3.3%, aOR 0.7; 95% CI 0.7-0.7) and Hispanics were more likely to receive pain medication (7.6%, aOR 1.5; 95% CI 1.4-1.6). Black patients were also less likely to receive opioids (1.8% for Black v 3.0% for White, aOR 0.7; 95% CI 0.6-0.7), while Hispanic patients were more likely to receive opioids (4.9%, aOR 1.4; 95% CI 1.3-1.5). The odds of receiving pain medication within 20 minutes was lower for Black patients (aOR 0.9; 95% CI 0.8-0.95) but no different for Hispanic patients (aOR 1.0; 95% CI 0.9-1.1), when compared to White patients.Conclusion: Pain medication administration is uncommon for non-traumatic pain complaints. While Black patients were less likely than White patients to receive pain medications and receive pain medication within 20 minutes, Hispanics were more likely to receive pain medications.

Racial/ethnic and gender disparities of the impact of the COVID-19 pandemic in out-of-hospital cardiac arrest (OHCA) in Texas.

INTRODUCTION: Prior research shows a greater disease burden, lower BCPR rates, and worse outcomes in Black and Hispanic patients after OHCA. Female OHCA patients have lower rates of BCPR compared to men and other survival outcomes vary. The influence of the COVID-19 pandemic on OHCA incidence and outcomes in different health disparity populations is unknown. METHODS: We used data from the Texas Cardiac Arrest Registry to Enhance Survival (CARES). We determined the association of both prehospital characteristics and survival outcomes with the pandemic period in each study group through Pearson's χ2 test or Fisher's exact tests. We created mixed multivariable logistic regression models to compare odds of cardiac arrest care and outcomes between 2019 and 2020 for the study groups. RESULTS: Black OHCA patients (aOR = 0.73; 95% CI: 0.65 - 0.82) had significantly lower odds of BCPR compared to White OHCA patients, were less likely to achieve ROSC (aOR = 0.86; 95% CI: 0.74 - 0.99) or have a good CPC score (aOR = 0.47; 95% CI: 0.29 - 0.75). Compared to White patients with OHCA, Hispanic persons were less likely to have a field TOR (aOR = 0.86; 95% CI: 0.75 - 0.99) or receive BCPR (aOR = 0.78; 95% CI: 0.69 - 0.87). Female OHCA patients had higher odds of surviving to hospital admission compared to males (aOR = 1.29; 95% CI: 1.15 - 1.44). CONCLUSION: Many OHCA outcomes worsened for Black and Hispanic patients. While some aspects of care worsened for women, their odds of survival improved compared to males.

The impact of COVID-19 on incidence and outcomes from out-of-hospital cardiac arrest (OHCA) in Texas.

INTRODUCTION: Emerging research demonstrates lower rates of bystander cardiopulmonary resuscitation (BCPR), public AED (PAD), worse outcomes, and higher incidence of OHCA during the COVID-19 pandemic. We aim to characterize the incidence of OHCA during the early pandemic period and the subsequent long-term period while describing changes in OHCA outcomes and survival. METHODS: We analyzed adult OHCAs in Texas from the Cardiac Arrest Registry to Enhance Survival (CARES) during March 11-December 31 of 2019 and 2020. We stratified cases into pre-COVID-19 and COVID-19 periods. Our prehospital outcomes were bystander cardiopulmonary resuscitation (BCPR), public AED use (PAD), sustained ROSC, and prehospital termination of resuscitation (TOR). Our hospital survival outcomes were survival to hospital admission, survival to hospital discharge, good neurological outcomes (CPC Score of 1 or 2) and Utstein bystander survival. We created a mixed effects logistic regression model analyzing the association between the pandemic on outcomes, using EMS agency as the random intercept. RESULTS: There were 3619 OHCAs (45.0% of overall study population) in 2019 compared to 4418 (55.0% of overall study population) in 2020. Rates of BCPR (46.2% in 2019 to 42.2% in 2020, P < 0.01) and PAD (13.0% to 7.3%, p < 0.01) decreased. Patient survival to hospital admission decreased from 27.2% in 2019 to 21.0% in 2020 (p < 0.01) and survival to hospital discharge decreased from 10.0% in 2019 to 7.4% in 2020 (p < 0.01). OHCA patients were less likely to receive PAD (aOR = 0.5, 95% CI [0.4, 0.8]) and the odds of field termination increased (aOR = 1.5, 95% CI [1.4, 1.7]). CONCLUSIONS: Our study adds state-wide evidence to the national phenomenon of long-term increased OHCA incidence during COVID-19, worsening rates of BCPR, PAD use and survival outcomes.

Quality Management of Prehospital Airway Programs: An NAEMSP Position Statement and Resource Document.

Prehospital airway management encompasses a multitude of complex decision-making processes, techniques, and interventions. Quality management (encompassing quality assurance and quality improvement activities) in EMS is dynamic, evidence-based, and most of all, patient-centric. Long a mainstay of the EMS clinician skillset, airway management deserves specific focus and attention and dedicated quality management processes to ensure the delivery of high-quality clinical care.It is the position of NAEMSP that:All EMS agencies should dedicate sufficient resources to patient-centric, comprehensive prehospital airway quality management program. These quality management programs should consist of prospective, concurrent, and retrospective activities. Quality management programs should be developed and operated with the close involvement of the medical director.Quality improvement and quality assurance efforts should operate in an educational, non-disciplinary, non-punitive, evidence-based medicine culture focused on patient safety. The highest quality of care is only achieved when the quality management program rewards those who identify and seek to prevent errors before they occur.Information evaluated in prehospital airway quality management programs should include both subjective and objective data elements with uniform reporting and operational definitions.EMS systems should regularly measure and report process, outcome, and balancing airway management measures.Quality management activities require large-scale bidirectional information sharing between EMS agencies and receiving facilities. Hospital outcome information should be shared with agencies and the involved EMS clinicians.Findings from quality management programs should be used to guide and develop initial education and continued training.Quality improvement programs must continually undergo evaluation and assessment to identify strengths and shortcomings with a focus on continuous improvement.

Community Variations in Out-of-Hospital Cardiac Arrest Care and Outcomes in Texas.

Background: Large and unacceptable variation exists in cardiac resuscitation care and outcomes across communities. Texas is the second most populous state in the US with wide variation in community and emergency response infrastructure. We utilized the Texas-CARES registry to perform the first Texas state analysis of out-of-hospital cardiac arrest (OHCA) in Texas, evaluating for variations in incidence, care, and outcomes.Methods: We analyzed the Texas-CARES registry, including all adult, non-traumatic OHCAs from 1/1/2014 through 12/31/2018. We analyzed the incidence and characteristics of OHCA care and outcome, overall and stratified by community. Utilizing mixed models accounting for clustering by community, we characterized variations in bystander CPR, bystander AED in public locations, and survival to hospital discharge across communities, adjusting for age, gender, race, location of arrest, and rate of witnessed arrest (bystander and 911 responder witnessed).Results: There were a total of 26,847 (5,369 per year) OHCAs from 13 communities; median 2,762 per community (IQR 444-2,767, min 136, max 9161). Texas care and outcome characteristics were: bystander CPR (43.3%), bystander AED use (9.1%), survival to discharge (9.1%), and survival with good neurological outcomes (4.0%). Bystander CPR rate ranged from 19.2% to 55.0%, and there were five communities above and five below the adjusted 95% confidence interval. Bystander AED use ranged from 0% to 19.5%, and there was one community below the adjusted 95% confidence interval. Survival to hospital discharge ranged from 6.7% to 14.0%, and there were three communities above and two below the adjusted 95% confidence interval.Conclusion: While overall OHCA care and outcomes were similar in Texas compared to national averages, bystander CPR, bystander AED use, and survival varied widely across communities in Texas. These variations signal opportunities to improve OHCA care and outcomes in Texas.

Community disparities in out of hospital cardiac arrest care and outcomes in Texas.

BACKGROUND: Large racial and socioeconomic inequalities exist for out-of-hospital cardiac arrest (OHCA) care and outcomes. We sought to characterize racial, ethnic, and socioeconomic disparities in OHCA care and outcomes in Texas. METHODS: We analyzed 2014-2018 Texas-Cardiac Arrest Registry to Enhance Survival (CARES) data. Using census tracts, we defined race/ethnicity neighborhoods based on majority race/ethnicity composition: non-Hispanic/Latino white, non-Hispanic/Latino black, and Hispanic/Latino. We also stratified neighborhoods into socioeconomic categories: above and below the median for household income, employment rate, and high school graduation. We defined outcomes as bystander CPR rates, public bystander AED use, and survival to hospital discharge. Using mixed models, we analyzed the associations between outcomes and neighborhood (1) racial/ethnic categories and (2) socioeconomic categories. RESULTS: We included data on 18,488 OHCAs. Relative to white neighborhoods, black neighborhoods had lower rates of AED use (OR 0.3, CI 0.2-0.4), and Hispanic/Latino neighborhoods had lower rates of bystander CPR (OR 0.7, CI 0.6-0.8), AED use (OR 0.4, CI 0.3-0.6), and survival (OR 0.8, CI 0.7-0.8). Lower income was associated with a lower rates of bystander CPR (OR 0.8, CI 0.7-0.8), AED use (OR 0.5, CI 0.4-0.8), and survival (OR 0.9, CI 0.9-0.98). Lower high school graduation was associated with a lower rate of bystander CPR (OR 0.8, CI 0.7-0.9) and AED use (OR 0.6, CI 0.4-0.9). Higher unemployment was associated with lower rates of bystander CPR (OR 0.9, CI 0.8-0.94) and AED use (OR 0.7, CI 0.5-0.99). CONCLUSION: Minority and poor neighborhoods in Texas experience large and unacceptable disparities in OHCA bystander response and outcomes.

Relationship Between Duration of Targeted Temperature Management, Ischemic Interval, and Good Functional Outcome From Out-of-Hospital Cardiac Arrest.

OBJECTIVES: Tailoring hypothermia duration to ischemia duration may improve outcome from out-of-hospital cardiac arrest. We investigated the association between the hypothermia/ischemia ratio and functional outcome in a secondary analysis of data from the Resuscitation Outcomes Consortium Amiodarone, Lidocaine, or Placebo Study trial. DESIGN: Cohort study of out-of-hospital cardiac arrest patients screened for Resuscitation Outcomes Consortium-Amiodarone, Lidocaine, or Placebo Study. SETTING: Multicenter study across North America. PATIENTS: Adult, nontraumatic, out-of-hospital cardiac arrest patients screened for Resuscitation Outcomes Consortium-Amiodarone, Lidocaine, or Placebo Study who survived to hospital admission and received targeted temperature management between May 2012 and October 2015. INTERVENTIONS: Targeted temperature management in comatose survivors of out-of-hospital cardiac arrest. We defined hypothermia/ischemia ratio as total targeted temperature management time (initiation through rewarming) divided by calculated total ischemia time (approximate time of arrest [9-1-1 call or emergency medical services-witnessed] to return of spontaneous circulation). MEASUREMENTS AND MAIN RESULTS: The primary outcome was hospital survival with good functional status (modified Rankin Score, 0-3) at hospital discharge. We fitted logistic regression models to estimate the association between hypothermia/ischemia ratio and the primary outcome, adjusting for demographics, arrest characteristics, and Resuscitation Outcomes Consortium enrolling site. A total of 3,429 patients were eligible for inclusion, of whom 36.2% were discharged with good functional outcome. Patients had a mean age of 62.0 years (SD, 15.8), with 69.7% male, and 58.0% receiving lay-rescuer cardiopulmonary resuscitation. Median time to return of spontaneous circulation was 21.1 minutes (interquartile range, 16.1-26.9), and median duration of targeted temperature management was 32.9 hours (interquartile range, 23.7-37.8). A total of 2,579 had complete data and were included in adjusted regression analyses. After adjustment for patient characteristics and Resuscitation Outcomes Consortium site, a greater hypothermia/ischemia ratio was associated with increased survival with good functional outcome (odds ratio, 2.01; 95% CI, 1.82-2.23). This relationship, however, appears to be primarily driven by time to return of spontaneous circulation in this patient cohort. CONCLUSIONS: Although a larger hypothermia/ischemia ratio was associated with good functional outcome after out-of-hospital cardiac arrest in this cohort, this association is primarily driven by duration of time to return of spontaneous circulation. Tailoring duration of targeted temperature management based on duration of time to return of spontaneous circulation or patient characteristics requires prospective study.

Time to Epinephrine Administration and Survival From Nonshockable Out-of-Hospital Cardiac Arrest Among Children and Adults.

BACKGROUND: Previous studies have demonstrated that earlier epinephrine administration is associated with improved survival from out-of-hospital cardiac arrest (OHCA) with shockable initial rhythms. However, the effect of epinephrine timing on patients with nonshockable initial rhythms is unclear. The objective of this study was to measure the association between time to epinephrine administration and survival in adults and children with emergency medical services (EMS)-treated OHCA with nonshockable initial rhythms. METHODS: We performed a secondary analysis of OHCAs prospectively identified by the Resuscitation Outcomes Consortium network from June 4, 2011, to June 30, 2015. We included patients of all ages with an EMS-treated OHCA and an initial nonshockable rhythm. We excluded those with return of spontaneous circulation in <10 minutes. We conducted a subgroup analysis involving patients <18 years of age. The primary exposure was time (minutes) from arrival of the first EMS agency to the first dose of epinephrine. Secondary exposure was time to epinephrine dichotomized as early (<10 minutes) or late (≥10 minutes). The primary outcome was survival to hospital discharge. We adjusted for Utstein covariates and Resuscitation Outcomes Consortium study site. RESULTS: From 55 568 EMS-treated OHCAs, 32 101 patients with initial nonshockable rhythms were included. There were 12 238 in the early group, 14 517 in the late group, and 5346 not treated with epinephrine. After adjusting for potential confounders, each minute from EMS arrival to epinephrine administration was associated with a 4% decrease in odds of survival for adults, odds ratio=0.96 (95% confidence interval, 0.95-0.98). A subgroup analysis (n=13 290) examining neurological outcomes showed a similar association (adjusted odds ratio, 0.94 per minute; 95% confidence interval, 0.89-0.98). When epinephrine was given late in comparison with early, odds of survival were 18% lower (odds ratio, 0.82; 95% confidence interval, 0.68-0.98). In a pediatric analysis (n=595), odds of survival were 9% lower (odds ratio, 0.91; 95% confidence interval, 0.81-1.01) for each minute delay in epinephrine. CONCLUSIONS: Among OHCAs with nonshockable initial rhythms, the majority of patients were administered epinephrine >10 minutes after EMS arrival. Each minute delay in epinephrine administration was associated with decreased survival and unfavorable neurological outcomes. EMS agencies should consider strategies to reduce epinephrine administration times in patients with initial nonshockable rhythms.

Unrecognized failed airway management using a supraglottic airway device.

BACKGROUND: 911 Emergency Medical Services (EMS) systems utilize supraglottic devices for either primary advanced airway management, or for airway rescue following failed attempts at direct laryngoscopy endotracheal intubation. There is, however, limited data on objective confirmation of supraglottic airway placement in the prehospital environment. Furthermore, the ability of EMS field providers to recognize a misplaced airway is unknown. METHODS: Retrospective review of patients who underwent airway management using the King LTS-D supraglottic airway in a large urban EMS system, between 3/1/15-9/30/2015. Subjective success was defined as documentation of successful airway placement by the EMS provider. Objective success was confirmed by review of waveform capnography, with the presence of a 4-phase waveform greater than 5mmHg. Sensitivity and specificity of the field provider's assessment of success were then calculated. RESULTS: A total of 344 supraglottic airway attempts were reviewed. No patients met obvious death criteria. 269 attempts (85.1%) met criteria for both subjective and objective success. 19 attempts (5.6%) were recognized failures by the EMS provider. 47 (13.8%) airways were misplaced but unrecognized by the EMS provider. 4 attempts (1.2%) were correctly placed but misidentified as failures, leading to the unnecessary removal and replacement of the airway. Sensitivity of the provider's assessment was 98.5%; specificity was 28.7%. CONCLUSION: The use of supraglottic airway devices results in unrecognized failed placement. Appropriate utilization and review of waveform capnography may remedy a potential blind-spot in patient safety, and systemic monitoring/feedback processes may therefore be used to prevent unrecognized misplaced airways.

Geriatric Trauma Patients With Cervical Spine Fractures due to Ground Level Fall: Five Years Experience in a Level One Trauma Center.

BACKGROUND: It has been found that significantly different clinical outcomes occur in trauma patients with different mechanisms of injury. Ground level falls (GLF) are usually considered "minor trauma" with less injury occurred in general. However, it is not uncommon that geriatric trauma patients sustain cervical spine (C-spine) fractures with other associated injuries due to GLF or less. The aim of this study is to determine the injury patterns and the roles of clinical risk factors in these geriatric trauma patients. METHODS: Data were reviewed from the institutional trauma registry of our local level 1 trauma center. All patients had sustained C-spine fracture(s). Basic clinical characteristics, the distribution of C-spine fracture(s), and mechanism of injury in geriatric patients (65 years or older) were compared with those less than 65 years old. Furthermore, different clinical variables including age, gender, Glasgow coma scale (GCS), blood alcohol level, and co-existing injuries were analyzed by multivariate logistic regression in geriatric trauma patients due to GLF and internally validated by random bootstrapping technique. RESULTS: From 2006 - 2010, a total of 12,805 trauma patients were included in trauma registry, of which 726 (5.67%) had sustained C-spine fracture(s). Among all C-spine fracture patients, 19.15% (139/726) were geriatric patients. Of these geriatric patients 27.34% (38/139) and 53.96% (75/139) had C1 and C2 fractures compared with 13.63% (80/587) and 21.98% (129/587) in young trauma patients (P < 0.001). Of geriatric trauma patients 13.67% (19/139) and 18.71% (26/139) had C6 and C7 fractures compared with 32.03% (188/587) and 41.40% (243/587) in younger ones separately (P < 0.001). Furthermore, 53.96% (75/139) geriatric patients had sustained C-spine fractures due to GLF with more upper C-spine fractures (C1 and C2). Only 3.2% of those had positive blood alcohol levels compared with 52.9% of younger patients (P < 0.001). In addition, 6.34% of geriatric patients due to GLF had intracranial pathology (ICP) which was one of the most common co-injuries with C-spine fractures. Logistic regression analysis showed the adjusted odds ratios of 1.17 (age) and 91.57 (male) in geriatric GLF patients to predict this co-injury pattern of C-spine fracture and ICP. CONCLUSION: Geriatric patients tend to sustain more upper C-spine fractures than non-geriatric patients regardless of the mechanisms. GLF or less not only can cause isolated C-spines fracture(s) but also lead to other significant injuries with ICP as the most common one in geriatric patients. Advanced age and male are two risk factors that can predict this co-injury pattern. In addition, it seems that alcohol plays no role in the cause of GLF in geriatric trauma patients.