Mobile Integrated Health Care Roles of US EMS Clinicians: A Descriptive Cross-Sectional Study.

OBJECTIVE: Mobile integrated health care (MIH) leverages emergency medical services (EMS) clinicians to perform local health care functions. Little is known about the individual EMS clinicians working in this role. We sought to describe the prevalence, demographics, and training of EMS clinicians providing MIH in the United States (US). METHODS: This is a cross-sectional study of US-based, nationally certified civilian EMS clinicians who completed the National Registry of Emergency Medical Technicians (NREMT) recertification application during the 2021-2022 cycle and completed the voluntary workforce survey. Workforce survey respondents self-identified their job roles within EMS, including MIH. If an MIH role was selected, additional questions clarified the primary role in EMS, type of MIH provided, and hours of MIH training received. We merged the workforce survey responses with the individual's NREMT recertification demographic profile. The prevalence of EMS clinicians with MIH roles and data on demographics, clinical care provided, and MIH training were calculated using descriptive statistics, including proportions with associated binomial 95% confidence intervals (CI). RESULTS: Of 38,960 survey responses, 33,335 met inclusion criteria and 490 (1.5%; 95%CI 1.3-1.6%) EMS clinicians indicated MIH roles. Of these, 62.0% (95%CI 57.7-66.3%) provided MIH as their primary EMS role. EMS clinicians with MIH roles were present in all 50 states and certification levels included emergency medical technician (EMT) (42.8%; 95%CI 38.5-47.2%), advanced emergency medical technician (AEMT) (3.5%; 95%CI 1.9-5.1%), and paramedic (53.7%; 95%CI 49.3-58.1%). Over one-third (38.6%; 95%CI 34.3-42.9%) of EMS clinicians with MIH roles received bachelor's degrees or above, and 48.4% (95%CI 43.9%-52.8%) had been in their MIH roles for less than 3 years. Nearly half (45.6%; 95%CI 39.8-51.6%) of all EMS clinicians with primary MIH roles received less than 50 hours (h) of MIH training; only one-third (30.0%; 95%CI 24.7-35.6%) received more than 100 h of training. CONCLUSION: Few nationally certified US EMS clinicians perform MIH roles. Only half of MIH roles were performed by paramedics; EMT and AEMT clinicians performed a substantial proportion of MIH roles. The observed variability in certification and training suggest heterogeneity in preparation and performance of MIH roles among US EMS clinicians.

Emergency Medical Services and Public Health Perspectives on Alternative Emergency Response Models.

CONTEXT: New approaches to emergency response are a national focus due to evolving needs and growing demands on the system, but perspectives of first responders and potential partners have not been evaluated. OBJECTIVE: This project aimed to inform the development and implementation of alternative emergency response models, including interdisciplinary partnerships, by identifying the perspectives of the frontline workforce regarding their evolving roles. DESIGN: An electronic survey was sent, querying respondents about their perceived roles in emergency response, interdisciplinary partnerships, and resources needed. SETTING: This study took place in a metropolitan, midwestern county with participants from 2 public health agencies and 1 emergency medical services (EMS) agency. PARTICIPANTS: The survey was completed by 945 EMS clinicians and 58 public health workers. MAIN OUTCOME MEASURES: The main outcome measures were agreement levels on each group's roles in prevention, response, and recovery after emergencies, as well as general feedback on new models. RESULTS: Overall, 97% of EMS clinicians and 42% of public health workers agreed that they have a role in immediate response to 9-1-1 emergencies. In mental health emergencies, 87% of EMS clinicians and 52% of public health workers agreed that they have a role, compared to 87% and 30%, respectively, in violent emergencies. Also, 84% of respondents felt multidisciplinary models are a needed change. However, 35% of respondents felt their agency has the resources necessary for changes. CONCLUSIONS: We observed differences between EMS clinicians and public health workers in their perceived roles during emergency response and beliefs about the types of emergencies within their scope. There is strong support for alternative approaches and a perception that this model may improve personal well-being and job satisfaction, but a need for additional resources to develop and implement.

Fifteen Years' Experience With Safe and Effective Procedural Sedation in Infants and Children in a General Emergency Department.

OBJECTIVE: To evaluate procedural sedation (PS) in infants/children, performed by emergency physicians in a general (nonpediatric) emergency department (ED). METHODS: Procedural sedation prospectively recorded on a standardized form over 15 years. Demographics, sedatives, and analgesia associations with adverse events were explored with logistic regressions. RESULTS: Of 3274 consecutive PS, 1177 were pediatric: 2 months to 21 years, mean age (±SD) 8.7 ± 5.2 years, 63% boys, 717 White, 435 Black, 25 other. Eight hundred and seventy were American Society of Anesthesiology (ASA) 1, 256 ASA 2, 39 ASA 3, 11 ASA 4, 1 ASA 5. Procedural sedation indications are as follows: fracture reduction (n = 649), dislocation reduction (n = 114), suturing/wound care (n = 244), lumbar puncture (n = 49), incision and drainage (n = 37), foreign body removal (n = 28), other (n = 56). Sedatives were ketamine (n = 762), propofol ( = 354), benzodiazepines (n = 157), etomidate (n = 39), barbiturates (n = 39). There were 47.4% that received an intravenous opioid. Success rate was 100%. Side effects included nausea/vomiting, itching/rash, emergence reaction, myoclonus, paradoxical reaction, cough, hiccups. Complications were oxygen desaturation less than 90%, bradypnea respiratory rate less than 8, apnea, tachypnea, hypotension, hypertension, bradycardia, tachycardia. Normal range of vital signs was age-dependent. Seventy-four PS (6.3%) resulted in a side effect and 8 PS (3.2%) a complication. No one died, required hospital admission, intubation, or any invasive procedure. CONCLUSIONS: Adverse events in infants/children undergoing PS in a general ED are low and comparable to a pediatric ED at a children's hospital. Pediatric PS can be done safely and effectively in a general ED by nonpediatric EM physicians for a wide array of procedures.

Clinical duties and compensation for U.S. emergency medicine fellows at academic centers: A descriptive, cross-sectional survey.

Objective: Fellowship training is increasingly popular among residency graduates and critical to the advancement of academic emergency medicine (EM). Little is known about the clinical hours worked and financial compensation received by fellows during training. We sought to describe the clinical duties and financial compensation of EM fellows at U.S. academic centers. Methods: This cross-sectional study surveyed U.S. academic EM department administrators who were members of the Society for Academic Emergency Medicine's Academy of Administrators in Academic Emergency Medicine (AAAEM) regarding their fellowship programs and fellows. We electronically distributed the validated survey instrument to 73 member sites between October 2022 and January 2023. Survey domains included fellow and fellowship demographics, base and total annual clinical hours, and base and total annual compensation. We calculated descriptive statistics and compared fellows by accreditation (Accreditation Council for Graduate Medical Education [ACGME] or non-ACGME) using chi-square and Wilcoxon rank-sum testing. We conducted a secondary analysis of base and total salary by gender and accreditation using Wilcoxon rank-sum testing. Results: We received 38 institutional responses (response rate 52%), which represented 217 individual fellows. Nearly three-fourths (n = 158, 72.8%) of fellows enrolled in non-ACGME fellowships, worked 33% more base hours annually than ACGME fellows (median 571 h vs. 768 h, p < 0.001), and received base compensation 20% higher than ACGME fellows ($88,540 vs. $70,777, p < 0.001). Accounting for additional compensation, the median total annual compensation for non-ACGME fellows remained 11% higher than ACGME fellows ($105,000 vs. $93,853, p = 0.004). We observed no significant differences salary when stratified by gender. Conclusions: Most EM fellows at U.S. academic institutions enrolled in non-ACGME fellowships with significantly higher base hours and financial compensation than ACGME fellowships. These results represent the first description of the clinical hours and financial compensation of academic EM fellows and should be considered in ongoing benchmarking efforts by AAAEM.

Layperson-Administered Naloxone Trends Reported in Emergency Medical Service Activations, 2020-2022.

Importance: Layperson-administered naloxone (LAN) is a powerful but incompletely characterized intervention to prevent opioid-related overdose mortality. LAN trends are relevant to policy and strategic planning in naloxone distribution initiatives. Objective: To assess the 2-year LAN trend for persons in the United States receiving naloxone during emergency medical services (EMS) activations. Design, Setting, and Participants: This retrospective cross-sectional study was conducted in the United States from June 2020 to June 2022 among 65 621 195 EMS activations from 911 responses, EMS standbys, or when EMS crews functioned in an ambulance intercept role or during mutual aid to another ambulance response. Activations within health care settings and interfacility or medical transports were excluded. Data are from the National Emergency Medical Services Information System (NEMSIS), the national EMS patient care record database. From June 2020 to June 2022, NEMSIS included more than 96 million EMS activations from nearly 14 000 agencies across 54 states and territories. Exposures: EMS clinician-reported LAN. Main Outcome and Measures: The primary outcome was the trend of receiving LAN, measured by EMS clinician documentation. Results: From June 2020 to June 2022, EMS reported 744 078 patients receiving naloxone, with 24 990 (3.4%) involving LAN. Patients were predominantly male (17 331 [69.4%]) and had a median (IQR) age of 42 (31-56) years, with the majority treated in urban homes or residences (21 692 [86.8%] urban; 13 223 [52.9%] in-home or residence). Of the total naloxone recipients, 243 985 patients (32.8%) had suspected drug overdose documentation as either the primary or secondary impression. Overall, the percentage change in naloxone administration rates decreased 6.1% over the study period (from 1140.1 [95% CI, 1135.1-1145.1] per 100 000 EMS activations to 1070.1 [95% CI, 1064.9-1075.3] per 100 000 EMS activations), while the percentage change of persons receiving LAN increased 43.5% (from 30.0 [95% CI, 29.2-30.8] per 100 000 EMS activations to 43.1 [95% CI, 42.0-44.1] per 100 000 EMS activations). Conclusions and Relevance: In this cross-sectional study, the LAN rate increased from June 2020 to June 2022 as reported in the national EMS database. These findings help inform policies and practices aimed at mitigating the devastating impacts of the opioid epidemic and saving lives. Novel public health strategies are needed to measure the effects of this intervention nationally, evaluate approaches to expand naloxone distribution, and address naloxone usage barriers.

RREACT: A mobile multidisciplinary response to overdose.

Opioid overdose is a leading cause of death in the United States, and engaging with patients following overdose to provide harm reduction and recovery resources can prove difficult. Quick response models use mobile, multidisciplinary teams to establish a time-sensitive connection between individuals who overdosed and harm reduction and recovery resources that improve outcomes. These quick response models are consistent with the broader field of mobile-integrated health programs that are growing in number and acceptability, though the literature base is sparse and programs vary. We describe the 5-year reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework of the Rapid Response Emergency Addiction and Crisis Team (RREACT), a fire/emergency medical services-led, multidisciplinary (firefighter/paramedic, law enforcement officer, social worker) mobile outreach team. RREACT provides harm reduction, linkage/transportation to care and wrap-around services to individuals following a nonfatal opioid overdose that resulted in an emergency response in Columbus, Franklin County, Ohio, United States. Between 2018 and 2022, RREACT made 22,157 outreach attempts to 11,739 unique patients. RREACT recorded 3,194 direct patient contacts during this time, resulting in 1,200 linkages to care: 799 direct transports to opioid use disorder treatment and 401 warm handoffs to community treatment agencies. Furthermore, RREACT's staffing increased from 4 full-time equivalent staff in 2018 to 15.5 in 2022 and was supported by the surrounding community through 287 community outreach events and the development of an alumni program. These preliminary results further support the deployment of multidisciplinary mobile outreach teams to increase access to harm reduction and recovery resources following opioid overdose.

Longitudinal Changes in Emergency Medical Services Advanced Airway Management.

Importance: Identifying longitudinal changes in advanced airway management by emergency medical services (EMS) is crucial for understanding practice patterns and optimizing care. Objective: To examine the longitudinal trends in endotracheal intubation (ETI) and supraglottic airway (SGA) utilization in a national EMS cohort. Design, Setting, and Participants: This retrospective cross-sectional study analyzed 2011 to 2022 data from the ESO Data Collaborative, a national database of US prehospital electronic health records. The study included all 911 EMS events in which advanced airway management was attempted. Data were analyzed from November 2022 to January 2024. Exposures: Advanced airway management attempts, including ETI, SGA, and surgical airways. Main Outcomes and Measures: The annual percentage of ETI and SGA attempts, stratified by underlying condition (cardiac arrest, nonarrest medical, nonarrest trauma, pediatrics). Results: Among 47.5 million EMS activations, 444 041 (mean [SD] age, 60.6 [19.8] years; 273 296 [61.5%] men) involved advanced airway management, including 305 584 (68.8%) that used ETI and 200 437 (45.1%) that used SGA. The overall incidence was 9.3 per 1000 EMS events. In the cardiac arrest cohort from 2011 to 2022, EMS events with ETI attempts decreased from 2470 of 2831 (87.3%) to 40 083 of 72 793 (55.1%) and those with SGA attempts increased from 711 of 2831 (25.1%) to 44 386 of 72 793 (61.0%). In the pediatric subset, there were similarly large decreases in ETI attempts, from 117 of 182 EMS events (97.3%) to 1573 of 2307 EMS events (68.2%), and increases in SGA attempts, from 11 of 182 EMS events (6.6%) to 1058 of 2307 EMS events (45.9%). In the nonarrest medical and nonarrest trauma cohorts, ETI attempts decreased and SGA attempts increased but to a much lower extent. Conclusions and Relevance: In this national cross-sectional study of EMS care episodes, there were marked shifts in advanced airway management practices, with the increased use of SGA and decreased use of ETI. These observations highlight current trends in EMS airway management practices.

Pediatric emergency department use by Afghan refugees at a temporary housing facility.

Objectives: In August 2021, "Operation Allies Welcome" evacuated 76,000 Afghan refugees to 8 US temporary housing facilities. The impact of refugee influx on local emergency department (ED) use and the resources needed during resettlement are poorly described. We report the frequency of pediatric ED visits and characterize the ED resources needed by pediatric Afghan refugees from 1 temporary housing facility. Methods: This single-center, retrospective cohort study identified participants via a refugee identifier in the medical record. The primary outcome was the frequency and timing of pediatric ED visits; secondary outcomes included resources used during ED evaluation and management. Trained reviewers collected data using a predefined instrument and descriptive statistics are reported. Results: This study included 175 pediatric ED visits by Afghan refugees. The highest volumes (n = 73, 42%) occurred 3-5 weeks after evacuation. Common presenting complaints included fever (36%), gastrointestinal (15%), and respiratory (13%). Resources used included radiography (64%), lab testing (63%), and medication (78%). Specialist consultation occurred in 43% of visits; infectious diseases (17%) and neurology (15%) were the most common. Discharge (61%) was more common than admission (39%), though 31% of discharged patients had a repeat ED visit. Only 51% attended a recommended follow-up appointment. Conclusion: In this study, most pediatric ED visits by refugees occurred within 5 weeks of arrival. Most patients were discharged after diagnostic testing, medication, and specialist consultation, but repeat ED visits were common. These patterns have important implications in preparing for future mass displacement events.

Addition of community paramedics to a physician home-visit program: A prospective cohort study.

BACKGROUND: Home-based primary care promotes aging in place but is not immediately responsive to urgent needs. Community paramedicine leverages emergency medical services clinicians to expedite in-home care, though limited evidence supports this model. We evaluated the primary care and acute care use of older adults evaluated urgently by a community paramedic with telemedicine physician compared to a physician home visit model. METHODS: This prospective cohort study enrolled older adults in home-based primary care who requested an urgent evaluation. We allocated participants to the physician home visit model or physician home visit plus community paramedic model by ZIP code. We observed primary care and acute care use for 6 months following enrollment. The primary outcome was the median number of primary care and acute care visits per participant. Secondary outcomes included 30-day readmission rates, median wait times, and physician productivity. Data analysis included descriptive statistics, comparison of means and proportions, and negative binomial regression modeling reported as incidence rate ratios (IRR). RESULTS: We screened 255 participants, determined 203 eligible, allocated 199, and completed observation for 167 (84 community paramedicine, 83 physician home visit). Participants were mostly female, age 76-86 years, with 3-5 comorbidities, living in a home/apartment. Community paramedic participants had 29% more primary care visits (IRR 1.29, 95% confidence interval [CI] 1.06-1.57) and shorter wait times for urgent evaluations (1 vs. 5 days, p < 0.001) without increasing acute care use (IRR 0.75, 95% CI 0.48-1.18) or 30-day readmissions (IRR 1.32, 95% CI 0.49-3.55). Physician productivity increased 81% (40 vs. 22 visits/week, p < 0.001). CONCLUSION: Older adults evaluated by a community paramedic for urgent needs were seen sooner, used acute care similarly to patients evaluated by a physician home visit, and nearly doubled physician efficiency. This suggests that older adults may benefit from combining emergency medical services and primary care resources for urgent evaluations.

Fallacy of Median Door-to-ECG Time: Hidden Opportunities for STEMI Screening Improvement.

Background ST-segment elevation myocardial infarction (STEMI) guidelines recommend screening arriving emergency department (ED) patients for an early ECG in those with symptoms concerning for myocardial ischemia. Process measures target median door-to-ECG (D2E) time of 10 minutes. Methods and Results This 3-year descriptive retrospective cohort study, including 676 ED-diagnosed patients with STEMI from 10 geographically diverse facilities across the United States, examines an alternative approach to quantifying performance: proportion of patients meeting the goal of D2E≤10 minutes. We also identified characteristics associated with D2E>10 minutes and estimated the proportion of patients with screening ECG occurring during intake, triage, and main ED care periods. We found overall median D2E was 7 minutes (IQR:4-16; range: 0-1407 minutes; range of ED medians: 5-11 minutes). Proportion of patients with D2E>10 minutes was 37.9% (ED range: 21.5%-57.1%). Patients with D2E>10 minutes, compared to those with D2E≤10 minutes, were more likely female (32.8% versus 22.6%, P=0.005), Black (23.4% versus 12.4%, P=0.005), non-English speaking (24.6% versus 19.5%, P=0.032), diabetic (40.2% versus 30.2%, P=0.010), and less frequently reported chest pain (63.3% versus 87.4%, P<0.001). ECGs were performed during ED intake in 62.1% of visits, ED triage in 25.3%, and main ED care in 12.6%. Conclusions Examining D2E>10 minutes can identify opportunities to improve care for more ED patients with STEMI. Our findings suggest sex, race, language, and diabetes are associated with STEMI diagnostic delays. Moving the acquisition of ECGs completed during triage to intake could achieve the D2E≤10 minutes goal for 87.4% of ED patients with STEMI. Sophisticated screening, accounting for differential risk and diversity in STEMI presentations, may further improve timely detection.