Evolution of a Post-Overdose Outreach Program in King County, Washington: Lessons Learned Through Continuous Quality Improvement.

OBJECTIVES: Emergency Medical Services patients who survive overdose are at high risk for subsequent overdose and death. Programs that seek to link overdose survivors to harm reduction and treatment services are increasingly common, though they vary in design and measured effect. Public Health - Seattle & King County (PHSKC) used a continuous quality improvement (CQI) process to assess and improve a phone-based model for post-overdose outreach in King County, Washington. METHODS: King County Emergency Medical Services (KC-EMS) health records are queried weekly to identify suspected opioid overdose and other drug-related encounters. Patients treated by KC-EMS that met outreach eligibility criteria were contacted by phone and offered referrals to local services. Three Plan-Do-Study-Act (PDSA) cycles were sequentially implemented to iteratively assess program indicators and implement program adaptations. The PDSA cycles varied in terms of eligibility criteria, outreach modality, and level of resources devoted to phone number searches. Program indicators and corresponding costs were measured for each phase and calculated per month, per eligible patient, and per patient referred to services. RESULTS: During the initial call-based outreach pilot, the fewest number of patients met eligibility criteria (monthly average =39) and were referred to services (monthly average =2). In Phase Two, outreach shifted to automated texting and eligibility criteria expanded, resulting in an increase in the monthly average number of eligible patients (monthly average =137) and patients referred to services (monthly average =3). Phase Three adaptations expanded eligibility criteria further but limited outreach to patients with a phone number documented in their KC-EMS record, resulting in an average of 405 eligible patients per month and four patients that were referred to services. The costs per patient referred to services changed from $454 in Phase one to $589 in Phase Two to $279 in Phase Three. CONCLUSIONS: The PDSA process helped PHSKC's post-overdose outreach team identify adaptations to improve the efficiency of the post-overdose outreach program. The number of people referred to services was modest, reflecting the challenges of post-incident phone-based outreach. Our experience highlights the value of incorporating CQI processes in ongoing program operations and the need for a multi-pronged overdose prevention strategy.

Pediatric Out-of-Hospital Cardiac Arrest: The Role of the Telecommunicator in Recognition of Cardiac Arrest and Delivery of Bystander Cardiopulmonary Resuscitation.

BACKGROUND: Telecommunicator CPR (T-CPR), whereby emergency dispatch facilitates cardiac arrest recognition and coaches CPR over the telephone, is an important strategy to increase early recognition and bystander CPR in adult out-of-hospital cardiac arrest (OHCA). Little is known about this treatment strategy in the pediatric population. We investigated the role of T-CPR and related performance among pediatric OHCA. METHODS AND RESULTS: This study was a retrospective cohort investigation of OHCA among individuals <18 years in King County, Washington, from April 1, 2013, to December 31, 2019. We reviewed the 911 audio recordings to determine if and how bystander CPR was delivered (unassisted or T-CPR), key time intervals in recognition of arrest, and key components of T-CPR delivery. Of the 185 eligible pediatric OHCAs, 23% (n=43) had bystander CPR initiated unassisted, 59% (n=109) required T-CPR, and 18% (n=33) did not receive CPR before emergency medical services arrival. Among all cases, cardiac arrest was recognized by the telecommunicator in 89% (n=165). Among those receiving T-CPR, the median (interquartile range) interval from start of call to OHCA recognition was 59 seconds (38-87) and first CPR intervention was 115 seconds (94-162). When stratified by age (≤8 versus >8), the older age group was less likely to receive CPR before emergency medical services arrival (88% versus 69%, P=0.002). For those receiving T-CPR, bystanders spent a median of 207 seconds (133-270) performing CPR. The median compression rate was 93 per minute (82-107) among those receiving T-CPR. CONCLUSIONS: T-CPR is an important strategy to increase early recognition and early CPR among pediatric OHCA.

Academic and Attendance Outcomes after Participation in a School Breakfast Program.

BACKGROUND: Little is known about how school breakfast programs are associated with school attendance and academic performance. This study evaluated Dallas Independent School District's (DISD) breakfast after the bell (BATB) program that provides breakfast for both habitually tardy and non-tardy students on (1) academic performance and (2) student attendance over 2 school years. METHODS: A pre-post study design evaluated the impact of the BATB program in elementary/middle/high schools on student attendance and academic outcomes. Paired t-tests evaluated changes in outcomes between 2017 to 2018 and 2018 to 2019 school years. RESULTS: The analytical sample consisted of 30,493 students (70.32% BATB participants, 50.47% male, 68.78% Hispanic). BATB participants were over 2.5 times more likely to attend school versus non-BATB participants (aOR = 2.55; 95% confidence interval [CI]: 2.23-2.92; p < .001). Compared to pre-participation (2017-2018), unadjusted models showed 2018 to 2019 BATB participants' mean reading scores increased from 1502.72 to 1545.76 during the 2018 to 2019 academic year (p < .001). There were no significant changes in reading and math scores over the 2-year implementation after adjustment. CONCLUSIONS: Results here showed that a school breakfast program that is housed in a large public school system that serves predominantly low resource, ethnically diverse students is associated with increased student attendance.

Analysis of Epinephrine Dose, Targeted Temperature Management, and Neurologic and Survival Outcomes Among Adults With Out-of-Hospital Cardiac Arrest.

Importance: Epinephrine improves return of spontaneous circulation after out-of-hospital cardiac arrest (OHCA). These beneficial cardiac effects do not directly translate to better neurologic outcomes, possibly because of epinephrine-induced microvascular effects that produce critical brain ischemia. Objective: To examine whether targeted temperature management (TTM) modifies the adverse association between increasing prehospital epinephrine dose and neurologically favorable survival. Design, Setting, and Participants: This retrospective cohort study assessed 14 612 adults from Seattle and King County, Washington, with nontraumatic OHCA between January 1, 2008, and December 31, 2018, and included those who achieved return of spontaneous circulation and were unconscious at hospital admission. Data analysis was performed from April 2021 to May 2022. Exposures: Epinephrine dose and TTM during prehospital resuscitation. Main Outcomes and Measures: Favorable neurologic survival (Cerebral Performance Category [CPC] 1 or 2) and survival to hospital discharge. Results: Of the 14 612 assessed adults, 5253 (median age, 63 years; IQR, 51-74 years; 3460 [65.8%] male) were eligible for the study. The median epinephrine dose was 2.0 mg (IQR, 1.0-3.0 mg); 3052 patients (58.1%) received TTM. In all, 1889 patients (36.0%) survived with CPC 1 to 2, and 2177 (41.4%) survived to discharge. Increasing doses of epinephrine were associated with a decreasing likelihood of CPC 1 to 2 (odds ratio [OR], 0.46; 95% CI 0.42-0.50 for each additional milligram of epinephrine) and survival (OR, 0.47; 95% CI, 0.43-0.51). The dose-dependent epinephrine association was modified by TTM. After adjusting for Utstein covariates, TTM was associated with a relative stepwise improvement in odds of CPC 1 to 2 (interaction OR, 1.36; 95% CI, 1.22-1.51) and survival (interaction OR, 1.37; 95% CI, 1.24-1.51). A significant interaction was also observed when the analysis was stratified according to initial rhythm among shockable OHCA and nonshockable OHCA (shockable interaction OR, 1.20; 95% CI, 1.04-1.39; and nonshockable interaction OR, 1.24, 95% CI, 1.07-1.45). Conclusions and Relevance: This cohort study found an interaction between TTM and epinephrine dose such that the beneficial association of TTM increased with increasing epinephrine dose, suggesting that TTM may attenuate the adverse effects of higher-dose epinephrine.

Validation of the detection of elder abuse through emergency care technicians (DETECT) screening tool: a study protocol.

INTRODUCTION: Elder mistreatment (EM) is a high prevalence threat to the health and well-being of older adults in the USA. Medics are well-positioned to help with identification of older adults at risk for EM, however, field robust screening tools appropriate for efficient, observation-based screening are lacking. Prior work by this team focused on the development and initial pilot testing of an observation-based EM screening tool named detection of elder abuse through emergency care technicians (DETECT), designed to be implemented by medics during the course of an emergency response (911) call. The objective of the present work is to validate and further refine this tool in preparation for clinical dissemination. METHODS AND ANALYSIS: Approximately 59 400 community-dwelling older adults who place 911 calls during the 36-month study observation period will be screened by medics responding to the call using the DETECT tool. Next, a random subsample of 2520 of the 59 400 older adults screened will be selected to participate in a follow-up interview approximately 2 weeks following the completion of the screening. Follow-up interviews will consist of a medic-led semistructured interview designed to assess the older adult's likelihood of abuse exposure, physical/mental health status, cognitive functioning, and to systematically evaluate the quality and condition of their physical and social living environment. The data from 25% (n=648) of these follow-up interviews will be presented to a longitudinal, experts and all data panel for a final determination of EM exposure status, representing the closest proxy to a 'gold standard' measure available. ETHICS AND DISSEMINATION: This study has been reviewed and approved by the Committee for the Protection of Human Subjects at the University of Texas School of Public Health. The results will be disseminated through formal presentations at local, national and international conferences and through publication in peer-reviewed scientific journals.

Evaluation of the Detection of Elder Mistreatment Through Emergency Care Technicians Project Screening Tool.

Importance: Elder mistreatment is underdetected and underreported. The more than 800 000 medics providing services in every county in the United States represent an important and underused surveillance system. Objective: To investigate the association between the Detection of Elder Mistreatment Through Emergency Care Technician (DETECT) screening tool use and the number of medic reports made to Adult Protective Services (APS) over a period of approximately 3 years. Design, Setting, and Participants: This quality improvement study used a difference in difference in differences design and included adults aged 65 years and older who were reported to Texas APS in the study region (246 cities in Denton, Johnson, and Tarrant Counties) between December 31, 2014, and February 28, 2018. Exposures: The DETECT screening tool. Main Outcomes and Measures: Reports to APS. Results: The mean (SD) age of the 11 178 older adults included in this study was 76 (8) years (range, 65-105 years); there was no reported data on patient sex. A total of 18 080 reports of elder mistreatment were recorded. Medics within the study region reported more cases of elder mistreatment during the implementation of the screening tool (relative risk [RR], 4.14; 95% CI, 3.25-5.27). After adjusting for changes in the number of elder mistreatment reports in the comparison groups (ie, underlying changes in reporting trends), the number of reports to APS increased (RR, 3.03; 95% CI, 2.06-4.46). The occurrence of elder mistreatment was validated in 83% (95% CI, 75%-91%) of the reports investigated by APS during the periods when medics did not have access to the screening tool compared with 82% (95% CI, 77%-87%) during the periods when medics had access to the screening tool, indicating that there were no differences in the proportion of reports that resulted in a validated APS investigation. Conclusions and Relevance: The findings suggest that incorporating the DETECT screening tool into the routine practices of medics is associated with substantial increases in the frequency with which clinicians report potential cases of elder mistreatment to APS.