Racial, Ethnic, and Socioeconomic Disparities in Out-of-Hospital Pain Management for Patients With Long Bone Fractures.

STUDY OBJECTIVE: To evaluate racial and ethnic disparities in out-of-hospital analgesic administration, accounting for the influence of clinical characteristics and community socioeconomic vulnerability, among a national cohort of patients with long bone fractures. METHODS: Using the 2019-2020 ESO Data Collaborative, we retrospectively analyzed emergency medical services (EMS) records for 9-1-1 advanced life support transport of adult patients diagnosed with long bone fractures at the emergency department. We calculated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for out-of-hospital analgesic administration by race and ethnicity, accounting for age, sex, insurance, fracture location, transport time, pain severity, and scene Social Vulnerability Index. We reviewed a random sample of EMS narratives without analgesic administration to identify whether other clinical factors or patient preferences could explain differences in analgesic administration by race and ethnicity. RESULTS: Among 35,711 patients transported by 400 EMS agencies, 81% were White, non-Hispanic, 10% were Black, non-Hispanic, and 7% were Hispanic. In crude analyses, Black, non-Hispanic patients with severe pain were less likely to receive analgesics compared with White, non-Hispanic patients (59% versus 72%; Risk Difference: -12.5%, 95% CI: -15.8% to -9.9%). After adjustment, Black, non-Hispanic patients remained less likely to receive analgesics compared with White, non-Hispanic patients (aOR:0.65, 95% CI:0.53 to 0.79). Narrative review identified similar rates of patients declining analgesics offered by EMS and analgesic contraindications across racial and ethnic groups. CONCLUSIONS: Among EMS patients with long bone fractures, Black, non-Hispanic patients were substantially less likely to receive out-of-hospital analgesics compared with White, non-Hispanic patients. These disparities were not explained by differences in clinical presentations, patient preferences, or community socioeconomic conditions.

Prehospital Sepsis Recognition and Outcomes for Patients with Sepsis by Race and Ethnicity.

BACKGROUND: First medical contact for patients with sepsis often initiates in the prehospital setting, yet limited studies have explored the EMS sepsis recognition-mortality relationship. Racial and ethnic minority patients often have worse sepsis outcomes, yet the role of prehospital recognition in this inequity has not been explored. Our objective was to describe prehospital sepsis recognition and hospital mortality, with analysis by patient race and ethnicity. METHODS: Using linked EMS and hospital records from the 2021 ESO Data Collaborative, we retrospectively analyzed 9-1-1 EMS transports for adult patients with emergency department ICD-10 sepsis diagnosis codes. EMS sepsis recognition was defined as a primary or secondary sepsis impression, use of an electronic health record specialty sepsis form, or a prehospital sepsis alert. We used multivariable logistic regression to assess the association between EMS sepsis recognition and hospital mortality, adjusting for age, sex, race and ethnicity, scene socioeconomic status, and documented clinical characteristics: altered mental status, hypotension, tachypnea, tachycardia, fever. We conducted a secondary analysis of patients who were positive for the quick sequential organ failure assessment (qSOFA) using first prehospital vital signs. RESULTS: We analyzed 20,172 records for EMS-transported patients with diagnosed sepsis. Overall, 8% of patients were Black, 8% were Hispanic, and 72% were White. Prehospital sepsis recognition was 18%. Prehospital sepsis recognition was similar across racial and ethnic groups (Black: 17.2%, Hispanic: 17.4%, White: 18.1%) and adjusted odds of sepsis recognition did not differ between racial and ethnic groups. Overall mortality was 11% (2,186). Prehospital sepsis recognition was associated with a 18% reduction in adjusted odds of mortality (OR: 0.82, 95% CI: 0.70-0.94). Of patients who were qSOFA positive in the field (n = 2,168), EMS sepsis recognition was 32% and was similar across race and ethnicities. Adjusted odds of mortality were 0.68 (95% CI: 0.53-0.88) when sepsis was recognized in the prehospital setting. CONCLUSION: EMS identified sepsis in fewer than one in three patients even after limiting to those positive for qSOFA, without differences by race and ethnicity. EMS sepsis recognition was associated with reduced odds of mortality; however, Black patients remained at greater odds of death suggesting additional factors that warrant investigation.

Predictors of Non-Transport for Older Adult EMS Patients Encountered for Falls.

BACKGROUND: Emergency medical services (EMS) encounters for falls among older adults have been linked to poor outcomes when the patient is not transported by EMS to a hospital. However, little is known regarding characteristics of this patient population. Our primary objective was to describe characteristics associated with non-transport among older adult EMS patients encountered for falls. METHODS: We performed a national retrospective cross-sectional study of 9-1-1 patient contacts from the 2019 ESO Data Collaborative. We included patients who had 9-1-1 encounters for ground-level falls and were aged 60 years or older. Patients residing in congregate living facilities, interfacility transports, cardiac arrests, and suspected drowning patients were excluded. Potential predictors of non-transport included patient demographics, initial vital signs, who requested 9-1-1 service, incident location, alcohol/substance use, and urbanicity. We used multivariable logistic regression to determine associations between non-transport and potential predictors. RESULTS: We identified 195,204 EMS encounters for older adults who fell in 2019, including 27,563 (14.1%) non-transports. Most patients were female (62.4%), non-Hispanic White (85.4%), and fell at a home or residence (80.4%). Greater odds of non-transport were identified among males (OR 1.37, 95% CI 1.32-1.42) and Hispanic/Latino patients (OR 1.24, 95% CI 1.14-1.35). Older age was associated with greater odds of non-transport compared to patients aged 60-69 years (70-79 [OR 1.42, 95% CI 1.35-1.49], 80-89 [OR 1.51, 95% CI 1.42-1.59], ≥90 [OR 1.45, 95% CI 1.35-1.55]). Patients residing in Census tracts with larger percentages of the population living in poverty had lower odds of non-transport compared to those in areas with ≤5% in poverty (6-15% poverty [OR 0.82, 95% CI 0.78-0.84), 15-25% poverty [OR 0.78, 95% CI 0.73-0.82], and >25% poverty [OR 0.78, 95% CI 0.72-0.84]). CONCLUSION: Males, older age groups, and Hispanic/Latino patients had higher odds of non-transport among this population of community-dwelling adults age 60 or greater. These findings may inform development of future targeted falls-related mobile integrated health or community paramedic services and referrals to community intervention programs. Future work is needed to understand underlying patient and clinician perspectives driving non-transport decisions among these patients to better equip EMS clinicians with tools and information on tailored risk/benefit discussions.

Community socioeconomic and urban-rural differences in emergency medical services times for suspected stroke in North Carolina.

OBJECTIVE: Our objectives were to describe time intervals of EMS encounters for suspected stroke patients in North Carolina (NC) and evaluate differences in EMS time intervals by community socioeconomic status (SES) and rurality. METHODS: This cross-sectional study used statewide data on EMS encounters of suspected stroke in NC in 2019. Eligible patients were adults requiring EMS transport to a hospital following a 9-1-1 call for stroke-like symptoms. Incident street addresses were geocoded to census tracts and linked to American Community Survey SES data and to rural-urban commuting area (RUCA) codes. Community SES was defined as high, medium, or low based on tertiles of an SES index. Urban, suburban, and rural tracts were defined by RUCA codes 1, 2-6, and 7-10, respectively. Multivariable quantile regression was used to estimate how the median and 90th percentile of EMS time intervals varied by community SES and rurality, adjusting for each other; patient age, gender, and race/ethnicity; and incident characteristics. RESULTS: We identified 17,117 eligible EMS encounters of suspected stroke from 2028 census tracts. The population was 65% 65+ years old; 55% female; and 69% Non-Hispanic White. Median response, scene, and transport times were 8 (interquartile range, IQR 6-11) min, 16 (IQR 12-20) min, and 14 (IQR 9-22) minutes, respectively. In quantile regression adjusted for patient demographics, minimal differences were observed for median response and scene times by community SES and rurality. The largest median differences were observed for transport times in rural (6.7 min, 95% CI 5.8, 7.6) and suburban (4.7 min, 95% CI 4.2, 5.1) tracts compared to urban tracts. Adjusted rural-urban differences in 90th percentile transport times were substantially greater (16.0 min, 95% CI 14.5, 17.5). Low SES was modesty associated with shorter median (-3.3 min, 95% CI -3.8, -2.9) and 90th percentile (-3.0 min, 95% CI -4.0, -2.0) transport times compared to high SES tracts. CONCLUSIONS: While community-level factors were not strongly associated with EMS response and scene times for stroke, transport times were significantly longer rural tracts and modestly shorter in low SES tracts, accounting for patient demographics. Further research is needed on the role of community socioeconomic deprivation and rurality in contributing to delays in prehospital stroke care.

Community Socioeconomic and Urban-Rural Disparities in Prehospital Notification of Stroke by Emergency Medical Services in North Carolina.

OBJECTIVES: Notification by emergency medical services (EMS) to the destination hospital of an incoming suspected stroke patient is associated with timelier in-hospital evaluation and treatment. Current data on adherence to this evidence-based best practice are limited, however. We examined the frequency of EMS stroke prenotification in North Carolina by community socioeconomic status (SES) and rurality. METHODS: Using a statewide database of EMS patient care reports, we selected 9-1-1 responses in 2019 with an EMS provider impression of stroke or documented stroke care protocol use. Eligible patients were 18 years old and older with a completed prehospital stroke screen. Incident street addresses were geocoded to North Carolina census tracts and linked to American Community Survey socioeconomic data and urban-rural commuting area codes. High, medium, and low SES tracts were defined by SES index tertiles. Tracts were classified as urban, suburban, and rural. We used multivariable logistic regression to estimate independent associations between tract-level SES and rurality with EMS prenotification, adjusting for patient age, sex, and race/ethnicity; duration of symptoms; incident day of week and time of day; 9-1-1 dispatch complaint; EMS provider primary impression; and prehospital stroke screen interpretation. RESULTS: The cohort of 9527 eligible incidents was mostly at least 65 years old (65%), female (55%), and non-Hispanic White (71%). EMS prenotification occurred in 2783 (29%) patients. Prenotification in low SES tracts (27%) occurred less often than in medium (30%) and high (32%) SES tracts. Rural tracts had the lowest frequency (21%) compared with suburban (28%) and urban (31%) tracts. In adjusted analyses, EMS prenotification was less likely in low SES (vs high SES; odds ratio 0.76, 95% confidence interval 0.67-0.88) and rural (vs urban; odds ratio 0.64, 95% confidence interval 0.52-0.77) tracts. CONCLUSIONS: Across a large, diverse population, EMS prenotification occurred in only one-third of suspected stroke patients. Furthermore, low SES and rural tracts were independently associated with a lower likelihood of prehospital notification. These findings suggest the need for education and quality improvement initiatives to increase EMS stroke prenotification, particularly in underserved communities.

Patient Outcomes Based on the 2011 CDC Guidelines for Field Triage of Injured Patients.

BACKGROUND: The Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients drive the destination decision for millions of emergency medical services (EMS)-transported trauma patients annually, yet limited information exists regarding performance and relationship with patient outcomes as a whole. OBJECTIVE: To evaluate the association of positive findings on Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients with hospitalization and mortality. METHODS: This retrospective study included all 911 responses from the 2019 ESO Data Collaborative research dataset with complete Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients and linked emergency department dispositions, excluding children and cardiac arrests prior to EMS arrival. Patients were categorized by Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients step(s) met. Outcomes were hospitalization and emergency department or inhospital mortality. RESULTS: There were 86,462 records included: n = 65,967 (76.3%) met no criteria, n = 16,443 (19.0%) met one step (n = 1,571 [9.6%] vitals, n = 1,030 [6.3%] anatomy of injury, n = 993 [6.0%] mechanism of injury, and n = 12,849 [78.1%] special considerations), and n = 4,052 (4.7%) met multiple. Compared with meeting no criteria, hospitalization odds increased threefold for vitals (odds ratio [OR]: 3.07, 95% confidence interval [CI]: 2.77-3.40), fourfold for anatomy of injury (OR: 3.94, 95% CI: 3.48-4.46), twofold for mechanism of injury (OR: 2.00, 95% CI: 1.74-2.29), or special considerations (OR: 2.46, 95% CI: 2.36-2.56). Hospitalization odds increased ninefold when positive in multiple steps (OR: 8.97, 95% CI: 8.37-9.62). Overall, n = 84,473 (97.7%) had mortality data available, and n = 886 (1.0%) died. When compared with meeting no criteria, mortality odds increased 10-fold when positive in vitals (OR: 9.58, 95% CI: 7.30-12.56), twofold for anatomy of injury (OR: 2.34, 95% CI: 1.28-4.29), or special considerations (OR: 2.10, 95% CI: 1.71-2.60). There was no difference when only positive for mechanism of injury (OR: 0.22, 95% CI: 0.03-1.54). Mortality odds increased 23-fold when positive in multiple steps (OR: 22.7, 95% CI: 19.7-26.8). CONCLUSIONS: Patients meeting multiple Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients steps were at greater risk of hospitalization and death. When meeting only one step, anatomy of injury was associated with greater risk of hospitalization; vital sign criteria were associated with greater risk of mortality.

Out-of-Hospital Ketamine: Indications for Use, Patient Outcomes, and Associated Mortality.

STUDY OBJECTIVE: To describe out-of-hospital ketamine use, patient outcomes, and the potential contribution of ketamine to patient death. METHODS: We retrospectively evaluated consecutive occurrences of out-of-hospital ketamine administration from January 1, 2019 to December 31, 2019 reported to the national ESO Data Collaborative (Austin, TX), a consortium of 1,322 emergency medical service agencies distributed throughout the United States. We descriptively assessed indications for ketamine administration, dosing, route, transport disposition, hypoxia, hypercapnia, and mortality. We reviewed cases involving patient death to determine whether ketamine could be excluded as a potential contributing factor. RESULTS: Indications for out-of-hospital ketamine administrations in our 11,291 patients were trauma/pain (49%; n=5,575), altered mental status/behavioral indications (34%; n=3,795), cardiovascular/pulmonary indications (13%; n=1,454), seizure (2%; n=248), and other (2%; n=219). The highest median dose was for altered mental status/behavioral indications at 3.7 mg/kg (interquartile range, 2.2 to 4.4 mg/kg). Over 99% of patients (n=11,274) were transported to a hospital. Following ketamine administration, hypoxia and hypercapnia were documented in 8.4% (n=897) and 17.2% (n=1,311) of patients, respectively. Eight on-scene and 120 in-hospital deaths were reviewed. Ketamine could not be excluded as a contributing factor in 2 on-scene deaths, representing 0.02% (95% confidence interval 0.00% to 0.07%) of those who received out-of-hospital ketamine. Among those with in-hospital data, ketamine could not be excluded as a contributing factor in 6 deaths (0.3%; 95% confidence interval 0.1% to 0.7%). CONCLUSION: In this large sample, out-of-hospital ketamine was administered for a variety of indications. Patient mortality was rare. Ketamine could not be ruled out as a contributing factor in 8 deaths, representing 0.07% of those who received ketamine.

Initial Prehospital Rapid Emergency Medicine Score (REMS) as a Predictor of Patient Outcomes.

Background: A standardized objective measure of prehospital patient risk of hospitalization or death is needed. The Rapid Emergency Medicine Score (REMS), a validated risk-stratification tool, has not been widely tested for prehospital use. This study's objective was to assess predictive characteristics of initial prehospital REMS for ED disposition and overall patient mortality. Methods: This retrospective analysis used linked prehospital and hospital data from the national ESO Data Collaborative. All 911 responses from 1/1/2019-12/31/2019 were included. REMS (0-26) was calculated using age and first prehospital values for: pulse rate, mean arterial pressure, respiratory rate, oxygen saturation, and Glasgow Coma Scale. Non-transports, patients <18 and cardiac arrests prior to EMS arrival were excluded. The primary outcome was ED disposition, dichotomized to discharge versus admission, transfer, or death. The secondary outcome was overall survival to discharge (ED or inpatient). Transfers and records without inpatient disposition were excluded from the secondary analysis. Predictive ability was assessed using area under the receiver operating curve (AUROC). Optimal REMS cut points were determined using test characteristic curves. Univariable logistic regression modeling was used to quantify the association between initial prehospital REMS and each outcome. Results: Of 579,505 eligible records, 94,640 (16%) were excluded due to missing data needed to calculate REMS. Overall, 62% (n = 298,223) of patients were discharged from the ED, 36% (n = 175,212) were admitted, 2% (n = 10,499) were transferred, and 0.2% (n = 931) died in the ED. A REMS of 5 or lower demonstrated optimal statistical prediction for ED discharge versus not discharged (admission/transfer/death) (AUROC: 0.68). Patients with initial prehospital REMS of 5 or lower showed a three-fold increase in odds of ED discharge (OR: 3.28, 95%CI: 3.24-3.32). Of the 457,226 patients included in overall mortality analysis, >98% (n = 450,112) survived. AUROC of initial prehospital REMS for overall mortality was 0.79. A score 7 or lower was statistically optimal for predicting survival. Initial prehospital REMS of 7 or lower was associated with a five-fold increase in odds of overall survival (OR:5.41, 95%CI:5.15-5.69). Conclusion: Initial prehospital REMS was predictive of ED disposition and overall patient mortality, suggesting value as a risk-stratification measure for EMS agencies, systems and researchers.

The Cincinnati Prehospital Stroke Scale Compared to Stroke Severity Tools for Large Vessel Occlusion Stroke Prediction.

BACKGROUND: Various screening tools, ranging in complexity, have been developed to predict large vessel occlusion (LVO) stroke in the prehospital setting. Our objective was to determine whether newly-developed LVO stroke scales offer a clinically-meaningful advantage over the Cincinnati Prehospital Stroke Scale (CPSS). METHODS: We retrospectively analyzed prehospital patient care records linked with hospital data from 151 EMS agencies in the United States, between January 1, 2018 and December 31, 2018. We compared the CPSS to the Rapid Arterial Occlusion Evaluation (RACE), Los Angeles Motor Scale (LAMS), and the Vision, Aphasia, Neglect (VAN) assessment for LVO prediction. For each stroke scale, we used the intersection of sensitivity and specificity curves to determine optimal prediction cut-points. We used area under the ROC curve and 95% confidence intervals to assess for differences in discriminative ability between scales. RESULTS: We identified 13,596 prehospital records with one or more documented stroke scales of interest. Among these, 4,228 patients were diagnosed with stroke. Over half (57%, n = 2,415) of patients diagnosed with stroke experienced an acute ischemic stroke. Of patients with ischemic stroke, 26% (n = 628) were diagnosed with LVO. A CPSS score of 2 or higher demonstrated sensitivity = 69% and specificity = 78% for LVO. A RACE score of 4 or higher demonstrated sensitivity = 63%, specificity = 73%. A LAMS score of 3 or higher demonstrated sensitivity = 63%, specificity = 72% and a positive VAN score demonstrated sensitivity = 86%, specificity = 65%. Comparing the area under the ROC curve for each scale revealed no statistically significant differences in discriminative ability for LVO stroke. CONCLUSIONS: In this large sample of real-world prehospital patient encounters, the CPSS demonstrated similar predictive performance characteristics compared to the RACE, LAMS, and VAN for detecting LVO stroke. Prior to implementing a specific screening tool, EMS agencies should evaluate ease of use and associated implementation costs. Scored 0-3, the simple, widely-used CPSS may serve as a favorable prehospital screening instrument for LVO detection with a cut-point of 2 or higher maximizing the tradeoff between sensitivity and specificity.

COVID-19 Preliminary Case Series: Characteristics of EMS Encounters with Linked Hospital Diagnoses.

BACKGROUND: Few studies have examined the prehospital presentation, assessment, or treatment of patients diagnosed with coronavirus disease 2019 (COVID-19). The objective of this preliminary report is to describe prehospital encounters for patients with a COVID-19 hospital diagnosis and/or COVID-19 EMS suspicion versus those with neither a hospital diagnosis nor EMS suspicion of the disease. METHODS: This case series evaluated electronic patient care records from EMS agencies participating in a large national bi-directional data exchange. All records for 9-1-1 responses between March 1 and April 19, 2020, resulting in transport to a hospital, with at least one ICD-10 outcome returned via the data exchange were included. Hospital ICD-10 codes used to determine COVID-19 diagnoses included B97.2, B97.21, B97.29, B34.2, and U07.1. COVID-19 EMS suspicion was defined as a documented EMS primary or secondary impression of COVID-19, or indication of COVID-19 suspicion in the prehospital free-text narrative. Comparisons were stratified by COVID-19 hospital diagnosis and COVID-19 EMS suspicion. Descriptive and comparative statistics are presented. RESULTS: There were 84,540 EMS patient records with linked hospital ICD-10 codes included. Of those, 814 (1%) patients had a COVID-19 hospital diagnosis. Overall, COVID-19 EMS suspicion was documented for 3,204 (4%) patients. A COVID-19 EMS suspicion was documented for 636 (78%) of hospital diagnosed COVID-19 patients. Those with COVID-19 hospital diagnoses were more likely to present with tachycardia, tachypnea, hypoxia, and fever during the EMS encounter. EMS responses for patients diagnosed with COVID-19 were also more likely to originate from a skilled nursing/assisted living facility. EMS PPE (eye protection, mask, or gown) use was more frequently documented on records of patients who had hospital diagnosed COVID-19. CONCLUSION: In this large sample of prehospital encounters, EMS COVID-19 suspicion demonstrated sensitivity of 78% and positive predictive value of 20% compared with hospital ICD-10 codes. These data indicate that EMS suspicion alone is insufficient to determine appropriate utilization of PPE.

A Statewide Assessment of Prehospital Electrocardiography Approaches of Acquisition and Interpretation for ST-Elevation Myocardial Infarction Based on Emergency Medical Services Characteristics.

Background: The American Heart Association recommends acquiring and interpreting prehospital electrocardiograms (ECG) for patients transported by Emergency Medical Services (EMS) to the emergency department with symptoms highly suspicious of acute coronary syndrome. If interpreted correctly, prehospital ECGs have the potential to improve early detection of ST-elevation myocardial infarction (STEMI) and inform prehospital activation of the cardiac catheterization laboratory, thus reducing total ischemic time and improving patient outcomes. Standardized protocols for prehospital ECG interpretation methods are lacking due to variations in EMS system design, training, and procedures. Objectives: We aimed to describe approaches for prehospital ECG interpretation in EMS systems across North Carolina (NC), and examine potential differences among systems. Methods: A 35-item internet survey was sent to all NC EMS systems (n = 99). Questions pertaining to prehospital ECG interpretation methods included: paramedic, computerized algorithm (i.e., software interpretation), combined approaches, and/or transmission for physician interpretation, transmission capability, cardiac catheterization laboratory activation, and EMS system characteristics (e.g. rural versus urban). Data were summarized and compared. Results: A total of 96 EMS systems across NC responded to the survey (97% response rate); of these, 69% were rural. EMS medical directors (53%) or EMS administrative directors (42%) completed the majority of surveys. While 91% of EMS systems had a prehospital ECG interpretation protocol in place, only 61% had a written cardiac catheterization laboratory activation policy. More than half (55%) of systems reported paramedic interpretation of prehospital ECGs, followed by a combined paramedic and software interpretation approach (39%), physician interpretation (4%), or software interpretation only approach (2%). Nearly 80% of EMS systems transmitted prehospital ECGs to receiving hospitals (always or sometimes), regardless of interpretation method. All EMS systems had some paid versus non-paid EMS personnel and the majority (86%) had both basic and advanced life support capabilities. Conclusions: Most NC EMS systems had a paramedic only ECG interpretation or paramedic in combination with a computerized algorithm approach. Very few used a physician read approach following transmission, even in rural service areas.

Emergency Medical Services Time Intervals for Acute Chest Pain in the United States, 2015-2016.

Background: Chest pain is a leading complaint in emergency settings. Timely emergency medical services (EMS) responses can reduce delays to treatment and improve clinical outcomes for acute myocardial infarction patients and other medical emergencies. We investigated national-level EMS response, scene, and transport times for acute chest pain patients in the United States. Methods: A retrospective analysis was performed using 2015-2016 data from the National EMS Information System (NEMSIS). Eligible patients were identified as having a provider impression of chest pain or discomfort and not due to trauma or resulting in cardiac arrest during EMS care. Descriptive analyses of prehospital time intervals and patient-, response-, and system-level covariates were performed. Multivariable logistic regression was used to measure associations between meeting response and scene time benchmarks (8-min and 15-min, respectively) and covariates. Results: Our study identified 1,672,893 eligible EMS encounters of chest pain. Patients had a mean age of 63.1 years (SD = 14.8). The population was evenly distributed by sex (51% male; 49% female). Most encounters occurred in home or residence (58%) and had lights and sirens response to scene (84%). Most encounters were in urban areas (78%). The median (interquartile range, IQR) response time was 7 (5-10) minutes. The median (IQR) scene time was 16 (12-20) minutes. The median (IQR) transport time was 13 (8-20) minutes. Generally, median response and transport times were longer in rural and frontier areas compared to urban and suburban areas. Only 65% and 49% met the 8-min response and 15-min scene time benchmarks. Responding with lights and sirens was associated with greater compliance with EMS response time benchmark. EMS care of older age groups and females was less likely to meet the scene time benchmark. Conclusions: Substantial proportions of EMS encounters for chest pain did not meet response and scene time benchmarks. Regional and urban-rural differences were observed in adherence with the response time benchmark. Our findings also suggest age and gender disparities in on-scene delays by EMS. Our study contributes important evidence on timely EMS responses for cardiac chest pain and provides suggestions for EMS system benchmarking and quality improvement.

Assessment of Key Health and Wellness Indicators Among North Carolina Emergency Medical Service Providers.

OBJECTIVE: The objective of this study was to characterize key health indicators in Emergency Medical Services (EMS) personnel and identify areas for intervention in order to ensure a strong and capable emergency health workforce. METHODS: Participants were EMS personnel delivering patients to 4 regional tertiary care emergency departments within North Carolina (NC). After transferring patient care and agreeing to participate, height, weight, and blood pressure (BP) measurements were recorded and each participant completed a questionnaire regarding demographics, activity levels, alcohol consumption, smoking, and medical history. Data were analyzed descriptively. RESULTS: A sample of 452 EMS personnel from across NC was enrolled. The cohort was predominantly male (74.1%) and employed full-time (85.5%). The prevalence of overweight and obesity (80.3%) among EMS personnel was higher than the NC population (65.6%) and the general United States (US) population (70.8%). A previous diagnosis of high BP was reported by only 18.3% of participants, but 65.1% had elevated BP at the time of measurement. Alcohol consumption in the past 30 days among participants (55.4%) was slightly higher than state estimates (48.0%) and similar to national estimates (57.1%). However, heavy drinking (22.2%) and binge drinking (28.8%) were reported at much higher rates than state (5.6% and 15.2%, respectively) and national (6.6% and 18.3%, respectively) estimates. The prevalence of current smoking (21.5%) and quit attempts (48.8%) in the cohort was similar to state (21.8% and 55.0%, respectively) and national (21.2% and 55.7%, respectively) estimates. Likewise, the proportion of EMS providers meeting the Center for Disease Control's activity guidelines (49.6%) was similar to that found in the NC (46.8%) and the general US (48.0%) populations. CONCLUSIONS: These findings suggest a high prevalence of overweight and obesity, heavy drinking, binge drinking, and high BP among NC EMS personnel. Similar to fire service personnel, these rates are higher than the general US population. As such, they suggest areas where intervention would have the greatest positive impact on the health and performance of the EMS workforce.

Availability of Hospital Resources and Specialty Services for Stroke Care in North Carolina.

OBJECTIVES: Effective regionalization of acute stroke care requires assessment and coordination of limited hospital resources. We described the availability of stroke-specific hospital resources (neurology specialty physicians and neuro-intensive care unit [neuro-ICU] bed capacity) for North Carolina overall and by region and population density. We also assessed daily trends in hospital bed availability. METHODS: This statewide descriptive study was conducted with data from the State Medical Asset Resource Tracking Tool (SMARTT), a Web-based system used by North Carolina to track available medical resources within the state. The SMARTT system was queried for stroke-specific physician and bed resources at each North Carolina hospital during a 1-year period (June 2015-May 2016), including daily availability of neuro-ICU beds. We compared hospital resources by geographic region and population density (metropolitan, urban, and rural). RESULTS: Data from 108 acute care hospitals located in 75 of 100 counties in North Carolina were included in the analysis. Fifty-seven percent of hospitals had no neurology specialty physicians. Western and eastern North Carolina had the lowest prevalence of these physicians. Most hospitals (88%) had general ICUs, whereas only 17 hospitals (16%) had neuro-ICUs. Neuro-ICUs were concentrated in metropolitan areas and in central North Carolina. On average, there were 276 general ICU and 27 neuro-ICU beds available statewide each day. Daily neuro-ICU bed availability was lowest in eastern and southeastern regions and during the week compared with weekends. CONCLUSIONS: In North Carolina, stroke-specific hospital subspecialists and resources are not distributed evenly across the state. Daily bed availability, particularly in neuro-ICUs, is lacking in rural areas and noncentral regions and appears to decrease on weekdays. Regionalization of stroke care needs to consider the geographic distribution and daily variability of hospital resources.

Prehospital Administration of Epinephrine in Pediatric Anaphylaxis - A Statewide Perspective.

OBJECTIVE: Timely administration of epinephrine is critical in the treatment of anaphylaxis. This study sought to determine the frequency of administration of epinephrine by EMS providers caring for pediatric patients in the prehospital setting. METHODS: We examined data from the NC EMS database (PreMIS) from 2010-3 to determine frequency of epinephrine administration in pediatric patients with anaphylaxis. We studied patients <18 years of age with an EMS provider impression of "allergic reaction." Anaphylaxis was present if there was hypotension (defined as SBP < 90 or DBP < 45 for patients age 11 and older, and SBP < 70 + (2 × age) for patients ages 0-10), or impaired respirations (defined as description of labored or absent respirations, or RR < 12 or > 30). We determined the overall frequency of epinephrine administration. A multivariate logistic regression was then constructed to examine the impact of the following variables on appropriate epinephrine administration: age < 10, non-white race, rural county of case origin, duration of transportation from scene, and presence of a paramedic. RESULTS: A total of 504 patients met inclusion criteria, of which 471 demonstrated anaphylaxis as previously defined. A total of 153 patients with anaphylaxis received epinephrine (32.4%, 95% CI 28.3-36.9%). Age < 10 was associated with increased odds of not receiving epinephrine appropriately (OR 2.90, 95% CI 1.85-4.54, p < 0.001). Other variables did not have statistically significant impact on epinephrine administration. CONCLUSION: There are missed opportunities for prehospital administration of epinephrine in pediatric patients with anaphylaxis. Very young children (age < 10) had increased odds for not receiving epinephrine.

Repeated Emergency Medical Services Use by Older Adults: Analysis of a Comprehensive Statewide Database.

STUDY OBJECTIVE: The objective of this study is to characterize repeated emergency medical services (EMS) transports among older adults across a large and socioeconomically diverse region. METHODS: Using the North Carolina Prehospital Medical Information System, we analyzed the frequency of repeated EMS transports within 30 days of an index EMS transport among adults aged 65 years and older from 2010 to 2015. We used multivariable logistic regressions to determine characteristics associated with repeated EMS transport. RESULTS: During the 6-year period, EMS performed 1,711,669 transports for 689,664 unique older adults in North Carolina. Of these, 303,099 transports (17.7%) were followed by another transport of the same patient within 30 days. The key characteristics associated with an increased adjusted odds ratio of repeated transport within 30 days include transport from an institutionalized setting (odds ratio [OR] 1.42; 95% confidence interval [CI] 1.38 to 1.47), blacks compared with whites (OR 1.29; 95% CI 1.24 to 1.33), a dispatch complaint of psychiatric problems (OR 1.38; 95% CI 1.25 to 1.52), back pain (OR 1.35; 95% CI 1.26 to 1.45), breathing problems (OR 1.21; 95% CI 1.15 to 1.30), and diabetic problems (OR 1.14; 95% CI 1.06 to 1.22). Falls accounted for 15.6% of all transports and had a modest association with repeated transports (OR 1.07; 95% CI 1.00 to 1.14). CONCLUSION: More than 1 in 6 EMS transports of older adults in North Carolina are followed by a repeated transport of the same patient within 30 days. Patient characteristics and chief complaints may identify increased risk for repeated transport and suggest the potential for targeted interventions to improve outcomes and manage EMS use.

Evaluation of the Implementation of the Trauma Triage and Destination Plan on the Field Triage of Injured Patients in North Carolina.

OBJECTIVE: Timely triage and appropriate destination decision making for injured patients are central challenges faced by emergency medical services (EMS) systems. In 2010, North Carolina (NC) adopted a statewide Trauma Triage and Destination Plan (TTDP) based on the CDC's Field Triage Guidelines to better address these challenges. We sought to characterize the implementation of these guidelines by quantifying their effect on multiple metrics of patient care. METHODS: We employed a retrospective pre-post study design utilizing a statewide EMS medical record database. We assessed several metrics of patient care-including changes in destination choice, appropriateness of EMS destination, transit time to first hospital, transit time to definitive care, and others-in a six-month period in the year before and after the implementation of the guidelines. RESULTS: We evaluated a total of 190,307 EMS encounters pre- (n = 93,927) and post-implementation (n = 96,380). Among all patients, there was not a significant difference in the percentage transported to a community hospital or Level I, II, or III trauma center as their first destination. Among those patients meeting TTDP guidelines for transport to a trauma center, the number transported to a Level I or II trauma center decreased 1.0% from 30.6% (n = 2,911) to 29.6% (n = 2,954) (95% CI: -0.2%, 2.2%). Those transported to a Level I trauma center decreased 0.4% from 21.2% to 20.8% in the post-period (95% CI: -0.7%, 1.5%). There were also no significant changes in EMS scene times (14.0 pre-, 14.1 post-) and transport times (12.9 pre-, 13.0 post-). While scene distance from a Level I trauma center showed a decreased likelihood of transport to that center, there was an overall post-implementation increase of 2.5% from 18.0% to 20.5% (95% CI: -3.6%, -1.3%) in transport to a Level I trauma center among patients meeting anatomic criteria across all distance ranges. CONCLUSIONS: We found that implementation of region-specific destination plans based on the Field Triage Guidelines had little effect on selected hospital destination, scene times, transport times, and other metrics of EMS decision making and effectiveness. We suspect this is due to delays in information dissemination and adoption by field providers.

EMS Provider Attitudes and Perceptions of Enrolling Patients without Consent in Prehospital Emergency Research.

The purpose of this study was to evaluate the attitudes and opinions of a broad population of EMS providers on enrolling patients in research without consent. A survey was conducted in 2010 of all EMS providers who participated in the National Registry of Emergency Medical Technicians (NREMT) reregistration process, which included half of all registered providers. Each reregistration packet included our optional survey, which had nine 6-point Likert scale questions concerning their opinion of research studies without consent as well as 8 demographic questions. Responses were collapsed to agree and disagree and then analyzed using descriptive statistics with 99% confidence intervals. A total of 65,993 EMS providers received the survey and 23,832 (36%) participated. Most respondents agreed (98.4%, 99%CI: 98.2-98.6) that EMS research is important, but only 30.9% (99%CI: 30.1-31.6) agreed with enrolling patients without their consent when it is important to learn about a new treatment. Only 46.6% (99%Cl: 45.7-47.4) were personally willing to be enrolled in a study without their consent. A majority (68.5% [99%Cl: 67.7-69.3]) of respondents believed that EMS providers should have the individual right to refuse to enroll patients in EMS research. While the majority of respondents agreed that EMS research is important, considerably less agree with enrolling patients without consent and less than half would be willing to be enrolled in a study without their consent. Prior to starting an Exception from Informed Consent (EFIC) study, researchers should discuss with EMS providers their perceptions of enrolling patients without consent and address their concerns.

Accuracy of EMS Trauma Transport Destination Plans in North Carolina.

Abstract Objective. Planning for time-sensitive injury may allow emergency medical services (EMS) systems to more accurately triage patients meeting accepted criteria to facilities most capable of providing life-saving treatment. In 2010, North Carolina (NC) implemented statewide Trauma Triage and Destination Plans (TTDPs) in all 100 of North Carolina's county-defined EMS systems. Each system was responsible for identifying the specific destination hospitals with appropriate resources to treat trauma patients. We sought to characterize the accuracy of their hospital designations. Methods. In this cross-sectional study, we collected TTDPs for each county-defined EMS system, including their assigned hospital capabilities (i.e., trauma center or community hospital). We conducted a survey with each EMS system to determine how their TTDP was constructed and maintained, as well as with each TTDP-designated hospital to verify their capabilities. We determined the accuracy of the EMS assigned hospital designations by comparing them to the hospital's reported capabilities. Results. The 100 NC EMS systems provided 380 designations for 112 hospitals. TTDPs were created by EMS administrators and medical directors, with only 55% of EMS systems engaging a hospital representative in the plan creation. Compared to the actual hospital capabilities, 97% of the EMS TTDP designations were correct. Twelve hospital designations were incorrect and the majority (10) overestimated hospital capabilities. Of the 100 EMS systems, 7 misclassified hospitals in their TTDP. EMS systems that did not verify their local hospitals' capabilities during TTDP development were more likely to incorrectly categorize a hospital's capabilities (p = 0.001). Conclusions. A small number of EMS systems misclassified hospitals in their TTDP, but most plans accurately reflected hospital capabilities. Misclassification occurred more often in systems that did not consult local hospitals prior to developing their TTDP. The potential of the TTDP to improve communication between EMS agencies and the facilities with which they work has not been fully realized. EMS agencies or systems should verify local hospital capabilities when engaging in destination planning efforts.

North Carolina College of Emergency Physicians' Guidance Document on Emergency Medical Services.

The North Carolina College of Emergency Physicians (NCCEP) Emergency Medical Services (EMS) Committee uses an evidence-based approach in writing its protocols and procedures. The most recent revision of the NCCEP document, which was started in late 2010, lasted for more than 1 year and utilized committee members from across the state. Four meetings were held at locations across North Carolina. In addition, 2 surveys were sent to get input from EMS providers. Since 2010, the document has been updated on an ongoing basis, aligning it with the latest evidence-based medicine.