Epidemiology of out-of-hospital pediatric airway management in the 2019 national emergency medical services information system data set.

OBJECTIVE: Airway management is an important priority in the care of critically ill children. We sought to provide updated estimates of the epidemiology of pediatric out-of-hospital airway management and ventilation interventions in the United States. METHODS: We used data from the 2019 National Emergency Medical Services Information System (NEMSIS) data set. We performed a descriptive analysis of all patients < 18 years receiving one or more of the following: bag-valve-mask ventilation (BVM), tracheal intubation (TI), supraglottic airway (SGA) insertion, continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP) and surgical airway placement. We determined success and complication rates for each airway procedure. RESULTS: Among 1,148,943 pediatric patient care encounters, airway and ventilation interventions occurred in 22,637 (1,970 per 100,000 pediatric Emergency Medical Services (EMS) activations), including 64% <11 years old, 56.1% male, 16.9% cardiac arrest, 16.6% injured, and 83.9% in urban areas. Airway interventions included: BVM 3,997 (17.7% of pediatric airway encounters), TI 3,165 (14.0%), SGA 582 (2.6%), CPAP/BiPAP 331 (1.5%) and surgical airway 29 (0.1%). TI success was 75.2% (95% CI 73.7-76.7%) and lowest for the 0-1 month age group (56.8%; 49.2-64.2%). SGA success was 88.0% (95% CI 85.1-90.6%). Vomiting was the most common airway complication (n = 223, 1%). CONCLUSIONS: BVM and advanced airway management occur in 1 of every 51 pediatric EMS encounters. BVM is the most commonly prehospital pediatric airway management technique, followed by TI and SGA insertion. These data provide contemporary perspectives of pediatric prehospital airway management.

Modeling to Optimize Hospital Evacuation Planning in EMS Systems.

OBJECTIVE: To develop optimal hospital evacuation plans within a large urban EMS system using a novel evacuation planning model and a realistic hospital evacuation scenario, and to illustrate the ways in which a decision support model may be useful in evacuation planning. METHODS: An optimization model was used to produce detailed evacuation plans given the number and type of patients in the evacuating hospital, resource levels (teams to move patients, vehicles, and beds at other hospitals), and evacuation rules. RESULTS: Optimal evacuation plans under various resource levels and rules were developed and high-level metrics were calculated, including evacuation duration and the utilization of resources. Using this model we were able to determine the limiting resources and demonstrate how strategically augmenting the resource levels can improve the performance of the evacuation plan. The model allowed the planner to test various evacuation conditions and resource levels to demonstrate the effect on performance of the evacuation plan. CONCLUSION: We present a hospital evacuation planning analysis for a hospital in a large urban EMS system using an optimization model. This model can be used by EMS administrators and medical directors to guide planning decisions and provide a better understanding of various resource allocation decisions and rules that govern a hospital evacuation.

Sex Differences in Survival From Out-of-Hospital Cardiac Arrest in the Era of Regionalized Systems and Advanced Post-Resuscitation Care.

BACKGROUND: The purpose of this study was to evaluate sex differences in out-of-hospital cardiac arrest (OHCA) characteristics, interventions, and outcomes. METHODS AND RESULTS: This is a retrospective analysis from a regionalized cardiac arrest system. Data on patients treated for OHCA are reported to a single registry, from which all adult patients were identified from 2011 through 2014. Characteristics, treatment, and outcomes were evaluated with stratification by sex. The adjusted odds ratio (OR) for survival with good neurological outcome (cerebral performance category 1 or 2) was calculated for women compared to men. There were 5174 out-of-hospital cardiac arrests (OHCAs; 3080 males and 2094 females). Women were older, median 71 (interquartile range [IQR], 59-82) versus 66 years (IQR, 55-78). Despite similar frequency of witnessed arrest, women were less likely to present with a shockable rhythm (22% vs 35%; risk difference [RD], 13%; 95% CI, 11-15), have ST-segment elevation myocardial infarction (23% vs 32%; RD, 13%; 95% CI, 7-11), or receive coronary angiography (11% vs 25%; RD, 14%; 95% CI, 12-16), percutaneous coronary intervention (5% vs 14%; RD, 9%; 95% CI, 7-11), or targeted temperature management (33% vs 40%; RD, 7%; 95% CI, 4-10). Women had decreased survival to discharge (33% vs 40%; RD, 7%; 95% CI, 4-10) and a lower proportion of good neurological outcome (16% vs 24%; RD, 8%; 95% CI, 6-10). In multivariable modeling, female sex was not associated with decreased survival with good neurological outcome (OR, 0.9; 95% CI, 0.8-1.1). CONCLUSIONS: Sex-related differences in OHCA characteristics and treatment are predictors of survival outcome disparities. With adjustment for these factors, sex was not associated with survival or neurological outcome after OHCA.

Survival and neurologic outcome after out-of-hospital cardiac arrest: results one year after regionalization of post-cardiac arrest care in a large metropolitan area.

BACKGROUND: Post-resuscitation care of cardiac arrest patients at specialized centers may improve outcome after out-of-hospital cardiac arrest (OOHCA). This study describes experience with regionalized care of resuscitated patients. METHODS: Los Angeles (LA) County established regionalized cardiac care in 2006. Since 2010, protocols mandate transport of nontraumatic OOHCA patients with field return of spontaneous circulation (ROSC) to a STEMI Receiving Center (SRC) with a hypothermia protocol. All SRC report outcomes to a registry maintained by the LA County Emergency Medical Services (EMS) Agency. We report the first year's data. The primary outcome was survival with good neurologic outcome, defined by a Cerebral Performance Category (CPC) score of 1 or 2. RESULTS: The SRC treated 927 patients from April 2011 through March 2012 with median age 67; 38% were female. There were 342 patients (37%) who survived to hospital discharge. CPC scores were unknown in 47 patients. Of the 880 patients with known CPC scores, 197 (22%) survived to hospital discharge with a CPC score of 1 or 2. The initial rhythm was VF/VT in 311 (34%) patients, of whom 275 (88%) were witnessed. For patients with an initial shockable rhythm, 183 (59%) survived to hospital discharge and 120 (41%) had survival with good neurologic outcome. Excluding patients who were alert or died in the ED, 165 (71%) patients with shockable rhythms received therapeutic hypothermia (TH), of whom 67 (42%) had survival with good neurologic outcome. Overall, 387 patients (42%) received TH. In the TH group, the adjusted OR for CPC 1 or 2 was 2.0 (95%CI 1.2-3.5, p = 0.01), compared with no TH. In contrast, the proportion of survival with good neurologic outcome in the City of LA in 2001 for all witnessed arrests (irrespective of field ROSC) with a shockable rhythm was 6%. CONCLUSION: We found higher rates of neurologically intact survival from OOHCA in our system after regionalization of post-resuscitation care as compared to historical data.