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.

Barriers to Discharge in Geriatric Long Staying Inpatient and Emergency Department Admissions: A Descriptive Study.

BACKGROUND: This study describes long length of stay during emergency department (ED) visits and hospital admissions, barriers to discharge, and discharge solutions for geriatric patients. METHODS: We conducted a retrospective medical record review of a random sample of 150 ED patients and 150 inpatients with long length of stay (LOS) encounters. Cohorts were characterized by demographics, social determinants of health (e.g., health insurance, housing), medical comorbidities at admission, discharge care coordination, and final disposition. RESULTS: In the ED, the primary barrier to discharge was inadequate inpatient bed availability (63%). In the inpatient setting, barriers to discharge were predominantly due to a demonstrated medical requirement for continued hospitalization (55%), followed by difficulty with coordinating discharge to a skilled nursing facility or rehabilitation center (22%). DISCUSSION: Among long LOS ED patients, discharge delays were often the result of unavailable inpatient beds and services. Reducing the LOS for ED patients may require further investigation as to which hospital services are most frequently utilized by geriatric patients and structuring inpatient bed allocation to prevent extended patient boarding in the ED. Reducing long inpatient LOS may require early identification of high-risk patients and strengthening of relationships with community-based services.

Characteristics, clinical care, and disposition barriers for mental health patients boarding in the emergency department.

BACKGROUND AND OBJECTIVES: Lack of mental health resources, such as inpatient psychiatric beds, has increased frequency and duration of boarding for mental health patients presenting to U.S. emergency departments (EDs). The purpose of this study is to describe characteristics of mental health patients with an ED length of stay of one week or longer and to identify barriers to their disposition. METHODS: This study was conducted in an academic ED in which emergency psychiatric evaluations and care are provided by a Psychiatric Emergency Services (PES) team contained within the Department of Emergency Medicine. Prolonged boarding was defined as an ED length of stay of 7 days or more. Pediatric, adult, and geriatric mental health patients with prolonged ED boarding from January 1 to August 31, 2019 were included. This study includes prospective data collection of the boarding group and retrospective identification and data collection of a comparison group of non-barding patients over the same 8-month period to compare patient characteristics and outcomes for each group. RESULTS: Between January 1 and August 31, 2019, the PES team completed 2,745 new assessments of mental health patients, of whom 39 met criteria for prolonged ED boarding. The following characteristics were associated with boarding: child (8%), male (64%), having Medicaid (49%) or both Medicaid and Medicare (18%), and having either a neurodevelopmental (15%) or neurocognitive disorder (15%) with a median stay of 18 days. Barriers to discharge included being declined from all state inpatient psychiatric hospitals (69%), declined from community living environments (21%), or declined from both (10%). The most common ED non-boarding patients were: Caucasian (64%), have a diagnosis of unspecified mental disorder (including suicidal ideation) or other specified mental disorder (59%) and have private insurance (42%) with a median stay of 1 day. CONCLUSION: In this study of mental health patients with prolonged ED stays, the primary barrier to disposition was the lack of patient acceptance to inpatient psychiatric hospitals, community settings, or other housing. Early identification of potential prolonged boarding, quality treatment and care for those patients, and effective case management, may resolve the ongoing challenges of boarding within the ED.

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.

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.

A geographic information system analysis of the impact of a statewide acute stroke emergency medical services routing protocol on community hospital bypass.

BACKGROUND: Our goal was to determine if a statewide Emergency Medical Services (EMSs) Stroke Triage and Destination Plan (STDP), specifying bypass of hospitals unable to routinely treat stroke patients with thrombolytics (community hospitals), changed bypass frequency of those hospitals. METHODS: Using a statewide EMS database, we identified stroke patients eligible for community hospital bypass and compared bypass frequency 1-year before and after STDP implementation. RESULTS: Symptom onset time was missing for 48% of pre-STDP (n = 2385) and 29% of post-STDP (n = 1612) cases. Of the remaining cases with geocodable scene addresses, 58% (1301) in the pre-STDP group and 61% (2,078) in the post-STDP group were ineligible for bypass, because a community hospital was not the closest hospital to the stroke event location. Because of missing data records for some EMS agencies in 1 or both study periods, we included EMS agencies from only 49 of 100 North Carolina counties in our analysis. Additionally, we found conflicting hospital classifications by different EMS agencies for 35% of all hospitals (n = 38 of 108). Given these limitations, we found similar community hospital bypass rates before and after STDP implementation (64%, n = 332 of 520 vs. 63%, n = 345 of 552; P = .65). CONCLUSIONS: Missing symptom duration time and data records in our state's EMS data system, along with conflicting hospital classifications between EMS agencies limit the ability to study statewide stroke routing protocols. Bypass policies may apply to a minority of patients because a community hospital is not the closest hospital to most stroke events. Given these limitations, we found no difference in community hospital bypass rates after implementation of the STDP.

Single-item or two-item literacy screener to predict the S-TOFHLA among adult hemodialysis patients.

OBJECTIVE: We compared single-item (SILS) and two-item (TILS) literacy screeners in predicting Short Test of Functional Health Literacy in Adults (S-TOFHLA) scores. METHODS: Adult hemodialysis patients completed SILS, which determines need for assistance when reading written medical information; TILS (last grade completed and self-reported reading ability); and S-TOFHLA. Receiver operator characteristic curves (ROC) and stratum specific likelihoods were calculated. RESULTS: Of 227 participants, median S-TOFHLA was 24 (IQR 15-34). 129 (55%) participants had adequate, 70 (30%) inadequate, and 37 (16%) marginal health literacy. SILS and TILS predicted S-TOFHLA scores equivalently. Test characteristics predicting inadequate health literacy were: SILS sensitivity for threshold >1, 54% (95%CI: 44, 64), for >2, 39% (29, 49) and specificity for >1, 73% (64, 80), for >2, 93% (87, 97), area under the ROC of 0.67 (0.60-0.74); TILS sensitivity for threshold >1, 72% (62, 80), for >2, 30% (21, 40) and specificity for >1, 54% (45, 63), for >2, 86% (79, 92), area under the ROC of 0.66 (0.59-0.73). CONCLUSION: SILS and TILS had similar test characteristics in predicting S-TOFHLA. PRACTICE IMPLICATIONS: While a positive result on either test increases the likelihood that a patient has low health literacy, the SILS is easier to administer and score.

Level of disaster preparedness in patients visiting the emergency department: results of the civilian assessment of readiness for disaster (CARD) survey.

BACKGROUND: Patients seeking care in public hospitals are often resource-limited populations who have in past disasters become the most vulnerable. The objective of this study was to determine the personal disaster preparedness of emergency department (ED) patients and to identify predictors of low levels of preparedness. It was hypothesized that vulnerable populations would be better prepared for disasters. METHODS: A prospective cross-sectional survey was conducted over a one-year period of patients seeking care in a public university hospital ED (census 65,000). Exclusion criteria were mentally impaired, institutionalized, or non-English speaking subjects. Subjects completed an anonymous survey detailing the 15 personal preparedness items from the Federal Emergency Management Agency's disaster preparedness checklist as well as demographic characteristics. Summary statistics were used to describe general preparedness. Chi-square tests were used to compare preparedness by demographics. RESULTS: During the study period, 857/1000 subjects completed the survey. Participants were predominantly male (57%), Caucasian (65%), middle-aged (mean 45 years), and high school graduates (83%). Seventeen percent (n = 146) reported having special needs and 8% were single parents. Most participants were not prepared: 451 (53%) had >75% of checklist items, 393 (46%) had food and water for 3 days, and 318 (37%) had food, water, and >75% of items. Level of preparedness was associated with age and parenting. Those aged 44 and older were more likely to be prepared for a disaster compared to younger respondents. (43.3% vs 31.1%, P = .0002). Similarly, single parents were more likely to be prepared than dual parenting households (47.1 vs 32.9%, P = .03). CONCLUSIONS: This study and others have found that only the minority of any group is actually prepared for disaster. Future research should focus on ways to implement disaster preparedness education, specifically targeting vulnerable populations, then measuring the effects of educational programs to demonstrate that preparedness has increased as a result.

Personal disaster preparedness of dialysis patients in North Carolina.

BACKGROUND AND OBJECTIVES: Dialysis patients are among the most vulnerable patients during a disaster because they are sensitive to a lapse in treatment. Although thorough preparation could mitigate disaster effects, we hypothesized that dialysis patients' personal and medical disaster preparedness was inadequate. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This prevalence study surveyed mentally competent adults requiring care at six regional dialysis centers. We asked questions regarding demographics, general disaster preparedness utilizing Homeland Security recommended item lists, dialysis-specific preparation for an individual to shelter in place, and preparatory steps for a forced evacuation. To determine if preparedness differed by demographic variables (gender, race, age, and education) chi-squared tests were used. RESULTS: Four hundred forty-two patients were approached, and 311 (70%) completed the survey. Participants were 54% male, 60% black, average age was 58 (± 15) years, and although 79% completed high school, 50% of our sample had marginal or low health literacy. Although all units had a disaster preparedness program in place, the general disaster preparedness of most participants was poor. Age, gender, race, education, literacy, and socioeconomic status did not affect general disaster preparedness. However, home peritoneal dialysis patients were significantly more likely to be prepared for a disaster compared with hemodialysis patients. No other significant associations were noted. CONCLUSIONS: Irrespective of sociodemographic characteristics, most subjects were unprepared for a disaster. Dialysis patients were poorly prepared to shelter in place or to evacuate in the face of a disaster. Education regarding personal and dialysis-specific disaster preparedness is warranted.

The North Carolina EMS Data System: a comprehensive integrated emergency medical services quality improvement program.

BACKGROUND: The EMS Agenda for the Future describes emergency medical services (EMS) as the intersection between public health, public safety, and health care. The most comprehensive method to describe, evaluate, and optimize these systems of care is using a state EMS data system. A centralized EMS data system can be a valuable tool to identify, evaluate, target, and improve EMS service delivery and patient care. Significant barriers, however, still exist to the standardization of EMS data systems and infrastructure nationally. Indeed, there is no comprehensive measurement of EMS service delivery or patient volume at the national level. OBJECTIVE: In this article, we describe the successful development of a fully integrated, statewide EMS data system for quality improvement of EMS service delivery and patient care in North Carolina. The article also provides a platform for linking EMS with emergency physicians, other health care providers, and public health agencies responsible for planning, disease surveillance, and disaster preparedness. RESULTS AND CONCLUSION: The North Carolina EMS Data System represents the successful development of a large, fully integrated, comprehensive statewide EMS database and quality improvement effort. The North Carolina EMS Data System applications include the Prehospital Medical Information System (PreMIS), the Credentialing Information System (CIS), the State Medical Asset Resource Tracking Tool (SMARTT), and the EMS Performance Improvement Toolkits. The system provides a quality and performance improvement program consistent with the idealized EMS design described in the EMS Agenda for the Future. The program has already achieved significant improvements in the quality of EMS service delivery, patient care, and integrated systems of care. Consistent with the goals of the 2007 Institute of Medicine's recommendations for EMS, the linkage of the North Carolina EMS Data System with other health care registries has created an environment that can evaluate larger systems of care and ultimate patient outcomes.

Workforce priorities: three steps to determine what they are & move forward.

In recent years, considerable media attention has been given to the shortage of EMTs and paramedics.(1-8) Reports appear often enough to raise concern among the public, the medical community and policymakers alike that an ongoing or pending nationwide "crisis" or "shortage" of EMS professionals is upon us. Rural challenges are particularly prevalent in media coverage.(5,6,9) The recent inclusion of a special rural EMS session at the National Conference of State Legislatures 2007 annual meeting suggests that concern among local politicians has reached a tipping point, which may prompt action.

Health literacy among Spanish-speaking patients in the emergency department.

STUDY OBJECTIVE: Health literacy influences a patient's ability to read and understand labels on medicine containers, appointment slips, informed-consent documents and medical instructions--all of which are considered basic health documents that a patient encounters in healthcare settings. Previous research suggests Spanish-speaking patients have low levels of health literacy. This study compares the functional health literacy (FHL) of Spanish- and English-speaking adult patients in a suburban emergency department (ED). METHODS: Through a prospective, matched cohort design, Spanish-speaking adult patients and pediatric guardians presenting to the ED were matched with English-speaking patients by age, gender and treatment area. Demographic information, including total years of school completed and self-assessed reading ability, was collected. The Test of Functional Health Literacy in Adults (TOFHLA) was administered in the subject's primary language. A score of <60 indicated inadequate FHL, 60-74 marginally adequate FHL, and >74 adequate literacy. RESULTS: Eighty-six matched pairs were enrolled. The median age was 30.5 years, and 56% were male. Spanish speakers averaged a TOFHLA score of 59.72, and English speakers 90.78. Only 7% of English speakers had less-than-adequate FHL compared to 74% of Spanish speakers. The average years of school completed were 10.59 (7.95 Spanish; 13.19 English), and 55% of English speakers reported "excellent" reading ability compared to 13% of Spanish speakers. Last grade completed (p=0.004) and self-assessed reading ability (p=0.0007) are predictors of TOFHLA scores. Those subjects who completed less than the eighth grade had inadequate FHL. CONCLUSIONS: The majority of Spanish-speaking subjects have less-than-adequate FHL. Self-reported reading ability and years of school completed appear to predict FHL and may be clinically useful. Due to the disproportionately low level of health literacy among Spanish-speaking patients demonstrated in this and previous studies, future efforts should focus on developing programs that improve health literacy by providing this population with oral translations and pictorial and video instructions.

Accuracy of EMS-recorded patient demographic data.

OBJECTIVE: Emergency medical services (EMS) research is frequently dependent on data recorded by prehospital personnel. Linking EMS information with hospital outcome depends on essential identifying data. We sought to determine the accuracy of these data in patients who activated EMS for chest pain and to describe the types of errors committed. METHODS: We performed a retrospective, consecutive case series study of all prehospital records for patients transported by the City of Pittsburgh Bureau of EMS (annual call volume, 60,000) for chest pain to three area hospitals during a three-month interval. Demographic data, including name, date of birth (DOB), and Social Security number (SSN), for each patient were extracted from the EMS record. These were compared to the definitive information in the hospital records. RESULTS: 360 prehospital records were examined, with 341 matches to hospital records. The correct patient name was recorded in 301 records (83.6%), the correct DOB was recorded 284 times (78.9%), and the correct SSN was recorded 120 times (33.3%). The overall error rate of demographic data recorded on EMS records was 73.9% (266/360). If SSN is not included as a demographic variable, then the overall error rate was 25.3% (91/360). CONCLUSION: The use of EMS-generated demographic data demonstrates moderate agreement and linkage with hospital records. Name and DOB are more reliable data elements for matching than SSN. Future research should examine the impact of electronic medical records and EMS identification numbers on data reliability.

Use of an emergency department by nonurgent patients.

OBJECTIVES: The objectives of this study are (1) to determine whether patients seeking emergency department (ED) nonurgent care have primary care providers (PCP) or know of other care sources and (2) to determine the reasons why they choose to use the ED. METHODS: A cross-sectional survey in a university ED was administered to self-referred nonurgent patients for 6 weeks. Use of a PCP, knowledge and attempts to seek other care, past use of the ED, urgency self-report, time of visit, and reasons for choosing an ED were recorded. RESULTS: Of the 563 approached subjects, 314 were eligible and 279 agreed to participate. One hundred fifty-seven (56%) had PCPs. For 183 (66%) subjects, the ED was the only place they knew to go for their present problem, and 75 (27%) reported that they depended on the ED for all medical care. Of those patients with a PCP, 73 (47%) rated the ED better for unscheduled care. Eighty-one (52%) subjects thought their PCP would be more efficient and 66 (42%) thought their PCP would be cheaper. CONCLUSIONS: Although most ED nonurgent patients were not dependent upon the ED, the majority was unaware of other places to go for their current health problem. Even those patients with a PCP sought care in the ED because the ED was believed to provide better care despite its perceived increase in both waiting time and cost.