False Electrical Capture in Prehospital Transcutaneous Pacing by Paramedics: A Case Series.

INTRODUCTION: The use of transcutaneous pacing (TCP) for unstable bradycardia has a class 2B recommendation from the American Heart Association. Prior studies have not adequately described the frequency or possible causes of treatment failure. EMS clinicians and leaders have reported false electrical capture as a potential cause. In this study, we aimed to describe the frequency of true electrical capture, documented verification of mechanical capture, and its association with systolic blood pressure (SBP) and survival. METHODS: This was a retrospective study of patients treated by an urban, hospital-based EMS network comprising two EMS agencies between March 2021 and March 2023. Inclusion criteria were adults with a heart rate of <60 bpm and attempted TCP. Variables included: initial electrocardiogram rhythm, SBP, current applied, neurological status at discharge, and diagnosis. The primary outcome was true electrical capture, defined as the presence of a visible wide QRS and T wave. This enabled calculation of false electrical capture. Additional outcomes included change in SBP and neurological status at discharge. RESULTS: 19 of the 23 (82.6%) patients who underwent TCP had false electrical capture despite all 23 having documented mechanical capture by palpated pulse. For patients with true electrical capture, the median change in SBP was +40 mmHg (IQR = 24.25, range= -12 to +49 mmHg). For patients with false electrical capture, the median change in SBP was -1 mmHg (IQR = 58.50, range= -90 to +23 mmHg). Median current for patients with true electrical capture was 95 mA (IQR = 13.75, range = 85-110) versus 70 mA (IQR = 30, range = 55-160) in those with false electrical capture. 16 (69.6%) had outcome data available. Patients with true electrical capture and outcome data (n = 2) survived to admission but only one survived to discharge with good functional capacity. Of 14 with false electrical capture and outcome data, 10 (71.4%) survived to admission; none survived to discharge with functional capacity. CONCLUSIONS: These findings suggest a high proportion of patients undergoing TCP are at risk of false electrical capture despite a recorded palpable pulse. While our analysis is limited to a single EMS network, these data raise concerns regarding the incidence of prehospital false electrical capture. Further research is warranted to calculate the incidence of false electrical capture and evaluate mitigation strategies.

Achieving Equity in EMS Care and Patient Outcomes Through Quality Management Systems: A Position Statement.

Improving health and safety in our communities requires deliberate focus and commitment to equity. Inequities are differences in access, treatment, and outcomes between individuals and across populations that are systemic, avoidable, and unjust. Within health care in general, and Emergency Medical Services (EMS) in particular, there are demonstrated inequities in the quality of care provided to patients based on a number of characteristics linked to discrimination, exclusion, or bias. Given the critical role that EMS plays within the health care system, it is imperative that EMS systems reduce inequities by delivering evidence-based, high-quality care for the communities and patients we serve. To achieve equity in EMS care delivery and patient outcomes, the National Association of EMS Physicians recommends that EMS systems and agencies: make health equity a strategic priority and commit to improving equity at all levels.assess and monitor clinical and safety quality measures through the lens of inequities as an integrated part of the quality management process.ensure that data elements are structured to enable equity analysis at every level and routinely evaluate data for limitations hindering equity analysis and improvement.involve patients and community stakeholders in determining data ownership and stewardship to ensure its ongoing evolution and fitness for use for measuring care inequities.address biases as they translate into the quality of care and standards of respect for patients.pursue equity through a framework rooted in the principles of improvement science.

Infant out-of-hospital cardiac arrest during nights and weekends.

BACKGROUND: A growing body of evidence suggests outcomes for cardiac arrest in adults are worse during nights and weekends when compared with daytime and weekdays. Similar research has not yet been carried out in the infant setting. METHODS: We examined the National Emergency Medical Services Information System (NEMSIS), a database containing millions of emergency medical services (EMS) runs in the United States. Inclusion criteria were infant out-of-hospital cardiac arrests (patients <1 years old) taking place prior to EMS arrival between January 2021 and December 2022 where EMS documented whether return of spontaneous circulation (ROSC) was achieved. Cardiac arrests were classified as occurring during either the day (defined as 0800-1959) or the night (defined as 2000-0759) and weekends (Saturday/Sunday) or weekdays (Monday-Friday). Rates of ROSC achievement were compared. RESULTS: A total of 8549 infant cardiac arrests met inclusion criteria: 5074 (59.4%) took place during daytime compared with 3475 (40.6%) during nighttime, and 5989 (70.1%) arrests occurred on weekdays compared with 2560 (29.9%) on weekends. Rates of ROSC achievement were significantly lower on weekends versus weekdays (16.8% vs. 14.1%; p = 0.00097). A difference in ROSC rates when comparing daytime and nighttime was seen, but this difference was not statistically significant (16.4% vs. 15.3%; p = 0.08076). CONCLUSION: ROSC achievement rates for infant out-of-hospital cardiac arrest are significantly lower on weekends when compared with weekdays. Further study and quality improvement work is needed to better understand this.