Evaluating methods for risk prediction of Covid-19 mortality in nursing home residents before and after vaccine availability: a retrospective cohort study.

BACKGROUND: SARS-CoV-2 vaccines are effective in reducing hospitalization, COVID-19 symptoms, and COVID-19 mortality for nursing home (NH) residents. We sought to compare the accuracy of various machine learning models, examine changes to model performance, and identify resident characteristics that have the strongest associations with 30-day COVID-19 mortality, before and after vaccine availability. METHODS: We conducted a population-based retrospective cohort study analyzing data from all NH facilities across Ontario, Canada. We included all residents diagnosed with SARS-CoV-2 and living in NHs between March 2020 and July 2021. We employed five machine learning algorithms to predict COVID-19 mortality, including logistic regression, LASSO regression, classification and regression trees (CART), random forests, and gradient boosted trees. The discriminative performance of the models was evaluated using the area under the receiver operating characteristic curve (AUC) for each model using 10-fold cross-validation. Model calibration was determined through evaluation of calibration slopes. Variable importance was calculated by repeatedly and randomly permutating the values of each predictor in the dataset and re-evaluating the model's performance. RESULTS: A total of 14,977 NH residents and 20 resident characteristics were included in the model. The cross-validated AUCs were similar across algorithms and ranged from 0.64 to 0.67. Gradient boosted trees and logistic regression had an AUC of 0.67 pre- and post-vaccine availability. CART had the lowest discrimination ability with an AUC of 0.64 pre-vaccine availability, and 0.65 post-vaccine availability. The most influential resident characteristics, irrespective of vaccine availability, included advanced age (≥ 75 years), health instability, functional and cognitive status, sex (male), and polypharmacy. CONCLUSIONS: The predictive accuracy and discrimination exhibited by all five examined machine learning algorithms were similar. Both logistic regression and gradient boosted trees exhibit comparable performance and display slight superiority over other machine learning algorithms. We observed consistent model performance both before and after vaccine availability. The influence of resident characteristics on COVID-19 mortality remained consistent across time periods, suggesting that changes to pre-vaccination screening practices for high-risk individuals are effective in the post-vaccination era.

Post-Pandemic Growth in 9-1-1 Paramedic Calls and Emergency Department Transports Surpasses Pre-Pandemic Rates in the COVID-19 Era: Implications for Paramedic Resource Planning.

OBJECTIVES: The COVID-19 pandemic led to a decline in emergency department (ED) visits and a subsequent return to baseline pre-pandemic levels. It is unclear if this trend extended to paramedic services and if patient cohorts accessing paramedics changed. We examined trends and associations between paramedic utilization (9-1-1 calls and ED transports) and the COVID-19 timeframe. METHODS: We conducted a retrospective cross-sectional study using paramedic call data from the Hamilton Paramedic Services from January 2016 to December 2023. We included all 9-1-1 calls where paramedics responded to an incident, excluding paramedic interfacility transfers. We calculated lines of best fit for the pre-pandemic period (January 2016 to January 2020) and compared their predictions to the actual volumes in the post-pandemic period (May 2021 to December 2023). We used an interrupted time series regression model to determine the association between pandemic timeframes (pre-, during-, post-COVID-19) and paramedic utilization (9-1-1 calls and ED transports), while testing for annual seasonality. RESULTS: During the study timeframe, 577,278 calls for paramedics were received and 413,491 (71.6%) were transported to the ED. Post-pandemic, 9-1-1 calls exceeded predicted pre-pandemic levels by 1,298 per month, while ED transports exceeded by 543 per month. The pandemic significantly reduced monthly 9-1-1 calls (-588.2, 95% CI -928.8 to -247.5) and ED transports (-677.3, 95% CI -927.0 to -427.5). Post-pandemic, there was a significant and sustained resurgence in monthly 9-1-1 calls (1,208.0, 95% CI 822.1 to 1,593.9) and ED transports (868.8, 95% CI 585.8 to 1,151.7). Both models exhibited seasonal variations. CONCLUSIONS: Post-pandemic, 9-1-1-initiated paramedic calls experienced a substantial increase, surpassing pre-pandemic growth rates. ED transports returned to pre-pandemic levels but with a steeper and continuous pattern of growth. The resurgence in paramedic 9-1-1 calls and ED transports post-COVID-19 emphasizes an urgent necessity to expedite development of new care models that address how paramedics respond to 9-1-1 calls and transport to overcrowded EDs.

Ventricular Fibrillation Simulated Electrocardiogram Artifact by a Deep Brain Stimulator.

Deep brain stimulation devices can disrupt cardiac rhythm interpretation by causing electrocardiogram artifact. We report the case of a deep brain stimulating device initiating ventricular fibrillation simulated electrocardiogram artifact in the prehospital setting. Mimicked ventricular fibrillation due to a deep brain stimulator has not been documented, and if unrecognized could influence unwarranted or potentially harmful clinical decisions.

Clinical factors associated with recent medical care visits in nursing homes: a multi-site cross-sectional study.

OBJECTIVES: We examined which resident-level clinical factors influence the provision of a recent medical care visit in nursing homes (NHs). DESIGN: Multi-site cross-sectional. SETTING AND PARTICIPANTS: We extracted data on 3,556 NH residents from 18 NH facilities in Ontario, Canada, who received at minimum, an admission and first-quarterly assessment with the Resident Assessment Instrument Minimum Data Set (MDS) 2.0 between November 1, 2009, and October 31, 2017. METHODS: We conducted a secondary analysis of routinely collected MDS 2.0 data. The provision of a recent medical care visit by a physician (or authorized clinician) was assessed in the 14-day period preceding a resident's first-quarterly MDS 2.0 assessment. We utilized best-subset multivariable logistic regression to model the adjusted associations between resident-level clinical factors and a recent medical care visit. RESULTS: Two thousand eight hundred fifty nine (80.4%) NH residents had one or more medical care visits prior to their first-quarterly MDS 2.0 assessment. Six clinically relevant factors were identified to be associated with recent medical care visits in the final model: exhibiting wandering behaviours (OR = 1.34, 95% CI 1.09 - 1.63), presence of a pressure ulcer (OR = 1.37, 95% CI 1.05 - 1.78), a urinary tract infection (UTI) (OR = 1.52, 95% CI 1.06 - 2.18), end-stage disease (OR = 9.70, 95% CI 1.32 - 71.02), new medication use (OR = 1.31, 95% CI 1.09 - 1.57), and analgesic use (OR = 1.24, 95% CI 1.03 - 1.49). CONCLUSIONS AND IMPLICATIONS: Our findings suggest that resident-level clinical factors drive the provision of medical care visits following NH admission. Clinical factors associated with medical care visits align with the minimum competencies expected of physicians in NH practice, including managing safety risks, infections, medications, and death. Ensuring that NH physicians have opportunities to acquire and strengthen these competencies may be transformative to meet the ongoing needs of NH residents.

Examining the association between paramedic transport to the emergency department and hospital admission: a population-based cohort study.

BACKGROUND: Increasing hospitalization rates present unique challenges to manage limited inpatient bed capacity and services. Transport by paramedics to the emergency department (ED) may influence hospital admission decisions independent of patient need/acuity, though this relationship has not been established. We examined whether mode of transportation to the ED was independently associated with hospital admission. METHODS: We conducted a retrospective cohort study using the National Ambulatory Care Reporting System (NACRS) from April 1, 2015 to March 31, 2020 in Ontario, Canada. We included all adult patients (≥18 years) who received a triage score in the ED and presented via paramedic transport or self-referral (walk-in). Multivariable binary logistic regression was used to determine the association of mode of transportation between hospital admission, after adjusting for important patient and visit characteristics. RESULTS: During the study period, 21,764,640 ED visits were eligible for study inclusion. Approximately one-fifth (18.5%) of all ED visits were transported by paramedics. All-cause hospital admission incidence was greater when transported by paramedics (35.0% vs. 7.5%) and with each decreasing Canadian Triage and Acuity Scale level. Paramedic transport was independently associated with hospital admission (OR = 3.76; 95%CI = 3.74-3.77), in addition to higher medical acuity, older age, male sex, greater than two comorbidities, treatment in an urban setting and discharge diagnoses specific to the circulatory or digestive systems. CONCLUSIONS: Transport by paramedics to an ED was independently associated with hospital admission as the disposition outcome, when compared against self-referred visits. Our findings highlight patient and visit characteristics associated with hospital admission, and can be used to inform proactive healthcare strategizing for in-patient bed management.

Out-of-hospital cardiac arrest in high-rise buildings: delays to patient care and effect on survival.

BACKGROUND: The increasing number of people living in high-rise buildings presents unique challenges to care and may cause delays for 911-initiated first responders (including paramedics and fire department personnel) responding to calls for out-of-hospital cardiac arrest. We examined the relation between floor of patient contact and survival after cardiac arrest in residential buildings. METHODS: We conducted a retrospective observational study using data from the Toronto Regional RescuNet Epistry database for the period January 2007 to December 2012. We included all adult patients (≥ 18 yr) with out-of-hospital cardiac arrest of no obvious cause who were treated in private residences. We excluded cardiac arrests witnessed by 911-initiated first responders and those with an obvious cause. We used multivariable logistic regression to determine the effect on survival of the floor of patient contact, with adjustment for standard Utstein variables. RESULTS: During the study period, 7842 cases of out-of-hospital cardiac arrest met the inclusion criteria, of which 5998 (76.5%) occurred below the third floor and 1844 (23.5%) occurred on the third floor or higher. Survival was greater on the lower floors (4.2% v. 2.6%, p = 0.002). Lower adjusted survival to hospital discharge was independently associated with higher floor of patient contact, older age, male sex and longer 911 response time. In an analysis by floor, survival was 0.9% above floor 16 (i.e., below the 1% threshold for futility), and there were no survivors above the 25th floor. INTERPRETATION: In high-rise buildings, the survival rate after out-of-hospital cardiac arrest was lower for patients residing on higher floors. Interventions aimed at shortening response times to treatment of cardiac arrest in high-rise buildings may increase survival.

Validating the Emergency Department Avoidability Classification (EDAC): A cluster randomized single-blinded agreement study.

INTRODUCTION: The Emergency Department Avoidability Classification (EDAC) retrospectively classifies emergency department (ED) visits that could have been safely managed in subacute primary care settings, but has not been validated against a criterion standard. A validated EDAC could enable accurate and reliable quantification of avoidable ED visits. We compared agreement between the EDAC and ED physician judgements to specify avoidable ED visits. MATERIALS AND METHODS: We conducted a cluster randomized, single-blinded agreement study in an academic hospital in Hamilton, Canada. ED visits between January 1, 2019, and December 31, 2019 were clustered based on EDAC classes and randomly sampled evenly. A total of 160 ED visit charts were randomly assigned to ten participating ED physicians at the academic hospital for evaluation. Physicians judged if the ED visit could have been managed appropriately in subacute primary care (an avoidable visit); each ED visit was evaluated by two physicians independently. We measured interrater agreement between physicians with a Cohen's kappa and 95% confidence intervals (CI). We evaluated the correlation between the EDAC and physician judgements using a Spearman rank correlation and ordinal logistic regression with odds ratios (ORs) and 95% CIs. We examined the EDAC's precision to identify avoidable ED visits using accuracy, sensitivity and specificity. RESULTS: ED physicians agreed on 139 visits (86.9%) with a kappa of 0.69 (95% CI 0.59-0.79), indicating substantial agreement. Physicians judged 96.2% of ED visits classified as avoidable by the EDAC as suitable for management in subacute primary care. We found a high correlation between the EDAC and physician judgements (0.64), as well as a very strong association to classify avoidable ED visits (OR 80.0, 95% CI 17.1-374.9). The EDACs avoidable and potentially avoidable classes demonstrated strong accuracy to identify ED visits suitable for management in subacute care (82.8%, 95% CI 78.2-86.8). DISCUSSION: The EDAC demonstrated strong evidence of criterion validity to classify avoidable ED visits. This classification has important potential for accurately monitoring trends in avoidable ED utilization, measuring proportions of ED volume attributed to avoidable visits and informing interventions intended at reducing ED use by patients who do not require emergency or life-saving healthcare.

Prehospital prediction of hospital admission for emergent acuity patients transported by paramedics: A population-based cohort study using machine learning.

INTRODUCTION: The closest emergency department (ED) may not always be the optimal hospital for certain stable high acuity patients if further distanced ED's can provide specialized care or are less overcrowded. Machine learning (ML) predictions may support paramedic decision-making to transport a subgroup of emergent patients to a more suitable, albeit more distanced, ED if hospital admission is unlikely. We examined whether characteristics known to paramedics in the prehospital setting were predictive of hospital admission in emergent acuity patients. MATERIALS AND METHODS: We conducted a population-level cohort study using four ML algorithms to analyze ED visits of the National Ambulatory Care Reporting System from January 1, 2018 to December 31, 2019 in Ontario, Canada. We included all adult patients (≥18 years) transported to the ED by paramedics with an emergent Canadian Triage Acuity Scale score. We included eight characteristic classes as model predictors that are recorded at ED triage. All ML algorithms were trained and assessed using 10-fold cross-validation to predict hospital admission from the ED. Predictive model performance was determined using the area under curve (AUC) with 95% confidence intervals and probabilistic accuracy using the Brier Scaled score. Variable importance scores were computed to determine the top 10 predictors of hospital admission. RESULTS: All machine learning algorithms demonstrated acceptable accuracy in predicting hospital admission (AUC 0.77-0.78, Brier Scaled 0.22-0.24). The characteristics most predictive of admission were age between 65 to 105 years, referral source from a residential care facility, presenting with a respiratory complaint, and receiving home care. DISCUSSION: Hospital admission was accurately predicted based on patient characteristics known prehospital to paramedics prior to arrival. Our results support consideration of policy modification to permit certain emergent acuity patients to be transported to a further distanced ED. Additionally, this study demonstrates the utility of ML in paramedic and prehospital research.

Evaluating emergency department transfers from urgent care centres: insights for paramedic integration with subacute healthcare.

OBJECTIVE: Paramedics redirecting non-emergent patients from emergency departments (EDs) to urgent care centres is a new and forthcoming strategy to reduce overcrowding and improve primary care integration. Which patients are likely not suitable for paramedic redirection are unknown. To describe and specify patients inappropriate for urgent care centres, we examined associations between patient characteristics and transfer to the ED after patients initially presented to an urgent care centre. METHODS: A population-based retrospective cohort study of all adult (≥18 years) visits to an urgent care centre from 1 April 2015 to 31 March 2020 in Ontario, Canada. Binary logistic regression was used to determine unadjusted and adjusted associations between patient characteristics and being transferred to an ED using OR and 95% CIs. We calculated the absolute risk difference for the adjusted model. RESULTS: A total of 1 448 621 urgent care visits were reported, with 63 343 (4.4%) visits transferred to an ED for definitive care. Being 65 years and older (OR 2.29, 95% CI 2.23 to 2.35), scored an emergent Canadian Triage and Acuity Scale of 1 or 2 (OR 14.27, 95% CI 13.45 to 15.12) and higher comorbidity count (OR 1.51, 95% CI 1.46 to 1.58) had added odds of association with being transferred out to an ED. CONCLUSION: Readily available patient characteristics were independently associated with interfacility transfers between urgent care centres and the ED. This study can support paramedic redirection protocol development, highlighting which patients may not be best suited for ED redirection.

Inclusion of patient-level emergency department characteristics to classify potentially redirectable visits to subacute care: a modified Delphi consensus study.

BACKGROUND: Most patients transported by Ontario paramedics to the emergency department have non-emergent conditions and may be more appropriately served by subacute community-based care centres. We sought to determine consensus on a set of patient characteristics that could be useful to classify retrospective emergency department visits that had a high probability of being primary care-like and potentially redirectable to a subacute care centre by paramedics. METHODS: We conducted a modified Delphi study to assess expert consensus on characteristics of patients transported by paramedics to the emergency department from August to October 2021. An expert Delphi committee was constructed of emergency and family physicians in Ontario using purposive sampling. Experts rated whether each characteristic was useful to be included in a classification to identify potentially redirectable visits retrospectively, as well as characteristic details (e.g., upper and lower bounds). Consensus was considered 75% agreement. RESULTS: Sixteen experts participated in the study; the experts were mostly male (75%) and evenly divided between emergency and family medicine. After 2 rounds, consensus was achieved on 8 of 9 characteristics (89%). Four characteristics were determined as useful to classify potentially redirectable emergency department visits: age (81%), triage acuity (100%), specialist consult in the emergency department (94%) and emergency department visit outcome (81%). Specifications of each characteristic were refined as follows: young and middle-aged adults with a non-emergent triage acuity, did not receive a specialist physician consult in the emergency department and discharged from the emergency department. INTERPRETATION: Strong consensus was achieved to specify a classification system for potentially redirectable emergency department visits. These results will be combined with knowledge of which subacute care centres could conduct the main physician interventions to retrospectively identify emergency department visits that could have been suitable for paramedic redirection for further research. STUDY REGISTRATION: ID ISRCTN22901977.

Examining the "Potentially Preventable Emergency Department Transfer" Indicator Among Nursing Home Residents.

OBJECTIVE: To determine if nursing home (NH) resident characteristics associated with potentially preventable emergency department transfers (PPEDs) are similarly associated with non-potentially preventable emergency department transfers (non-PPEDs). DESIGN: We conducted a population-level retrospective cohort study using linked administrative data reported using the Resident Assessment Instrument-Minimum Data Set Version 2.0 and the National Ambulatory Care Reporting System for emergency department transfers. SETTING AND PARTICIPANTS: We assessed all NH residents transferred to the emergency department within 92 days after admission. The cohort included 56,433 NH resident admissions assessment of which 3498 NH residents experienced PPEDs, and 9331 residents experienced non-PPEDs. METHODS: We assessed Ontario NH residents admission assessments collected between January 1, 2017, and December 31, 2018. We used cumulative incidence functions and Cox regression to compare resident characteristics between residents experiencing PPEDs and non-PPEDs. PPEDs were defined based on the International Classification of Diseases, 10th Revision. RESULTS: Approximately 23% of residents experienced an emergency department transfer within 92 days of NH admission. The cumulative incidence of PPEDs was 6.3% and non-PPEDs was 16.8%. After adjusting for clinically relevant features, 14 of 18 resident admission characteristics were associated with both types of transfers. Resident admission characteristics associated with a greater risk of PPEDs solely were pneumonia [hazard ratio (HR) 1.48; CI 1.25-1.70] and oxygen therapy (HR 1.88; CI 1.69-2.10). Resident admission characteristics associated with a greater risk of non-PPEDs solely are experiencing a change in mood (HR 1.09; CI 1.01-1.18) and delirium (HR 1.08; CI 1.04-1.13). CONCLUSIONS AND IMPLICATIONS: PPEDs were associated with a similar cluster of NH resident characteristics as those transferred for non-ambulatory reasons, suggesting that the clinical distinction between PPEDs vs non-PPEDs within the NH might be unclear. These findings highlight that the PPED indicator could be revised to improve specificity.

Quantifying the escalating impact of paramedic transported emergency department visits for opioid-related conditions in Ontario, Canada: A population-based cohort study.

INTRODUCTION: While overdoses comprise the majority of opioid research, the comprehensive impact of the opioid crisis on emergency departments (EDs) and paramedic services has not been reported. We examined temporal changes in population-adjusted incidence rates of ED visits and paramedic transports due to opioid-related conditions. MATERIALS AND METHODS: We conducted a population-based cohort study of all ED visits in the National Ambulatory Care Reporting System from January 1, 2009 to December 31, 2019 in Ontario, Canada. We included all patients with a primary diagnosis naming opioids as the underlying cause for the visit, without any other drugs or substances. We clustered geographic regions using Local Health Integration Network boundaries. Descriptive statistics, incidence rate ratios (IRR) and 95% confidence intervals (CIs) were calculated to analyze population-adjusted temporal changes. RESULTS: Overall, 86,403 ED visits were included in our study. Incidence of opioid-related ED visits increased by 165% in the study timeframe, with paramedic transported patients increasing by 429%. Per 100,000 residents, annual ED visits increased from 40.4 to 97.2, and paramedic transported patients from 12.1 to 67.9. The proportion of opioid-related ED visits transported by paramedics increased from 35.0% to 69.9%. The medical acuity of opioid-related ED visits increased throughout the years (IRR 6.8. 95% CI 5.9-7.7), though the proportion of discharges remained constant (~75%). The largest increases in ED visits and paramedic transports were concentrated to urbanized regions. DISCUSSION: Opioid-related ED visits and paramedic transports increased substantially between 2009 and 2019. The proportion of ED visits transported by paramedics doubled. Our findings could provide valuable support to health stakeholders in implementing timely strategies aimed at safely reducing opioid-related ED visits. The increased use of paramedics followed by high rates of ED discharge calls for exploration of alternative care models within paramedic systems, such as direct transport to specialized substance abuse centres.

The Association Between Frailty and a Nurse-Identified Need for Comprehensive Geriatric Assessment Referral from the Emergency Department.

BACKGROUND: Emergency nurses commonly conduct geriatric assessments in the emergency department (ED). However, little is known about what geriatric syndromes or clinical presentations prompt a nurse to document an identified need for comprehensive geriatric assessment (CGA). OBJECTIVES: To examine the association between geriatric syndromes, like frailty, and a nurse-identified need for a CGA following emergency care. METHODS: We conducted a secondary analysis of a multi-province Canadian cohort from the InterRAI Multinational Cohort Study. We collected data at ED registration from patients 75 years of age and older (n = 2,274) from eight ED sites across Canada between November 2009 and April 2012. Geriatric syndromes were assessed by trained emergency nurses using the interRAI ED Contact Assessment; and we retrospectively calculated the ED frailty index. We employed binary logistic regression to determine the adjusted associations between geriatric syndromes and a nurse-identified need for a CGA. RESULTS: Approximately one-quarter (28%) of older adults were identified to need a CGA following emergency care. A 0.1 unit increase in the ED frailty index increased the likelihood of a nurse identify a need for CGA (RD: 6.6; 95% CI = 5.5-7.9). Most geriatric syndromes increased the probability of a nurse documenting the need for a CGA. CONCLUSION: When assessed by emergency nurses, the identified need for CGA is strongly linked to the presence of geriatric syndromes, including frailty. We provide face validity for the continued use of emergency nurses for screening and assessing older ED patients.

Prognostic Association Between Frailty and Post-Arrest Health Outcomes in Patients Receiving Home Care: A Population-Based Retrospective Cohort Study.

AIM: To evaluate the association between frailty and post-cardiac arrest survival, functional decline, and cognitive decline, among patients receiving home care. METHODS: Frailty was measured using the Clinical Frailty Scale (CFS) and a valid frailty index. We used multivariable logistic regression to measure the association between frailty and post-arrest outcomes after adjusting for age, sex, and arrest setting. Functional independence and cognitive performance were measured using the interRAI ADL Long-Form and Cognitive Performance Scale, respectively. We conducted sub-group analytics of in-hospital and out-of-hospital arrests. RESULTS: Our cohort consisted of 7,901 home care clients; most patients arrested out-of-hospital (55.4%) and were 75 years or older (66.3%). Most were classified as frail (94.2%) with a CFS score of 5 or greater. The 30-day survival rate was higher for in-hospital (26.6%) than out-of-hospital cardiac arrests (5.2%). Most patients who survived to discharge had declines in post-arrest functional independence (65.8%) and cognitive performance (46.5%). A one-point increase in the CFS decreased the odds of 30-day survival by 8% (aOR = 0.92; 95%CI = 0.87-0.97). A 0.1 unit increase in the frailty index reduced the odds of 30-day survival by 9% (aOR = 0.91; 95%CI = 0.86-0.96). The frailty index was associated with declines in functional independence (OR = 1.16; 95%CI = 1.02-1.31) and cognitive performance (OR = 1.24; 95%CI = 1.09-1.42), while the CFS was not. CONCLUSION: Frailty is associated with cardiac arrest survival and post-arrest cognitive and functional status in patients receiving home care. Post-cardiac arrest cognitive and functional status are best predicted using more comprehensive frailty indices.

Emergency department interventions that could be conducted in subacute care settings for patients with nonemergent conditions transported by paramedics: a modified Delphi study.

BACKGROUND: As the number of patients with nonemergent conditions who are transported by paramedics continues to increase in Ontario, redirecting specific patients to subacute settings may be more beneficial and suitable for both patients and emergency departments. We aimed to evaluate whether emergency department interventions conducted on patients with nonemergent conditions who are transported by paramedics could be conducted in subacute health centres. METHODS: We conducted a RAND/UCLA modified Delphi study in Ontario between Oct. 13 and Dec. 19, 2020. We used purposive sampling to recruit practising emergency and primary care physicians for an expert panel. We abstracted interventions given to adult patients with nonemergent conditions (18 yr of age or older) who were transported by paramedics to an emergency department from the National Ambulatory Care Reporting System (NACRS) database (Jan. 1, 2014, to Mar. 31, 2018). Participants in the expert panel rated the suitability of the 150 most frequently recorded emergency department interventions from the NACRS database, for completion in subacute health care centres. We set consensus at 70% agreement. RESULTS: We invited 25 physician experts, 21 of whom consented to participate; 20 physicians completed round 1, and 18 physicians completed both rounds. After 2 rounds, consensus was reached on 146 (97.3%) interventions; 103 interventions (68.7%) were suitable for subacute centres, 43 (28.7%) for only the emergency department and 4 (2.6%) did not receive consensus. For subacute centres, all 103 interventions were rated for urgent care centres; walk-in medical centres were applicable for 46 (30.6%) interventions and clinics led by nurse practitioners for 47 (31.3%) interventions. INTERPRETATION: Most interventions provided to patients with nonemergent conditions transported by paramedics to emergency departments were identified as suitable for urgent care clinics, with one-third being suitable for either walk-in medical centres or clinics led by nurse practitioners. This study has potential to inform a patient classification model for paramedic-initiated redirection of patients from emergency departments, although further contextualization is required for this to be implemented in clinical practice. STUDY REGISTRATION: ID ISRCTN22901977.

Increased demand for paramedic transports to the emergency department in Ontario, Canada: a population-level descriptive study from 2010 to 2019.

PURPOSE: We examined changes in annual paramedic transport incidence over the ten years prior to COVID-19 in comparison to increases in population growth and emergency department (ED) visitation by walk-in. METHODS: We conducted a population-level cohort study using the National Ambulatory Care Reporting System from January 1, 2010 to December 31, 2019 in Ontario, Canada. We included all patients triaged in the ED who arrived by either paramedic transport or walk-in. We clustered geographical regions using the Local Health Integration Network boundaries. Descriptive statistics, rate ratios (RR), and 95% confidence intervals were calculated to explore population-adjusted changes in transport volumes. RESULTS: Overall incidence of paramedic transports increased by 38.3% (n = 264,134), exceeding population growth fourfold (9.4%) and walk-in ED visitation threefold (13.4%). Population-adjusted transport rates increased by 26.2% (rate ratio 1.26, 95% CI 1.26-1.27) compared to 3.4% for ED visit by walk-in (rate ratio 1.03, 95% CI 1.03-1.04). Patient and visit characteristics remained consistent (age, gender, triage acuity, number of comorbidities, ED disposition, 30-day repeat ED visits) across the years of study. The majority of transports in 2019 had non-emergent triage scores (60.0%) and were discharged home directly from the ED (63.7%). The largest users were persons aged 65 or greater (43.7%). The majority of transports occurred in urbanized regions, though rural and northern regions experienced similar paramedic transport growth rates. CONCLUSION: There was a substantial increase in the demand for paramedic transportation. Growth in paramedic demand outpaced population growth markedly and may continue to surge alongside population aging. Increases in the rate of paramedic transports per population were not bound to urbanized regions, but were province-wide. Our findings indicate a mounting need to develop innovative solutions to meet the increased demand on paramedic services and to implement long-term strategies across provincial paramedic systems.

RéSUMé: OBJECTIFS: Nous avons examiné l'évolution de l'incidence annuelle du transport paramédical au cours des dix années précédant la COVID-19 par rapport à l'augmentation de la croissance de la population et des visites à l'urgence en personne. MéTHODES: Nous avons mené une étude de cohorte au niveau de la population en utilisant le Système national d'information sur les soins ambulatoires du 1er janvier 2010 au 31 décembre 2019 en Ontario, au Canada. Nous avons inclus tous les patients triés aux urgences qui sont arrivés par transport paramédical ou sans rendez-vous. Nous avons regroupé les régions géographiques en utilisant les limites du Réseau local d'intégration des services de santé. Des statistiques descriptives, des rapports de taux (RR) et des intervalles de confiance à 95% ont été calculés pour examiner les variations des volumes de transport ajustées en fonction de la population. RéSULTATS: L'incidence globale des transports paramédicaux a augmenté de 38.3% (n = 264 134), soit quatre fois plus que la croissance démographique (9.4%) et trois fois plus que la fréquentation des urgences sans rendez-vous (13.4 %). Les taux de transport ajustés à la population ont augmenté de 26.2 % (ratio de taux 1.26, IC à 95% 1.26­1.27), contre 3.4 % pour la visite aux urgences sans rendez-vous (ratio de taux 1.03, IC à 95% 1.03­1.04). Les caractéristiques des patients et des visites sont restées constantes (âge, sexe, acuité du triage, nombre de comorbidités, disposition des urgences, visites répétées aux urgences à 30 jours) au cours des années d'étude. La majorité des transports en 2019 avaient des scores de triage non urgents (60.0 %) et ont été renvoyés chez eux directement du service d'urgence (63.7 %). Les plus grands utilisateurs étaient les personnes âgées de 65 ans ou plus (43.7 %). La majorité des transports ont eu lieu dans les régions urbanisées, bien que les régions rurales et du Nord aient connu des taux de croissance du transport paramédical similaires. CONCLUSION: Il y a eu une augmentation considérable de la demande de transport paramédical. La croissance de la demande de services paramédicaux a nettement dépassé la croissance de la population et pourrait continuer d'augmenter parallèlement au vieillissement de la population. Les augmentations du taux de transports paramédicaux par population n'étaient pas limitées aux régions urbanisées, mais s'étendaient à l'ensemble de la province. Nos constatations indiquent un besoin croissant d'élaborer des solutions novatrices pour répondre à la demande accrue de services paramédicaux et mettre en œuvre des stratégies à long terme dans l'ensemble des systèmes paramédicaux provinciaux.

Validation of a classification to identify emergency department visits suitable for subacute and virtual care models: a randomised single-blinded agreement study protocol.

INTRODUCTION: Redirecting suitable patients from the emergency department (ED) to alternative subacute settings may assist in reducing ED overcrowding while delivering equivalent care. The Emergency Department Avoidance Classification (EDAC) was constructed to retrospectively classify ED visits that may have been suitable for safe management in a subacute or virtual clinical setting. The EDAC has established face and content validity but has not been tested against a reference standard as a criterion. OBJECTIVES: Our primary objective is to examine the agreement between the EDAC and ED physician judgements in retrospectively identifying ED visits suitable for subacute care management. Our secondary objective is to assess the validity of ED physicians' judgement as a criterion standard. Our tertiary objective is to examine how the ED physician's perception of a virtual ED care alternative correlates with the EDAC. METHODS AND ANALYSIS: A randomised single-centre, single-blinded agreement study. We will randomly select ED charts between 1 January and 31 December 2019 from an academic hospital in Hamilton, Canada. ED charts will be randomly assigned to participating ED physicians who will evaluate if this ED visit could have been managed appropriately and safely in a subacute and/or virtual model of care. Each chart will be reviewed by two physicians independently. We compute our needed sample size to be 79 charts. We will use kappa statistics to measure inter-rater agreement. A repeated measures regression model of physician ratings will provide variance estimates that we will use to assess the intraclass correlation of ED physician ratings and the EDAC. ETHICS AND DISSEMINATION: This study has been approved by the Hamilton Integrated Research Ethics Board (2022-14625). If validated, the EDAC may provide an ED-based classification to identify potentially avoidable ED visits, monitor ED visit trends, and proactively delineate those best suited for subacute or virtual care models.

Prognosis of cardiac arrest in home care clients and nursing home residents: A population-level retrospective cohort study.

Aim: To evaluate the prognosis of 30-day survival post-cardiac arrest among patients receiving home care and nursing home residents. Methods: We conducted a population-level retrospective cohort study of community-dwelling adults (≥18 years) who received cardiac arrest care at a hospital in Ontario, Canada, between 2006 to 2018. We linked population-based health datasets using the Home Care Dataset to identify patients receiving home care and the Continuing Care Reporting System to identify nursing home residents. We included both out-of-hospital and in-hospital cardiac arrests. We determined unadjusted and adjusted associations using logistic regression after adjusting for age and sex. We converted relative measures to absolute risks. Results: Our cohort contained 86,836 individuals. Most arrests (55.5 %) occurred out-of-hospital, with 9,316 patients enrolled in home care and 2,394 residing in a nursing home. When compared to those receiving no support services, the likelihood of survival to 30-days was lower for those receiving home care (RD = -6.5; 95 %CI = -7.5 - -5.0), with similar results found within sub-groups of out-of-hospital (RD = -6.7; 95 %CI = -7.6 - -5.7) and in-hospital arrests (RD = -8.7; 95 %CI = -10.6 - -7.3). The likelihood of 30-day survival was lower for nursing home residents (RD = -7.2; 95 %CI = -9.3 - -5.3) with similar results found within sub-groups of out-of-hospital (RD = -8.6; 95 %CI = -10.6 - -5.7) and in-hospital arrests (RD = -5.0; 95 %CI = -7.8 - -2.1). Conclusion: Patients receiving home care and nursing home residents had worse overall prognoses of survival post-cardiac arrest compared to those receiving no pre-arrest support, highlighting two medically-complex groups likely to benefit from advance care planning.

Development of the PriCARE classification for potentially preventable emergency department visits by ambulance: a RAND/UCLA modified Delphi study protocol.

INTRODUCTION: Ontario ambulances are restricted from patient transportation to sub-acute levels of care when these facilities may be more suitable than emergency departments for non-emergent conditions. There is no known patient classification specifically constructed to inform ED diversion protocols and guidance for sub-acute centre transportation for primary care-like patient conditions. OBJECTIVE: To construct a novel patient classification of potentially preventable emergency department visits following transport by ambulance, and analyse patient-level characteristic associations with this classification based in Ontario secondary data. METHODS AND ANALYSIS: The Primary Care-like Ambulance transports following Response for 911-Emergencies (PriCARE) patient classification will be constructed using a two-phase RAND/UCLA modified Delphi design. All experts included are physicians with relevant experience in emergency and/or primary care in Ontario. The first phase of the study will determine consensus of the expert committee on which ED interventions performed on patients with non-emergent acuities could be conducted in sub-acute healthcare centres. The second phase will assess consensus of which patient, hospital and acuity factors are most appropriate to be incorporated into a PriCARE classification. We will also investigate secondary outcomes on consensus of which ED interventions could be transferred to a paramedic context given an expanded scope of practice and patient-level characteristics of PriCARE classified individuals. ETHICS AND DISSEMINATION: This study received a research ethics board exemption waiver from the Hamilton Integrated Research Ethics Board; review reference 2020-11451-GRA. Results will be submitted for publication in a peer-reviewed journal and presented at relevant conferences. The results will be shared with Ontario paramedic services and governing institutions. This study will be used to inform patient classification protocols and clinical decision tools for ambulances to transport to sub-acute healthcare centres. TRIAL REGISTRATION NUMBER: ISRCTN22901977.