Effects of the COVID-19 pandemic on out-of-hospital cardiac arrest care in Detroit.

INTRODUCTION: In response to the COVID-19 pandemic in Detroit, an earlier termination of resuscitation protocol was initiated in March 2020. To characterize pre-hospital cardiac arrest careduring COVID-19 in Detroit, we analyzed out-of-hospital cardiac arrest (OHCA) rate of ROSC (return of spontaneous circulation) and patient characteristics before and during the COVID-19 pandemic. METHODS: OHCA data was analyzed between March 10th, 2020 - April 30th, 2020 and March 10th, 2019 - April 30th, 2019. ROSC, patient demographics, arrest location, initial rhythms, bystander CPR and field termination were compared before and during the pandemic. Descriptive statistics were utilized to compare arrest characteristics between years, and the odds of achieving vs. not achieving ROSC. 2020 vs. 2019 as a predictor for ROSC was assessed with logistic regression. RESULTS: 471 patients were included. Arrests increased to 291 during the pandemic vs. 180 in 2019 (62% increase). Age (mean difference + 6; 95% CI: +2.4 to +9.5), arrest location (nursing home OR = 2.42; 95% CI: 1.42-4.31; public place OR = 0.47; 95% CI: 0.25-0.88), BLS response (OR = 0.68; 95% CI: 0.47-0.99), and field termination of resuscitation (OR = 2.36; 95% CI: 1.36-4.07) differed significantly in 2020 compared to 2019. No significant difference was found in the confounder-adjusted odds of ROSC in 2020 vs 2019 (OR = 0.61; 95% CI: 0.34-1.11). CONCLUSION: OHCA increased by 62% during COVID-19 in Detroit, without a significant change in prehospital ROSC. The rate of ROSC remained similar despite the implementation of an early termination of resuscitation protocol in response to COVID-19.

A Pilot Study: Emergency Medical Services-Related Violence in the Out-of-Hospital Setting in Southeast Michigan.

BACKGROUND: Emergency Medical Services (EMS) personnel in the out-of-hospital setting continue to be at high risk for violence, in spite of continued research on a national scale. OBJECTIVE: Our aim was to determine the prevalence and type of violence perpetrated against Southeast Michigan EMS personnel, and characteristics of victims in the out-of-hospital setting. METHODS: EMS personnel from urban and suburban counties in Southeastern Michigan were surveyed online about their experience with violence, including description and outcomes, while working in the out-of-hospital setting within the previous 6 months. Gift card incentive and recruitment scripts were provided and read to participants. This was a pilot study that was limited to 150 respondents and ran for 3 months. Descriptive statistical analysis was done with an odds ratio, p value, and two-sample independent t-test analysis. RESULTS: There were 137 surveys respondents. Most respondents, 75 of 128 (58.6%) reported being a victim of violence within the previous 6 months. Perpetrators were primarily patients and occasionally family members. Substance abuse or mental health issues were frequently associated with violence. Although not common, women reported violence perpetrated by a coworker more often than men (odds ratio 5.17; 95% confidence interval 1.67-16.0). Only 55 of 117 respondents (47.0%) felt that the training did an adequate job protecting them from violence. CONCLUSIONS: More than one-half of responding EMS personnel experienced work-related violence within the previous 6 months in Southeast Michigan. This high rate of violence supports the need for additional research and policies that ensure the safety of EMS providers in this region.

Improving ED Emergency Severity Index Acuity Assignment Using Machine Learning and Clinical Natural Language Processing.

INTRODUCTION: Triage is critical to mitigating the effect of increased volume by determining patient acuity, need for resources, and establishing acuity-based patient prioritization. The purpose of this retrospective study was to determine whether historical EHR data can be used with clinical natural language processing and machine learning algorithms (KATE) to produce accurate ESI predictive models. METHODS: The KATE triage model was developed using 166,175 patient encounters from two participating hospitals. The model was tested against a random sample of encounters that were correctly assigned an acuity by study clinicians using the Emergency Severity Index (ESI) standard as a guide. RESULTS: At the study sites, KATE predicted accurate ESI acuity assignments 75.7% of the time compared with nurses (59.8%) and the average of individual study clinicians (75.3%). KATE's accuracy was 26.9% higher than the average nurse accuracy (P <.001). On the boundary between ESI 2 and ESI 3 acuity assignments, which relates to the risk of decompensation, KATE's accuracy was 93.2% higher, with 80% accuracy compared with triage nurses 41.4% accuracy (P <.001). DISCUSSION: KATE provides a triage acuity assignment more accurate than the triage nurses in this study sample. KATE operates independently of contextual factors, unaffected by the external pressures that can cause under triage and may mitigate biases that can negatively affect triage accuracy. Future research should focus on the impact of KATE providing feedback to triage nurses in real time, on mortality and morbidity, ED throughput, resource optimization, and nursing outcomes.

Disparity in Receipt and Utilization of Telecommunicator CPR Instruction.

Introduction: Telecommunicator Assisted Cardiopulmonary Resuscitation (T-CPR) is independently associated with improved survival and improved functional outcome after adult Out of Hospital Cardiac Arrest (OHCA). The objective of this study was to evaluate whether there are racial and socioeconomic disparities in the provision of T-CPR instruction and subsequent CPR performance. Methods: We performed a retrospective review of a convenience sample of EMS agencies throughout the United States that utilized the Cardiac Arrest Registry to Enhance Survival (CARES) dispatch registry during the period 1/2014-12/2017. Data were collected by dispatch agencies after review of 9-1-1 OHCA audio recordings. Elements related to dispatcher CPR instruction, barriers to bystander CPR (BCPR) performance, patient race (White, Black, Hispanic-Latino, or other) and Utstein data were captured from the CARES database. These data were merged with census tract data from incident locations. The effects of race and income (Socioeconomic status, SES) on outcome were analyzed using multilevel logistic regression. Results: A total of 3,807 cases were identified from 37 dispatch agencies in 6 states. The sample was predominantly White (57.5%) and male (64.9%) with an average age of 60.3 ± 19.9. In the adjusted analysis, there were no differences in the odds of receiving CPR instruction by race (black vs white), OR = 0.96 (95% CI. 0.70, 1.32) or for increased income, (OR = 1.00, 95% CI 0.99, 1.02). There was a significant difference in receipt of T-CPR instruction by patient age, OR = 0.99 (95% CI, 0.98, 0.99). Subsequent utilization of T-CPR instruction to perform BCPR was less likely for patients that had a lower income, OR = 1.03 (95% CI 1.01, 1.05). There was also a decreased rate of BCPR provision by patient age OR = 0.99 (95% CI, 0.99, 1.00), but there was no difference in rate of BCPR provision by race, OR = 0.86 (95% CI 0.61, 1.23). Conclusion: We identified differences in age but not race or SES in the provision of T-CPR instruction by dispatch centers. We also identified decreased CPR provision by age and income after receipt of T-CPR instructions. In this sample, we found no evidence of racial disparities in the provision of T-CPR instruction or subsequent provision of BCPR.

Intrastate Variation in Treatment and Outcomes of Out-of-Hospital Cardiac Arrest.

OBJECTIVE: Our objective was to analyze and compare out-of-hospital cardiac arrest (OHCA) system of care performance and outcomes at the Medical Control Authority (MCA) level in the state of Michigan. We hypothesized that clinically and statistically significant variations in treatment and outcomes of OHCA exists within a single U.S. state. METHODS: We performed a retrospective, observational study of all non-traumatic EMS-treated OHCA from the state of Michigan CARES registry for 2014-2015. Geocoding of the OHCA incident address was used to assign records to individual MCAs. MCA-based demographics, arrest characteristics, system of care performance and outcomes were quantified and compared. Associations between demographics, system of care parameters, and outcomes were examined at the MCA level. RESULTS: A total of 8,115 records with complete data were available for analysis. Eleven MCAs met study inclusion criteria of >100 cases, producing a final sample size of 7,788 records (96%). Statistically significant variations in survival to hospital discharge ranged from 4.5% to 15% (p < 0.001) (Adjusted odds ratio [AOR] range 0.6-2.0) and survival with good neurologic outcome 2.7-12.5% (p < 0.001; AOR range 0.5-2.2,) were observed across MCAs. Bystander CPR ranged from 32% to 53% (p < 0.001) and bystander AED application ranged from 3.5% 11.5% (p < 0.05). Of patients admitted to the hospital alive, 29-68% received targeted temperature management. In hospital mortality ranged from 53.1% to 73.9% (p < 0.05). CONCLUSION: Significant intrastate variability in OHCA system of care performance and outcomes currently exist and are similar to what has been previously reported across North America almost a decade ago. This degree of variability highlights the opportunity to optimize modifiable factors within local systems of care to improve OHCA outcomes.

Comparison of bronchodilator administration with vibrating mesh nebulizer and standard jet nebulizer in the emergency department.

INTRODUCTION: Projects comparing bronchodilator response by aerosol devices in the ED are limited. Evidence suggests that the vibrating mesh nebulizer (VMN) provides 5-fold greater aerosol delivery to the lung as compared to a jet nebulizer (JN). The aim of this project was to evaluate a new nebulizer deployed in an Emergency Department. METHODS: A quality improvement evaluation using a prospectively identified data set from the electronic medical record comparing all ED patients receiving aerosolized bronchodilators with the JN during September 2015 to those receiving aerosolized bronchodilators with the VMN during October 2015. RESULTS: 1594 records were extracted, 879 patients received bronchodilators via JN and 715 patients via the VMN. Admission rates in the VMN group were 28.1% and in the JN group at 41.4%. The total albuterol dose administered was significantly lower in the VMN group compared to the JN (p<0.001). No patient in the VMN group required >5mg albuterol to control symptoms (85% of the VMN group received only 2.5mg) whereas dosing in the JN group was higher in some patients (with 47% receiving only 2.5mg). The use of VMN was also associated with a 13% (37min) reduction in median length of stay in the ED. CONCLUSIONS: The VMN was associated with fewer admissions to the hospital, shorter length of stay in the ED and a reduction in albuterol dose. The device type was a predictor of discharge, disposition and amount of drug used. Randomized controlled studies are needed to corroborate these findings.

Emergency department visits in patients with low acuity conditions: Factors associated with resource utilization.

OBJECTIVES: To identify health beliefs of emergency department (ED) patients with low acuity conditions and how these affect ambulance (AMB) utilization. METHODS: We performed a prospective, observational study on a convenience sample of patients 18years or older, who presented to the ED of an urban, academic hospital with an Emergency Severity Index (ESI) triage level of 4 or 5. Demographics, treatment, and disposition data were obtained along with self-administered surveys. Characteristics of patients with low acuity conditions who presented to the ED by AMB were compared to the patients who came to the ED by private transportation (PT). Data were analyzed with the chi-square test, t-test, and Mann-Whitney test. RESULTS: A total of 197 patients (97 AMB and 100 PT) were enrolled. Compared to PT, AMB patients were more likely to: be insured (82% vs. 56%; p=0.000), have a primary care provider (62% vs. 44%; p=0.048), and lack a regular means of transportation (53% vs. 33%; p=0.005). Three surveys were used the SF-8, Short Test of Functional Health Literacy in Adults [STOFHLA], and Health Belief Model [HBM]. Answers to HBM showed patients perceive that their illness required care within one hour of arrival (38% vs. 21%; p=0.04), have used an ambulance in the past year (76% vs. 33%; p=0.001) and to utilize an ambulance in the future for similar concerns (53% vs. 15%; p=0.000). AMB patients were more likely to call an ambulance for any health concern (p=0.035) and felt that there were enough ambulances for all patients in the city (p=0.01). There were no differences in age, employment, level of income and education, nor hospital admission rate between groups. CONCLUSIONS: Ambulance use in low-acuity ED patients is associated with misperceptions regarding severity of illness and resource allocation as well as limited access to private transportation. Understanding patient perceptions of illness and other barriers to receiving care is imperative for the development of interventions aimed at enabling change in health behaviors such as the elective use of limited resources.

Resistant starch alters colonic contractility and expression of related genes in rats fed a Western diet.

BACKGROUND AND AIM: Dietary fiber shortens gut transit time, but data on the effects of fiber components (including resistant starch, RS) on intestinal contractility are limited. We have examined RS effects in male Sprague-Dawley rats fed either a high-amylose maize starch (HAMS) or a wholemeal made from high-amylose wheat (HAW) on ileal and colonic contractility ex vivo and expression of genes associated with smooth muscle contractility. METHODS: Rats were fed diets containing 19 % fat, 20 % protein, and either low-amylose maize starch (LAMS), HAMS, wholemeal low-amylose wheat (LAW) or HAW for 11 week. Isolated ileal and proximal colonic sections were induced to contract electrically, or by receptor-independent (KCl) or receptor-dependent agents. Colonic gene expression was assessed using an Affymetrix microarray. RESULTS: Ileal contractility was unaffected by treatment. Maximal proximal colonic contractility induced electrically or by angiotensin II or carbachol was lower for rats fed HAMS and LAW relative to those fed LAMS (P < 0.05). The colonic expression of genes, including cholinergic receptors (Chrm2, Chrm3), serotonin receptors (Htr5a, Htr7), a protease-activated receptor (F2r), a prokineticin receptor (Prokr1), prokineticin (Prok1), and nitric oxide synthase 2 (Nos2), was altered by dietary HAMS relative to LAMS (P < 0.05). HAW did not significantly affect these genes or colonic contractility relative to effects of LAMS. CONCLUSIONS: RS and other fiber components could influence colorectal health through modulation of stool transit time via effects on muscular contractility.

An innovative, multidisciplinary, process-driven approach to acute stroke in a community health system network.

Stroke is one of the major causes of death and disability in the United States, yet it is undertreated by many major medical centers across the country. Timely recognition and treatment of acute ischemic stroke remains a challenge due to confusing clinical presentations, hospital logistics, communication barriers among providers, and lack of standardized treatment algorithms. By creating a system-wide Code Stroke protocol, St. John Providence Health System improved documentation, increased intravenous tissue plasminogen activator delivery, reduced specialist call-back times, improved door-to-computer tomography scan and door-to-needle time, and identified appropriate patients for endovascular therapy.

Headpulse measurement can reliably identify large-vessel occlusion stroke in prehospital suspected stroke patients: Results from the EPISODE-PS-COVID study.

BACKGROUND: Large-vessel occlusion (LVO) stroke represents one-third of acute ischemic stroke (AIS) in the United States but causes two-thirds of poststroke dependence and >90% of poststroke mortality. Prehospital LVO stroke detection permits efficient emergency medical systems (EMS) transport to an endovascular thrombectomy (EVT)-capable center. Our primary objective was to determine the feasibility of using a cranial accelerometry (CA) headset device for prehospital LVO stroke detection. Our secondary objective was development of an algorithm capable of distinguishing LVO stroke from other conditions. METHODS: We prospectively enrolled consecutive adult patients suspected of acute stroke from 11 study hospitals in four different U.S. geographical regions over a 21-month period. Patients received device placement by prehospital EMS personnel. Headset data were matched with clinical data following informed consent. LVO stroke diagnosis was determined by medical chart review. The device was trained using device data and Los Angeles Motor Scale (LAMS) examination components. A binary threshold was selected for comparison of device performance to LAMS scores. RESULTS: A total of 594 subjects were enrolled, including 183 subjects who received the second-generation device. Usable data were captured in 158 patients (86.3%). Study subjects were 53% female and 56% Black/African American, with median age 69 years. Twenty-six (16.4%) patients had LVO and 132 (83.6%) were not LVO (not-LVO AIS, 33; intracerebral hemorrhage, nine; stroke mimics, 90). COVID-19 testing and positivity rates (10.6%) were not different between groups. We found a sensitivity of 38.5% and specificity of 82.7% for LAMS ≥ 4 in detecting LVO stroke versus a sensitivity of 84.6% (p < 0.0015 for superiority) and specificity of 82.6% (p = 0.81 for superiority) for the device algorithm (CA + LAMS). CONCLUSIONS: Obtaining adequate recordings with a CA headset is highly feasible in the prehospital environment. Use of the device algorithm incorporating both CA and LAMS data for LVO detection resulted in significantly higher sensitivity without reduced specificity when compared to the use of LAMS alone.

Genomic homeostasis is dysregulated in favour of apoptosis in the colonic epithelium of the azoxymethane treated rat.

BACKGROUND: The acute response to genotoxic carcinogens in rats is an important model for researching cancer initiation events. In this report we define the normal rat colonic epithelium by describing transcriptional events along the anterior-posterior axis and then investigate the acute effects of azoxymethane (AOM) on gene expression, with a particular emphasis on pathways associated with the maintenance of genomic integrity in the proximal and distal compartments using whole genome expression microarrays. RESULTS: There are large transcriptional changes that occur in epithelial gene expression along the anterior-posterior axis of the normal healthy rat colon. AOM administration superimposes substantial changes on these basal gene expression patterns in both the distal and proximal rat colonic epithelium. In particular, the pathways associated with cell cycle and DNA damage and repair processes appear to be disrupted in favour of apoptosis. CONCLUSIONS: The healthy rats' colon exhibits extensive gene expression changes between its proximal and distal ends. The most common changes are associated with metabolism, but more subtle expression changes in genes involved in genomic homeostasis are also evident. These latter changes presumably protect and maintain a healthy colonic epithelium against incidental dietary and environmental insults. AOM induces substantial changes in gene expression, resulting in an early switch in the cell cycle process, involving p53 signalling, towards cell cycle arrest leading to the more effective process of apoptosis to counteract this genotoxic insult.

Effect on efficiency and cost-effectiveness when an observation unit is managed as a closed unit vs an open unit.

OBJECTIVE: To compare efficiency and cost-effectiveness of an observation unit (OU) when managed as a closed unit vs an open unit. METHODS: This observational, retrospective study of a 30-bed OU compared three time periods: Nov 2007 to Aug 2008 (period 1), Nov 2008 to Aug 2009 (period 2) and Nov 2010 to Aug 2011 (period 3). The OU was managed and staffed by non-emergency department physicians as an open unit during period 1, and a closed unit by emergency department physicians during periods 2 and 3. RESULTS: OU volume was greatest in period 3 (1 vs 3, 95% CI -235.8 to -127.9; 2 vs 3, 95% CI -191.9 to -84.095%). Periods 2 and 3 had shorter lengths of stay for discharged (1 vs 2, 95% CI -6.6 to 1.7; 1 vs 3, 95% CI -8.1 to -3.1) and admitted (1 vs 2, 95% CI -11.4 to -8.6; 1 vs 3, 95% CI -11.8 to -9.0) patients, less admission rates (P < .001), and less 30-day all cause admission rates after discharge (P < .0001). Cost was less during periods 2 and 3 for direct (1 vs 2, 95% CI -392.5 to -305.9; 1 vs 3, 95% CI -471.4 to -388.4), indirect (1 vs 2, 95% CI -249.5 to - 199.8; 1 vs 3, 95% CI -187 to-139.4) and total cost (1 vs 2, 95% CI -640.7 to -507; 1 vs 3, 95% CI -657.2 to -529). CONCLUSION: The same OU was more efficient and cost-effective when managed as a closed unit vs an open unit.

Treatment and outcome variation in out-of-hospital cardiac arrest among four urban hospitals in Detroit.

AIMS: To determine whether out-of-hospital cardiac arrest (OHCA) post-resuscitation management and outcomes differ between four Detroit hospitals. INTRODUCTION: Significant variation exists in treatment/outcomes from OHCA. Disparities between hospitals serving a similar population is not well known. METHODS: Retrospective OHCA data was collected from the Detroit-Cardiac Arrest Registry (DCAR) between January 2014 to December 2019. Four hospitals were compared on two treatments (angiography, do not resuscitate (DNR)) and two outcomes (cerebral performance category (CPC) ≤ 2, in-hospital death). Models for death and CPC were tested with and without coronary angiography and DNR status. RESULTS: 999 patients at hospitals A - D differed (p < 0.05) before multivariable adjustment by age, race, witnessed arrest, dispatch-emergency department (ED) time, TTM, coronary angiography, DNR order, and in-hospital death. Rates of death and CPC ≤ 2 were worse in Hospital A (82.8%, 10%, respectively) compared to others (69.1%, 14.1%). After multivariable adjustment, Hospital A performed angiography less compared to B (OR = 0.17) and was more likely to initiate new DNR status than B (OR = 2.9), C (OR = 16.1), or D (OR = 3.6). CPC ≤ 2 were worse in Hospital A compared to B (OR = 0.27) and D (OR = 0.35). After sensitivity analysis, CPC ≤ 2 odds did not differ for A versus B (OR = 0.58, adjusted for angiography) or D (OR = 0.65, adjusted for DNR). Odds of death, despite angiography and DNR differences, were worse in Hospital A compared to B (OR = 1.87) and D (OR = 1.81). CONCLUSION: Differing rates of DNR and coronary angiography was associated with observed disparities in favorable neurologic outcome, but not death, between four Detroit hospitals.

Thresholding Gini variable importance with a single-trained random forest: An empirical Bayes approach.

Random forests (RFs) are a widely used modelling tool capable of feature selection via a variable importance measure (VIM), however, a threshold is needed to control for false positives. In the absence of a good understanding of the characteristics of VIMs, many current approaches attempt to select features associated to the response by training multiple RFs to generate statistical power via a permutation null, by employing recursive feature elimination, or through a combination of both. However, for high-dimensional datasets these approaches become computationally infeasible. In this paper, we present RFlocalfdr, a statistical approach, built on the empirical Bayes argument of Efron, for thresholding mean decrease in impurity (MDI) importances. It identifies features significantly associated with the response while controlling the false positive rate. Using synthetic data and real-world data in health, we demonstrate that RFlocalfdr has equivalent accuracy to currently published approaches, while being orders of magnitude faster. We show that RFlocalfdr can successfully threshold a dataset of 106 datapoints, establishing its usability for large-scale datasets, like genomics. Furthermore, RFlocalfdr is compatible with any RF implementation that returns a VIM and counts, making it a versatile feature selection tool that reduces false discoveries.

Resistant starches protect against colonic DNA damage and alter microbiota and gene expression in rats fed a Western diet.

Resistant starch (RS), fed as high amylose maize starch (HAMS) or butyrylated HAMS (HAMSB), opposes dietary protein-induced colonocyte DNA damage in rats. In this study, rats were fed Western-type diets moderate in fat (19%) and protein (20%) containing digestible starches [low amylose maize starch (LAMS) or low amylose whole wheat (LAW)] or RS [HAMS, HAMSB, or a whole high amylose wheat (HAW) generated by RNA interference] for 11 wk (n = 10/group). A control diet included 7% fat, 13% protein, and LAMS. Colonocyte DNA single-strand breaks (SSB) were significantly higher (by 70%) in rats fed the Western diet containing LAMS relative to controls. Dietary HAW, HAMS, and HAMSB opposed this effect while raising digesta levels of SCFA and lowering ammonia and phenol levels. SSB correlated inversely with total large bowel SCFA, including colonic butyrate concentration (R(2) = 0.40; P = 0.009), and positively with colonic ammonia concentration (R(2) = 0.40; P = 0.014). Analysis of gut microbiota populations using a phylogenetic microarray revealed profiles that fell into 3 distinct groups: control and LAMS; HAMS and HAMSB; and LAW and HAW. The expression of colonic genes associated with the maintenance of genomic integrity (notably Mdm2, Top1, Msh3, Ung, Rere, Cebpa, Gmnn, and Parg) was altered and varied with RS source. HAW is as effective as HAMS and HAMSB in opposing diet-induced colonic DNA damage in rats, but their effects on the large bowel microbiota and colonocyte gene expression differ, possibly due to the presence of other fiber components in HAW.

Strengthening Behavioral Health Services Through Partnerships and Data Integration.

Background There has been an increase in emergency medical service (EMS) use for behavioral health reasons. Detroit Wayne Integrated Health Network (DWIHN) and Detroit East Medical Control Authority (DEMCA) collaborated to study the rising number of behavioral health (mental disorders and substance use disorders) calls to EMS. Methodology To examine the trend, DWIHN and DEMCA partnered on a data-sharing project and identified that a high volume of EMS runs (responses by EMS as a result of an emergency call) involved individuals served by DWIHN. Results Over a period of 2.5 years, an average of one-third (33.73%) of EMS runs involved individuals who receive behavioral health services through DWIHN. Conclusions DWIHN used the data to create interventions and internal process improvements that can help coordinate medical and behavioral healthcare for individuals who have been using EMS increasingly. The findings were also used to develop prevention efforts to decrease the occurrence of such crises and to avoid unwarranted member involvement with the justice system. We suggest that other comparable organizations consider similar partnerships, especially given the increasingly high EMS and Emergency Department use for behavioral health reasons.

Describing Prehospital Deliveries in the State of Michigan.

Introduction We observed clinically that prehospital deliveries locally appeared to have a high rate of complications and appeared associated with midwife deliveries. There is scant literature that addresses prehospital deliveries across a state. We set out to describe utilization, complications, and short-term outcomes of EMS-attended prehospital deliveries in Michigan in 2015, and to describe the relationship between prehospital delivery and socioeconomic status (SES). Methods We identified candidate cases for prehospital deliveries through the Michigan EMS Information System (MI-EMSIS). To assess the relationship of SES with the frequency of EMS delivery, we utilized the mean income of the patient residences' zip codes. Results We identified 223 EMS-attended deliveries from 1.6 million MI-EMSIS records. Most births were normal vaginal deliveries on the scene or en route to the hospital (92, 40.0%) or delivered prior to EMS arrival (58, 25.4%). Maternal or fetal complications were identified in 69 (32.0%) deliveries. We identified a few midwife-attended deliveries (31), but these had a high rate of complications (19, 61.3%). The frequency of prehospital delivery was inversely related to estimated patient income (Pearson=-0.85). Conclusions EMS deliveries were rare and most were normal vaginal deliveries, but almost a third had complications. Midwife and EMS-attended deliveries were rare, but when they occurred, had high rates of complications. Although an imperfect measure of patient SES, frequency of delivery was inversely related to patient income, and agencies that provide care in these communities should have focused training.

Factors Associated With Voluntary Refusal of Emergency Medical System Transport for Emergency Care in Detroit During the Early Phase of the COVID-19 Pandemic.

Importance: Emergency department (ED) and emergency medical services (EMS) volumes decreased during the COVID-19 pandemic, but the amount attributable to voluntary refusal vs effects of the pandemic and public health restrictions is unknown. Objective: To examine the factors associated with EMS refusal in relation to COVID-19 cases, public health interventions, EMS responses, and prehospital deaths. Design, Setting, and Participants: A retrospective cohort study was conducted in Detroit, Michigan, from March 1 to June 30, 2020. Emergency medical services responses geocoded to Census tracts were analyzed by individuals' age, sex, date, and community resilience using the Centers for Disease Control and Prevention Social Vulnerability Index. Response counts were adjusted with Poisson regression, and odds of refusals and deaths were adjusted by logistic regression. Exposures: A COVID-19 outbreak characterized by a peak in local COVID-19 incidence and the strictest stay-at-home orders to date, followed by a nadir in incidence and broadly lifted restrictions. Main Outcomes and Measures: Multivariable-adjusted difference in 2020 vs 2019 responses by incidence rate and refusals or deaths by odds. The Social Vulnerability Index was used to capture community social determinants of health as a risk factor for death or refusal. The index contains 4 domain subscores; possible overall score is 0 to 15, with higher scores indicating greater vulnerability. Results: A total of 80 487 EMS responses with intended ED transport, 2059 prehospital deaths, and 16 064 refusals (62 636 completed EMS to ED transports) from 334 Census tracts were noted during the study period. Of the cohort analyzed, 38 621 were women (48%); mean (SD) age was 49.0 (21.4) years, and mean (SD) Social Vulnerability Index score was 9.6 (1.6). Tracts with the highest per-population EMS transport refusal rates were characterized by higher unemployment, minority race/ethnicity, single-parent households, poverty, disability, lack of vehicle access, and overall Social Vulnerability Index score (9.6 vs 9.0, P = .002). At peak COVID-19 incidence and maximal stay-at-home orders, there were higher total responses (adjusted incident rate ratio [aIRR], 1.07; 1.03-1.12), odds of deaths (adjusted odds ratio [aOR], 1.60; 95% CI, 1.20-2.12), and refusals (aOR, 2.33; 95% CI, 2.09-2.60) but fewer completed ED transports (aIRR, 0.82; 95% CI, 0.78-0.86). With public health restrictions lifted and the nadir of COVID-19 cases, responses (aIRR, 1.01; 0.97-1.05) and deaths (aOR, 1.07; 95% CI, 0.81-1.41) returned to 2019 baselines, but differences in refusals (aOR, 1.27; 95% CI, 1.14-1.41) and completed transports (aIRR, 0.95; 95% CI, 0.90-0.99) remained. Multivariable-adjusted 2020 refusal was associated with female sex (aOR, 2.71; 95% CI, 2.43-3.03 in 2020 at the peak; aOR 1.47; 95% CI, 1.32-1.64 at the nadir). Conclusions and Relevance: In this cohort study, EMS transport refusals increased with the COVID-19 outbreak's peak and remained elevated despite receding public health restrictions, COVID-19 incidence, total EMS responses, and prehospital deaths. Voluntary refusal was associated with decreased EMS transports to EDs, disproportionately so among women and vulnerable communities.

Prehospital Tibial Intraosseous Drug Administration is Associated with Reduced Survival Following Out of Hospital Cardiac Arrest: A study for the CARES Surveillance Group.

BACKGROUND: Recent reports have questioned the efficacy of intraosseous (IO) drug administration for out-of-hospital cardiac arrest (OHCA) resuscitation. Our aim was to determine whether prehospital administration of resuscitative medications via the IO route was associated with lower rates of return of spontaneous circulation (ROSC) and survival to hospital discharge than peripheral intravenous (IV) infusion in the setting of OHCA. METHODS: We obtained data on all OHCA patients receiving prehospital IV or IO drug administration from the three most populous counties in Michigan over three years. Data was from the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) database. The association between route of drug administration and outcomes was tested using a matched propensity score analysis. RESULTS: From a total of 10,626 OHCA patients, 6869 received parenteral drugs during their prehospital resuscitation (37.8% by IO) and were included in analysis. Unadjusted outcomes were lower in patients with IO vs. IV access: 18.3% vs. 23.8% for ROSC (p < 0.001), 3.2% vs. 7.6% for survival to hospital discharge (p < 0.001), and 2.0% vs. 5.8% for favorable neurological function (p < 0.001). After adjustment, IO route remained associated with lower odds of sustained ROSC (OR 0.72, 95% CI 0.63-0.81, p < 0.001), hospital survival (OR 0.48, 95% CI 0.37-0.62, p < 0.001), and favorable neurological outcomes (OR 0.42, 95% CI 0.30-0.57, p < 0.001). CONCLUSION: In this cohort of OHCA patients, the use of prehospital IO drug administration was associated with unfavorable clinical outcomes.