A Comparison of Injectable Diazepam and Lorazepam in the Goal-Directed Management of Severe Alcohol Withdrawal.

BACKGROUND: Benzodiazepines are the gold standard for treatment of alcohol withdrawal, yet the selection of a preferred benzodiazepine is limited due to a lack of comparative studies. OBJECTIVES: The primary objective of this study was to compare the efficacy and safety of injectable lorazepam (LZP) and diazepam (DZP) in the treatment of severe alcohol withdrawal syndrome (AWS). METHODS: Retrospective cohort study of adult patients admitted to an intensive care unit with a primary diagnosis of AWS. Subjects who received at least 12 LZP equivalent units (LEU) of injectable DZP or LZP within 24 hours of initiation of the severe AWS protocol were included. The primary outcome was time with Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) scores at goal over the first 24 hours of treatment. RESULTS: A total of 191 patients were included (DZP n = 89, LZP n = 102). Time with CIWA-Ar scores at goal during the first 24 hours was similar between groups (DZP 12 hours [interquartile range, IQR, = 9-15] vs LZP 14 hours [IQR = 10-17]), P = 0.06). At 24 hours, LEU requirement was similar (DZP 40 [IQR = 22-78] vs LZP 32 [IQR = 18-56], P = 0.05). Drug cost at 24 hours was higher in the DZP group ($204.6 [IQR = 112.53-398.97] vs $8 [IQR = 4.5-14], P < 0.01). CONCLUSION AND RELEVANCE: DZP or LZP are equally efficacious for the treatment of severe AWS. LZP may be preferred due to cost but both medications can be used interchangeably based on availability.

Time Savings and Safety of EMS Administration of Antibiotics for Open Fractures.

INTRODUCTION: Early administration of antibiotics for open fractures reduces serious bone and soft tissue infections. The effectiveness of antibiotics in reducing these infections is time-dependent, with various surgical associations recommending administration within one hour of injury, or within one hour of patient arrival to the emergency department (ED). The extent to which prehospital antibiotic administration in these situations might reduce the time to treatment has not been previously reported. The purpose of this study was to describe current prehospital use of antibiotics for traumatic injury, to assess the safety of prehospital antibiotic administration, and to estimate the potential time-savings associated with antibiotic administration by EMS clinicians. METHODS: This was a retrospective analysis of the 2019 through 2022 ESO Data Collaborative research data set. Included subjects were patients that had a linked ICD-10 code indicating an open extremity fracture and who received prehospital antibiotics. Time to antibiotic administration was calculated as the elapsed time from EMS dispatch until antibiotic administration. The minimum potential time saved by EMS antibiotic administration was calculated as the elapsed time from administration until ED arrival. To assess safety, epinephrine and diphenhydramine administration were used as proxies for the adverse events of anaphylaxis and minor allergic reactions. RESULTS: There were 523 patients meeting the inclusion criteria. The median (and interquartile range [IQR]) elapsed time from EMS dispatch until antibiotic administration was 31 (IQR: 24-41) minutes. The median potential time savings associated with prehospital antibiotic administration was 15 (IQR: 8-22) minutes. Notably, 144 (27.5%) of the patients who received prehospital antibiotics had total prehospital times exceeding one hour. None of the patients who received antibiotics also received epinephrine for presumed anaphylaxis. CONCLUSIONS: EMS clinicians were able to safely administer antibiotics to patients with open fractures a median of 15 minutes before arrival at the hospital, and 99 percent of the patients receiving antibiotics had them administered within one hour of EMS dispatch. EMS administration of antibiotics may be a safe way to increase compliance with recommendations for early antibiotic administration for open fractures.

Utilizing Nurse Practitioners and Physician Assistants in Academic Emergency Departments Does Not Reduce Residents' Exposure to More Complex Patients.

BACKGROUND: Whether integration of nurse practitioners (NPs) and physician assistants (PAs) into academic emergency departments (EDs) affects emergency medicine (EM) resident clinical learning opportunities is unclear. OBJECTIVE: We sought to compare EM resident exposure to more-complex patients, as well as patients undergoing Accreditation Council for Graduate Medical Education (ACGME)-required procedures, at nonpediatric academic EDs with lower, moderate, and higher levels of NP/PA utilization. METHODS: In this cross-sectional study of National Hospital Ambulatory Medical Care Survey (NHAMCS) data for 2016-2020, nonpediatric academic EDs were classified into the following three groups based on the percentage of patients seen by an NP or PA: lower (≤ 10%), moderate (10.1-30%), and higher (> 30%) NP/PA utilization. The proportion of EM resident-seen patients meeting previously established complex patient criteria was then determined for EDs at each level of NP/PA utilization. The proportion of EM resident-seen patients receiving certain ACGME-required procedures was also determined. Survey analytic procedures and weighting as recommended by NHAMCS were used to calculate and compare proportions using 95% CIs. RESULTS: The weighted 2016-2020 NHAMCS data sets represent 44,130,996 adult resident-seen patients presenting to nonpediatric academic EDs. The proportion of resident-seen patients meeting complex patient criteria did not significantly differ for lower (43.2%; 95% CI 30.6-56.8%), moderate (41.7%; 95% CI 33.0-50.9%), or higher (38.9%; 95% CI 29.3-49.4%) NP/PA utilization EDs. The proportion of patients undergoing an ACGME-required procedure also did not significantly differ across level of NP/PA utilization. CONCLUSIONS: Higher levels of NP/PA utilization in nonpediatric academic EDs do not appear to reduce EM resident exposure to more-complex patients or ACGME-required procedures.

Prehospital Intervention Improves Outcomes for Patients Presenting in Atrial Fibrillation with Rapid Ventricular Response.

OBJECTIVE: To compare outcomes of patients presenting to emergency medical services (EMS) with atrial fibrillation with rapid ventricular response (AF-RVR) who did and did not receive prehospital advanced life support (ALS) rate or rhythm control intervention(s). METHODS: This retrospective cohort study used the 2021 ESO Data Collaborative (Austin, TX) dataset. We identified 9-1-1 scene responses for patients aged 16 to 100 years old presenting with AF and an initial heart rate ≥ 110 beats per minute (bpm). Prehospital ALS interventions for AF-RVR included medications (e.g., calcium channel blockers, beta blockers, etc.) or electrical cardioversion. Outcome measures included prehospital rate control (i.e., final prehospital heart rate < 110 bpm), emergency department (ED) discharge to home, ED and hospital length of stay, and mortality. We also evaluated prehospital adverse events-specifically bradycardia, hypotension, and cardiac arrest. We used propensity score matching to compare outcomes among treated and untreated patients with similar demographic and clinical characteristics. We determined the average treatment effect on the treated (ATET) with 95% confidence intervals (CI) and the number needed to treat (NNT). RESULTS: After propensity score matching, prehospital outcomes were available for 4,859 treated patients matched with 4,859 similar untreated patients. Prehospital rate control was more frequent for treated than for untreated patients (41.0% vs. 18.2%, ATET +22.8%, CI: +21.1%; +24.6%, NNT = 5). Hospital outcomes were available for 1,347 treated patients matched with 1,347 similar untreated patients. Treated patients were more likely to be discharged from the ED (37.9% vs. 34.0%, ATET +3.9%, CI: +0.2%; +7.5%, NNT = 26) and less likely to die (4.3% vs. 6.7%, ATET -2.5%, CI: -4.2%; -0.8%, NNT = 40) compared to untreated patients. Hypotension occurred more often in treated patients (ATET +2.6%, CI: +1.5%; +3.7%), but resolved before ED arrival in 73% of affected patients. Otherwise, adverse event rates did not significantly differ for the two groups. CONCLUSIONS: In this propensity score matched study of patients presenting to EMS with AF-RVR, prehospital ALS interventions were associated with more frequent prehospital rate control, more frequent discharge to home from the ED, and lower mortality.

The EMS Modified Early Warning Score (EMEWS): A Simple Count of Vital Signs as a Predictor of Out-of-Hospital Cardiac Arrests.

Objective: For patients at risk for out-of-hospital cardiac arrest (OHCA) after Emergency Medical Services (EMS) arrival, outcomes may be mitigated by identifying impending arrests and intervening before they occur. Tools such as the Modified Early Warning Score (MEWS) have been developed to determine the risk of arrest, but involve relatively complicated algorithms that can be impractical to compute in the prehospital environment. A simple count of abnormal vital signs, the "EMS Modified Early Warning Score" (EMEWS), may represent a more practical alternative. We sought to compare to the ability of MEWS and EMEWS to identify patients at risk for EMS-witnessed OHCA.Methods: We conducted a retrospect analysis of the 2018 ESO Data Collaborative database of EMS encounters. Patients without cardiac arrest before EMS arrival were categorized into those who did or did not have an EMS-witnessed arrest. MEWS was evaluated without its temperature component (MEWS-T). The performance of MEWS-T and EMEWS in predicting EMS witnessed arrest was evaluated by comparing receiver-operating characteristic curves.Results: Of 369,064 included encounters, 4,651 were EMS witnessed arrests. MEWS-T demonstrated an area under the curve (AUC) of 0.79 (95% CI: 0.79 - 0.80), with 86.8% sensitivity and 51.0% specificity for MEWS-T ≥ 3. EMEWS demonstrated an AUC of 0.74 (95% CI: 0.73 - 0.75), with 81.3% sensitivity and 53.9% specificity for EMEWS ≥ 2.Conclusions: EMEWS showed a similar ability to predict EMS-witnessed cardiac arrest compared to MEWS-T, despite being significantly simpler to compute. Further study is needed to evaluate whether the implementation of EMEWS can aid EMS clinicians in anticipating and preventing OHCA.

Virtual Peer-to-Peer Learning to Enhance and Accelerate the Health System Response to COVID-19: The HHS ASPR Project ECHO COVID-19 Clinical Rounds Initiative.

Tasked with identifying digital health solutions to support dynamic learning health systems and their response to COVID-19, the US Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response partnered with the University of New Mexico's Project ECHO and more than 2 dozen other organizations and agencies to create a real-time virtual peer-to-peer clinical education opportunity: the COVID-19 Clinical Rounds Initiative. Focused on 3 "pressure points" in the COVID-19 continuum of care-(1) the out-of-hospital and/or emergency medical services setting, (2) emergency departments, and (3) inpatient critical care environments-the initiative has created a massive peer-to-peer learning network for real-time information sharing, engaging participants in all 50 US states and more than 100 countries. One hundred twenty-five learning sessions had been conducted between March 24, 2020 and February 25, 2021, delivering more than 58,000 total learner-hours of contact in the first 11 months of operation.

Ketamine for Prehospital Pain Management Does Not Prolong Emergency Department Length of Stay.

BACKGROUND: Ketamine is gaining acceptance as an agent for prehospital pain control, but the associated risks of agitation, hallucinations and sedation have raised concern about its potential to prolong emergency department (ED) length of stay (LOS). This study compared ED LOS among EMS patients who received prehospital ketamine, fentanyl or morphine specifically for pain control. We hypothesized ED LOS would not differ between patients receiving the three medications. METHODS: This retrospective observational study utilized the 2018 ESO Research Database, which includes more than 7.5 million EMS events attended by more than 1,200 agencies. Inclusion criteria were a 9-1-1 scene response; age ≥ 18 years; a recorded pain score greater than 4; an initial complaint or use of a treatment protocol indicating a painful condition; prehospital administration of ketamine, fentanyl or morphine; and ED LOS data available. Patients were excluded if they received a combination of the medications, or if there were indications that medication administration could have been for airway management (i.e., altered mental status, head injury, respiratory distress/depression) or agitation control (e.g., behavioral complaints). Kruskal-Wallis test was used to compare ED LOS among patients receiving each of the three medications. Post-hoc evaluations of between-group differences were conducted using Wilcoxon Rank Sum test and a Bonferroni-corrected alpha value of 0.017. RESULTS: Of 9,548 patients who met the inclusion criteria, 119 received ketamine, 1,359 received morphine, and 8,070 received fentanyl. Patient and event characteristics did not significantly differ between the three groups. Median (IQR) ED LOS was 3.5 (2.5-6.1) hours for patients who received ketamine, 4.0 (2.7-6.1) hours for patients who received morphine, and 3.7 (2.6-5.4) hours for patients who received fentanyl (p = 0.002). In post-hoc pairwise comparisons, patients who received morphine had significantly longer ED LOS than patients who received fentanyl (p < 0.001); there was no significant difference in ED LOS for patients who received ketamine vs. morphine (p = 0.161) or for patients who received ketamine vs. fentanyl (p = 0.809). CONCLUSION: ED LOS is not longer for patients who receive prehospital ketamine, versus morphine or fentanyl, for management of isolated painful non-cardiorespiratory conditions.

Using Red Lights and Sirens for Emergency Ambulance Response: How Often Are Potentially Life-Saving Interventions Performed?

BACKGROUND: Emergency Medical Services (EMS) often respond to 911 calls using red lights and sirens (RLS). RLS is associated with increased collisions and increased injuries to EMS personnel. While some patients might benefit from time savings, there is little evidence to guide targeted RLS response strategies. OBJECTIVE: To describe the frequency and nature of 911 calls that result in potentially life-saving interventions (PLSI) during the call. METHODS: Using data from ESO (Austin, Texas, USA), a national provider of EMS electronic health records, we analyzed all 911 calls in 2018. We abstracted the use of RLS, call nature, and interventions performed. A liberal definition of PLSI was developed a priori through a consensus process and included both interventions, medications, and critical hospital notifications. We calculated the proportion of calls with RLS response and with PLSI performed, both overall and stratified by call nature. RESULTS: There were 5,977,612 calls from 1,187 agencies included in the analysis. The majority (85.8%) of calls utilized RLS, yet few (6.9%) resulted in PLSI. When stratified by call nature, cardiac arrest calls had the highest frequency PLSI (45.0%); followed by diabetic problems (37.0%). Glucose was the most frequently given PLSI, n = 69,036. When including multiple administrations to the same patient, epinephrine was given most commonly PLSI, n = 157,282 administrations). CONCLUSION: In this large national dataset, RLS responses were very common (86%) yet potentially life-saving interventions were infrequent (6.9%). These data suggest a methodology to help EMS leaders craft targeted RLS response strategies.

Development of a Binary End-of-Event Outcome Indicator for the NEMSIS Public Release Research Dataset.

INTRODUCTION: Emergency department and hospital discharge status are available for less than 2% of events recorded in the National EMS Information System (NEMSIS) Public Release Research dataset. The purpose of this project was to develop a binary ("dead" vs. "alive") end-of-event outcome indicator for the NEMSIS dataset. METHODS: The data dictionary for the Version 3 NEMSIS dataset was evaluated to identify elements and codes providing information about a patient's end-of-event status-defined as the point at which EMS providers stopped providing care for an encountered patient, whether at the scene of the event or the transport destination. Those element and code combinations were then used to test the criteria using the NEMSIS-2017 dataset. After revising the criteria based on the NEMSIS-2017 results, the final criteria were then applied to the 2018 NEMSIS dataset. To assess representativeness, the characteristics of events with a determinable outcome were compared to those of the entire dataset. To assess accuracy, the end-of-event indicator was compared with the final reported outcome for patients with a known emergency department disposition. RESULTS: Eighteen NEMSIS element and code combinations suggest a patient was likely "dead" at the end of EMS care, and 15 combinations suggest a patient was likely "alive" at the end of EMS care. A binary end-of-event outcome indicator could be determined for 13,045,887 (98.6%) of the 13,229,079 NEMSIS-2018 9-1-1 initiated ground EMS responses in which patient contact was established, and for 132,728 (89.1%) of the 148,963 events with documented cardiac arrest. The characteristics of the events with determinable end-of-event outcomes did not differ from those of the full dataset. Among patients with a known outcome, 99.6% of those with an "alive" end-of-event indicator were in fact alive at the time of emergency department disposition. CONCLUSION: A binary end-of-event outcome indicator can be determined for 98.6% of 9-1-1 initiated ground EMS scene responses and 89.1% of cardiac arrests included in the NEMSIS dataset. The events with a determinable outcome appear representative of the larger dataset and the end-of-event indicators are generally consistent with reported emergency department outcomes.

Injury rates per mile of travel for electric scooters versus motor vehicles.

OBJECTIVE: This study determined the vehicle-miles-traveled (VMT)-based injury rate for stand-up, dockless electric rental scooters (e-scooters), and compare it with the VMT-based injury rate for motor vehicle travel. METHODS: In this secondary analysis of existing data, the e-scooter injury rate was calculated based on e-scooter injuries presenting to an emergency department or the emergency medical services system in Austin, TX between September and November 2018. Injuries were identified by Austin Public Health through a targeted e-scooter epidemiological injury investigation; e-scooter VMT data were reported by e-scooter vendors as a condition of their city licensing. Comparative injury rates for motor vehicle travel in Texas, and specifically in Travis County were calculated using annual motor vehicle crash (MVC) injury and VMT data reported by the Texas Department of Transportation. RESULTS: There were 160 confirmed e-scooter injuries identified by the e-scooter injury investigation, with 891,121 reported miles of e-scooter travel during the study period. This produces an injury rate estimate of 180 injuries/million VMT (MVMT). The injury rates for motor vehicle travel for Texas and for Travis County were 0.9 injuries/MVMT and 1.0 injuries/MVMT, respectively. CONCLUSION: The observed VMT-based e-scooter injury rate was approximately 175 to 200 times higher than statewide or county specific injury rates for motor vehicle travel. These findings raise concerns about the potential higher injury rate associated with e-scooters, and highlight the need for further injury surveillance, research and prevention activities addressing this emerging transportation technology.

Uncomplicated Distal Radius Fractures: An Opportunity to Reduce Emergency Medicine Opioid Prescribing?

OBJECTIVES: To assess emergency physician prescribing for simple extremity fractures-specifically, distal radius fractures-and describe the opportunity for reducing opioid prescribing. METHODS: An electronic survey was distributed to 1238 emergency physicians employed by a nationwide practice serving 220 sites in 20 states. The survey presented two plain film views of a simple Colles fracture and asked: "For the last patient you discharged . . . with the above injury, which pain medications did you prescribe or recommend?" Responses were collected using a clickable checklist of common opioid and nonopioid pain medications. Respondents also specified the number of days covered by any prescription. We assessed associations between physician characteristics and opioid prescribing using the χ2 test, the Wilcoxon rank-sum test, and multivariable regression models. RESULTS: Responses were received from 447 (36%) physicians working in 18 states; 93% were trained in emergency medicine, 33% worked at academic sites, 68% had site volumes between 25,000 and 75,000, and the median experience was 10 (interquartile range 5-19) years. Overall, 92% (95% confidence interval 89%-95%) had prescribed an opioid for a median of 3 (interquartile range 3-4) days. The most commonly prescribed opioids were hydrocodone/acetaminophen (55%) and oxycodone/acetaminophen (20%). Physicians at academic sites prescribed opioids less frequently than those at nonacademic sites (88% vs 94%), but in multivariable regression there were no significant associations between physician characteristics and opioid prescribing. CONCLUSIONS: Emergency physicians commonly prescribe opioids for simple distal radius fractures. This represents a potential opportunity to reduce opioid prescribing.

Is Use of Warning Lights and Sirens Associated With Increased Risk of Ambulance Crashes? A Contemporary Analysis Using National EMS Information System (NEMSIS) Data.

STUDY OBJECTIVE: We compare reported crash rates for US ambulances responding to or transporting patients from a 911 emergency scene with or without lights and sirens. Our null hypothesis is that there will be no difference in the rate of ambulance crashes whether lights and sirens are used. METHODS: For this retrospective cohort study, we used the 2016 National EMS Information System data set to identify 911 scene responses and subsequent patient transports by transport-capable emergency medical services (EMS) units. We used the system's "response mode to scene" and "transport mode from scene" fields to determine lights and sirens use. We used the "type of response delay" and "type of transport delay" fields to identify responses and transports that were delayed because of a crash involving the ambulance. We calculated the rate of crash-related delays per 100,000 responses or transports and used multivariable logistic regression with clustered (by agency) standard errors to calculate adjusted odds ratios (AORs) (with 95% confidence intervals [CIs]) for the association between crash-related delays and lights and sirens use for responses and transports separately. RESULTS: Among 19 million included 911 scene responses, the response phase crash rate was 4.6 of 100,000 without lights and sirens and 5.4 of 100,000 with lights and sirens (AOR 1.5; 95% CI 1.2 to 1.9). For the transport phase, the crash rate was 7.0 of 100,000 without lights and sirens and 17.1 of 100,000 with lights and sirens (AOR 2.9; 95% CI 2.2 to 3.9). Excluding responses and transports with only partial lights and sirens use did not meaningfully alter the results (response AOR 1.5, 95% CI 1.2 to 1.9; transport AOR 2.8, 95% CI 2.1 to 3.8). CONCLUSION: Ambulance use of lights and sirens is associated with increased risk of ambulance crashes. The association is greatest during the transport phase. EMS providers should weigh these risks against any potential time savings associated with lights and sirens use.

Non-Auto-Injector Epinephrine Administration by Basic Life Support Providers: A Literature Review and Consensus Process.

Anaphylaxis is a life-threatening condition with a known effective prehospital intervention: parenteral epinephrine. The National Association of EMS Physicians (NAEMSP) advocates for emergency medical services (EMS) providers to be allowed to carry and administer epinephrine. Some states constrain epinephrine administration by basic life support (BLS) providers to administration using epinephrine auto-injectors (EAIs), but the cost and supply of EAIs limits the ability of some EMS agencies to provide epinephrine for anaphylaxis. This literature review and consensus report describes the extant literature and the practical and policy issues related to non-EAI administration of epinephrine for anaphylaxis, and serves as a supplementary resource document for the revised NAEMSP position statement on the use of epinephrine in the out-of-hospital treatment of anaphylaxis, complementing (but not replacing) prior resource documents. The report concludes that there is some evidence that intramuscular injection of epinephrine drawn up from a vial or ampule by appropriately trained EMS providers-without limitation to specific certification levels-is safe, facilitates timely treatment of patients, and reduces costs.

Emergency department patient payer status after implementation of the Affordable Care Act: A nationwide analysis using NHAMCS data.

OBJECTIVE: To evaluate changes in insurance status among emergency department (ED) patients presenting in the two years immediately before and after full implementation of the Affordable Care Act (ACA). METHODS: We evaluated National Hospital Ambulatory Medical Care Survey (NHAMCS) Emergency Department public use data for 2012-2015, categorizing patients as having any insurance (private; Medicare; Medicaid; workers' compensation) or no insurance. We compared the pre- and post-ACA frequency of insurance coverage-overall and within the older (≥65), working-age (18-64) and pediatric (<18) subpopulations-using unadjusted odds ratios with 95% confidence intervals. We also conducted a difference-in-differences analysis comparing the change in insurance coverage among working-age patients with that observed for older Medicare-eligible patients, while controlling for sex, race and underlying temporal trends. RESULTS: Overall, the proportion of ED patients with any insurance did not significantly change from 2012 to 2013 to 2014-2015 (74.2% vs 77.7%) but the proportion of working-age adult patients with at least one form of insurance increased significantly, from 66.0% to 71.8% (OR 1.31, CI: 1.13-1.52). The difference-in-differences analysis confirmed the change in insurance coverage among working-age adults was greater than that seen in the reference population of Medicare-eligible adults (AOR 1.70, CI: 1.29-2.23). The increase was almost entirely attributable to increased Medicaid coverage. CONCLUSION: In the first two years following full implementation of the ACA, there was a significant increase in the proportion of working-age adult ED patients who had at least one form of health insurance. The increase appeared primarily associated with expansion of Medicaid.

Out-of-hospital cardiac arrest outcomes with "pit crew" resuscitation and scripted initiation of mechanical CPR.

OBJECTIVE: To compare OHCA outcomes in patients managed with mechanical versus manual CPR in an EMS system with a "pit crew" approach to resuscitation and a scripted sequence for the initiation of mechanical CPR. METHODS: Through a year-long quality improvement effort we standardized the initial resuscitative efforts for OHCA, prioritizing a "pit crew" approach to high quality manual CPR, early defibrillation and basic airway management ahead of a scripted sequence for initiating mechanical CPR. We then analyzed outcomes for adult, non-traumatic OHCA attended in the following year (2016). We used a propensity score matched analysis to compare ROSC, survival to discharge, and neurologic status among patients managed with manual versus mechanical CPR while controlling for patient demographics and arrest characteristics. RESULTS: Of 444 eligible OHCAs, 217 received manual and 227 received mechanical CPR. Crude ROSC (39.2% vs. 29.1%) and survival to discharge (13.8% vs. 5.7%) were higher with manual CPR. In the propensity matched analysis (n = 176 manual CPR; 176 mechanical CPR), both ROSC (38.6% vs. 28.4%; difference: 10.2%; CI: 0.4% to 20.0%) and survival to discharge (13.6% vs. 6.8%; difference: 6.8%; CI: 0.5% to 13.3%) remained significantly higher for patients receiving manual CPR. CONCLUSIONS: In this EMS system with a standardized, "pit crew" approach to OHCA that prioritized initial high-quality initial resuscitative efforts and scripted the sequence for initiating mechanical CPR, use of mechanical CPR was associated with decreased ROSC and decreased survival to discharge.

Improving Decisions About Transport to the Emergency Department for Assisted Living Residents Who Fall.

Background: Residents of assisted living facilities who fall may not be seriously ill or injured, but policies often require immediate transport to an emergency department regardless of the patient's condition. Objective: To determine whether unnecessary transport can be avoided. Design: Prospective cohort study. Setting: One large county with a single system of emergency medical services. Participants: Convenience sample of residents in 22 assisted living facilities served by 1 group of primary care physicians. Intervention: Paramedics providing emergency medical services followed a protocol that included consulting with a physician by telephone. Measurements: The number of transports after a fall and the number of time-sensitive conditions in nontransported patients. Results: Of the 1473 eligible residents, 953 consented to participate in the study (mean age, 86 years; 76% female) and 359 had 840 falls in 43 months. The protocol recommended nontransport after 553 falls. Eleven of these patients had a time-sensitive condition. At least 7 of them received appropriate care: 4 requested and received transport despite the protocol recommendation, and 3 had minor injuries that were successfully managed on site. Three additional patients had fractures that were diagnosed by outpatient radiography. The final patient developed vomiting and diarrhea, started palliative care, and died 60 hours after the fall. At least 549 of the 553 patients (99.3% [95% CI, 98.2% to 99.8%]) with a protocol recommendation for nontransport received appropriate care. Limitation: The resources required for this program will preclude use in some locations. Conclusion: Shared decision making between paramedics and primary care physicians can prevent transport to the emergency department for many residents of assisted living facilities who fall. Primary Funding Source: None.

Effect of mobile phone proliferation on crash notification times and fatality rates.

INTRODUCTION: The purpose of this study was to evaluate whether increased proliferation of mobile telephones has been associated with decreased MVC notification times and/or decreased MVC fatality rates in the United States (US). METHODS: We used World Bank annual mobile phone market penetration data and US Fatality Analysis Reporting System (FARS) fatal MVC data for 1994-2014. For each year, phone proliferation was measured as mobile phones per 100 population. FARS data were used to calculate MVC notification time (time EMS notified - time MVC occurred) in minutes, and to determine the MVC fatality rate per billion vehicle miles traveled (BVMT). We used basic vector auto-regression modeling to explore relationships between changes in phone proliferation and subsequent changes in median and 90th percentile MVC notification times, as well as MVC fatality rates. RESULTS: From 1994 to 2014, larger year-over-year increases in phone proliferation were associated with larger decreases in 90th percentile notification times for MVCs occurring during daylight hours (p=0.004) and on the national highway system (p=0.046) two years subsequent, and crashes off the national highway system three years subsequent (p=0.023). There were no significant associations between changes in phone proliferation and subsequent changes in median crash notification times, nor with subsequent changes in MVC fatality rates. CONCLUSION: Between 1994 and 2014 increased mobile phone proliferation in the U.S. was associated with shorter 90th percentile EMS notification times for some subgroups of fatal MVCs, but not with decreases in median notification times or overall MVC fatality rates.

Crash Fatality Rates After Recreational Marijuana Legalization in Washington and Colorado.

OBJECTIVES: To evaluate motor vehicle crash fatality rates in the first 2 states with recreational marijuana legalization and compare them with motor vehicle crash fatality rates in similar states without recreational marijuana legalization. METHODS: We used the US Fatality Analysis Reporting System to determine the annual numbers of motor vehicle crash fatalities between 2009 and 2015 in Washington, Colorado, and 8 control states. We compared year-over-year changes in motor vehicle crash fatality rates (per billion vehicle miles traveled) before and after recreational marijuana legalization with a difference-in-differences approach that controlled for underlying time trends and state-specific population, economic, and traffic characteristics. RESULTS: Pre-recreational marijuana legalization annual changes in motor vehicle crash fatality rates for Washington and Colorado were similar to those for the control states. Post-recreational marijuana legalization changes in motor vehicle crash fatality rates for Washington and Colorado also did not significantly differ from those for the control states (adjusted difference-in-differences coefficient = +0.2 fatalities/billion vehicle miles traveled; 95% confidence interval = -0.4, +0.9). CONCLUSIONS: Three years after recreational marijuana legalization, changes in motor vehicle crash fatality rates for Washington and Colorado were not statistically different from those in similar states without recreational marijuana legalization. Future studies over a longer time remain warranted.