Prehospital hypoxemia, measured by pulse oximetry, predicts hospital outcomes during the New York City COVID-19 pandemic.

OBJECTIVE: To determine if oxygen saturation (out-of-hospital SpO2), measured by New York City (NYC) 9-1-1 Emergency Medical Services (EMS), was an independent predictor of coronavirus disease 2019 (COVID-19) in-hospital mortality and length of stay, after controlling for the competing risk of death. If so, out-of-hospital SpO2 could be useful for initial triage. METHODS: A population-based longitudinal study of adult patients transported by EMS to emergency departments (ED) between March 5 and April 30, 2020 (the NYC COVID-19 peak period). Inclusion required EMS prehospital SpO2 measurement while breathing room air, transport to emergency department, and a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcription polymerase chain reaction test. Multivariable logistic regression modeled mortality as a function of prehospital SpO2, controlling for covariates (age, sex, race/ethnicity, and comorbidities). A competing risk model also was performed to estimate the absolute risks of out-of-hospital SpO2 on the cumulative incidence of being discharged from the hospital alive. RESULTS: In 1673 patients, out-of-hospital SpO2 and age were independent predictors of in-hospital mortality and length of stay, after controlling for the competing risk of death. Among patients ≥66 years old, the probability of death was 26% with an out-of-hospital SpO2 >90% versus 54% with an out-of-hospital SpO2 ≤90%. Among patients <66 years old, the probability of death was 11.5% with an out-of-hospital SpO2 >90% versus 31% with an out-of-hospital SpO2 ≤ 90%. An out-of-hospital SpO2 level ≤90% was associated with over 50% decreased likelihood of being discharged alive, regardless of age. CONCLUSIONS: Out-of-hospital SpO2 and age predicted in-hospital mortality and length of stay: An out-of-hospital SpO2 ≤90% strongly supports a triage decision for immediate hospital admission. For out-of-hospital SpO2 >90%, the decision to admit depends on multiple factors, including age, resource availability (outpatient vs inpatient), and the potential impact of new treatments.

System impacts of the COVID-19 pandemic on New York City's emergency medical services.

OBJECTIVES: To describe the impact of the COVID-19 pandemic on New York City's (NYC) 9-1-1 emergency medical services (EMS) system and assess the efficacy of pandemic planning to meet increased demands. METHODS: Longitudinal analysis of NYC 9-1-1 EMS system call volumes, call-types, and response times during the COVID-19 peak-period (March 16-April 15, 2020) and post-surge period (April 16-May 31, 2020) compared with the same 2019 periods. RESULTS: EMS system received 30,469 more calls from March 16-April 15, 2020 compared with March 16-April 15, 2019 (161,815 vs 127,962; P < 0.001). On March 30, 2020, call volume increased 60% compared with the same 2019 date. The majority were for respiratory (relative risk [RR] = 2.50; 95% confidence interval [CI] = 2.44-2.56) and cardiovascular (RR = 1.85; 95% CI = 1.82-1.89) call-types. The proportion of high-acuity, life-threatening call-types increased compared with 2019 (42.3% vs 36.4%). Planned interventions to prioritize high-acuity calls resulted in the average response time increasing by 3 minutes compared with an 11-minute increase for low low-acuity calls. Post-surge, EMS system received fewer calls compared with 2019 (154,310 vs 193,786; P < 0.001). CONCLUSIONS: COVID-19-associated NYC 9-1-1 EMS volume surge was primarily due to respiratory and cardiovascular call-types. As the pandemic stabilized, call volume declined to below pre-pandemic levels. Our results highlight the importance of EMS system-wide pandemic crisis planning.

Acuity Prediction Using Emergency Medical Services Prenotifications in a Pediatric Emergency Department.

OBJECTIVES: Emergency medical services (EMS) prenotifications are critical, although they oftentimes inaccurately convey the arriving patient's true acuity, resulting in inappropriate preparation in the emergency department. The objectives of this study were (1) to determine interrater reliability of acuity prediction based on prenotifications among physicians and (2) to compare predicted versus actual patient acuity based on prenotifications. METHODS: A panel of physicians reviewed recordings of EMS prenotifications and then predicted the patient's acuity using the Emergency Severity Index (ESI). The scores were analyzed for interrater reliability using the weighted κ statistic. In the prospective phase of the study, physicians predicted an ESI before patient arrival based solely on the EMS prenotification and then calculated an actual ESI upon arrival. Descriptive statistics were calculated, and comparisons between the predicted and actual ESI were performed using Wilcoxon signed rank for matched pairs. RESULTS: Panelists reviewed a total of 23 recordings, and the interrater reliability was 0.23 overall (SE, 0.026; P < 0.001), indicating only fair agreement. One hundred patients were enrolled in the prospective analysis. There was a statistically significant difference between the predicted and actual ESI made by physicians (P = 0.0001). For 46 patients, the predicted and actual scores matched, but 13 patients were "undertriaged," and 41 patients were "overtriaged" based on predicted acuity. CONCLUSIONS: Interpretation of acuity using EMS prenotifications among physicians was only fairly reliable, and physicians had difficulty predicting actual acuity based on prenotifications. Improper preparation based on these prenotifications can potentially impact patient care and resource allocation.

Lesson From the New York City Out-of-Hospital Uncontrolled Donation After Circulatory Determination of Death Program.

STUDY OBJECTIVE: In 2006, the Institute of Medicine emphasized substantial potential to expand organ donation opportunities through uncontrolled donation after circulatory determination of death (uDCDD). We pilot an out-of-hospital uDCDD kidney program for New York City in partnership with communities that it was intended to benefit. We evaluate protocol process and outcomes while identifying barriers to success and means for improvement. METHODS: We conducted a prospective, participatory action research study in Manhattan from December 2010 to May 2011. Daily from 4 to 12 pm, our organ preservation unit monitored emergency medical services (EMS) frequencies for cardiac arrests occurring in private locations. After EMS providers independently ordered termination of resuscitation, organ preservation unit staff determined clinical eligibility and donor status. Authorized parties, persons authorized to make organ donation decisions, were approached about in vivo preservation. The study population included organ preservation unit staff, authorized parties, passersby, and other New York City agency personnel. Organ preservation unit staff independently documented shift activities with daily operations notes and teleconference summaries that we analyzed with mixed qualitative and quantitative methods. RESULTS: The organ preservation unit entered 9 private locations; all the deceased lacked previous registration, although 4 met clinical screening eligibility. No kidneys were recovered. We collected 837 notes from 35 organ preservation unit staff. Despite frequently recounting protocol breaches, most responses from passersby including New York City agencies were favorable. No authorized parties were offended by preservation requests, yielding a Bayesian posterior median 98% (95% credible interval 76% to 100%). CONCLUSION: In summary, the New York City out-of-hospital uDCDD program was not feasible. There were frequent protocol breaches and confusion in determining clinical eligibility. In the small sample of authorized persons we encountered during the immediate grieving period, negative reactions were infrequent.

Prehospital Stroke Identification: Factors Associated with Diagnostic Accuracy.

BACKGROUND: Stroke patients misdiagnosed by emergency medical services (EMS) providers have been shown to receive delayed in-hospital care. We aim at determining the diagnostic accuracy of Fire Department of New York (FDNY) EMS providers for stroke and identifying potential reasons for misdiagnosis. METHODS: Prehospital care reports of all patients transported by FDNY EMS to 3 hospitals from January 1, 2010, to December 31, 2011, were compared against the American Heart Association Get With The Guidelines (GWTG) database (reference standard) for the diagnosis of stroke. Age-adjusted logistic regression models were generated to explore prehospital patient characteristics which are associated with stroke misdiagnosis. RESULTS: Of 72,984 patient transports during the study period, 750 had a GWTG diagnosis of stroke, 468 (62%) of which were identified correctly in the field and 282 (38%) were missed. An additional 268 patients were misdiagnosed as stroke when in fact they had an alternative diagnosis. Overall sensitivity was 62.4% (95% confidence interval [CI], 58.9-65.8) and specificity was 99.6% (95% CI, 99.6-99.7). No patients who presented with unilateral weakness, facial weakness, or speech problems were missed, whereas patients with atypical complaints like general malaise, dizziness, and headache were more likely to be missed. Seizures led the EMS providers to both overcall a stroke and miss the diagnosis. CONCLUSIONS: FDNY EMS care providers missed more than a third of stroke cases. Seizures and other atypical presentations contribute significantly to stroke misdiagnosis in the field. Our findings highlight the need for better prehospital stroke identification methods.

A modified simple triage and rapid treatment algorithm from the New York City (USA) Fire Department.

INTRODUCTION: The objective of this study was to determine if modification of the Simple Triage and Rapid Treatment (START) system by the addition of an Orange category, intermediate between the most critically injured (Red) and the non-critical, non-ambulatory injured (Yellow), would reduce over- and under-triage rates in a simulated mass-casualty incident (MCI) exercise. METHODS: A computer-simulation exercise of identical presentations of an MCI scenario involving a 2-train collision, with 28 case scenarios, was provided for triaging to two groups: the Fire Department of the City of New York (FDNY; n=1,347) using modified START, and the Emergency Medical Services (EMS) providers from the Eagles 2012 EMS conference (Lafayette, Louisiana USA; n=110) using unmodified START. Percent correct by triage category was calculated for each group. Performance was then compared between the two EMS groups on the five cases where Orange was the correct answer under the modified START system. RESULTS: Overall, FDNY-EMS providers correctly triaged 91.2% of cases using FDNY-START whereas non-FDNY-Eagles providers correctly triaged 87.1% of cases using unmodified START. In analysis of the five Orange cases (chest pain or dyspnea without obvious trauma), FDNY-EMS performed significantly better using FDNY-START, correctly triaging 86.3% of cases (over-triage 1.5%; under-triage 12.2%), whereas the non-FDNY-Eagles group using unmodified START correctly triaged 81.5% of cases (over-triage 17.3%; under-triage 1.3%), a difference of 4.9% (95% CI, 1.5-8.2). CONCLUSIONS: The FDNY-START system may allow providers to prioritize casualties using an intermediate category (Orange) more properly aligned to meet patient needs, and as such, may reduce the rates of over-triage compared with START. The FDNY-START system decreases the variability in patient sorting while maintaining high field utility without needing computer assistance or extensive retraining. Comparison of triage algorithms at actual MCIs is needed; however, initial feedback is promising, suggesting that FDNY-START can improve triage with minimal additional training and cost.

Accuracy of weight estimates in pediatric patients by prehospital Emergency Medical Services personnel.

OBJECTIVES: Most medications administered to children are weight-based, and inaccurate weight estimation may contribute to medical errors. Previous studies have been limited to hypothetical patients and those in cardiopulmonary arrest. We aim to determine the accuracy of weight estimates by Emergency Medical Services (EMS) personnel of children receiving medications and to identify factors associated with accuracy. METHODS: EMS records of children <18 years old receiving weight-based medications were merged with EMS staffing data and hospital records. The rate of accurate weight estimates, defined as a value within 20% of the actual weight, was evaluated as the primary outcome. Factors associated with patients and prehospital personnel were also evaluated. RESULTS: 29233 transports occurring during the study period were reviewed, and 199 transports of 179 children were analyzed. The average experience of EMS personnel was 35.8 months (SD ±30.7). EMS personnel accurately estimated weights in 164/199 (82.4%) patients; estimated weights were within 10.8% (SD ±10.5) of the actual weights. Underestimated weights were associated with receiving doses outside of the therapeutic range. Inaccurate weight estimates were associated with age less than 10 years or cardiopulmonary arrest. There was a trend toward inaccurate weight estimates among children who presented with seizures. CONCLUSIONS: EMS personnel are generally accurate in estimating weights of children. There was an association between underestimated weights and inaccurate medication dosing. Younger children or those presenting with seizure or cardiopulmonary arrest were more likely to have inaccurate weight estimates.

A rationale in support of uncontrolled donation after circulatory determination of death.

In the United States, when people die unexpectedly, they are usually not considered as organ donors because of the difficulty of keeping organs viable when death occurs outside the hospital, in "uncontrolled" circumstances. New protocols to permit donation in these cases have renewed the debate about how we decide whether a person has died- and whether the moral imperative to help those in need of transplant should affect the determination of death.

Utilization of emergency medical services in a large urban area: description of call types and temporal trends.

BACKGROUND: Emergency medical services (EMS) systems are used by the public for a range of medically related problems. OBJECTIVE: To understand and analyze the patterns of EMS utilization and trends over time in a large urban EMS system so that we may better direct efforts toward improving those services. METHODS: The 63 call type designations from all New York City (NYC) 9-1-1 EMS calls between 1999 and 2007 were obtained and grouped into 10 broad and 30 specific medical categories. Aggregated numbers of total EMS calls and individual categories were divided by NYC resident population estimates to determine utilization rates. Temporal trends were evaluated for statistical significance with Spearman's rho (ρ). RESULTS: There were 9,916,904 EMS calls between 1999 and 2007, with an average of 1,101,878 calls/year. Utilization rates increased from 129.5 to 141.9 calls/1,000 residents/year over the study period (average annual rise of 1.16%). Among all medical/surgical call types (excluding trauma), there was an average annual increase of 1.8%/year. The most substantial increases were among "psychiatric/drug related" (+5.6%/year), "generalized illness" (+3.2%/year), and "environmental related" calls (+2.9%/year). The largest decrease was among "respiratory" calls (-1.2%/year), specifically for "asthma" (-5.0%/year). For trauma call types, there was an annual average decrease of 0.4%/year, with the category of "violence related" calls having the greatest decline (-3.3%/year). CONCLUSION: There was an increase in overall EMS utilization rates, though not all call types rose uniformly. Rather, a number of significant trends were identified reflecting either changing medical needs or changing patterns of EMS utilization in NYC's population.

Resuscitation center designation: recommendations for emergency medical services practices.

Regionalization of medical resources by designating specialty receiving centers, such as trauma and stroke centers, within emergency medical services (EMS) systems is intended to ensure the highest-quality patient care in the most efficient and fiscally responsible fashion. Significant advances in the past decade such as induction of therapeutic hypothermia following resuscitation from cardiac arrest and a time-driven, algorithmic approach to management of septic patients have created compelling arguments for similar designation for specialized resuscitative interventions. Resuscitation of critically ill patients is both labor- and resource-intensive. It can significantly interrupt emergency department (ED) patient throughput. In addition, clinical progress in developing resuscitation techniques is often dependent on the presence of a strong research infrastructure to generate and validate new therapies. It is not feasible for many hospitals to make the commitment to care for large numbers of critically ill patients and the accompanying investigational activities, whether in the prehospital, ED, or inpatient arena. Because of this, the question of whether EMS systems should designate specific hospitals as "resuscitation centers" has now come center stage. Just as EMS systems currently delineate criteria and monitor compliance for trauma, ST-elevation myocardial infarction (STEMI), and stroke centers, strong logic now exists to develop similar standards for resuscitation facilities. Accordingly, this discussion reviews the current applicable trends in resuscitation science and presents a rationale for resuscitation center designation within EMS systems. Potential barriers to the establishment of such centers are discussed and strategies to overcome them are proposed.

Success of organ donation after out-of-hospital cardiac death and the barriers to its acceptance.

It is well documented that transplants save lives and improve quality of life for patients suffering from kidney, liver, and heart failure. Uncontrolled donation after cardiac death (UDCD) is an effective and ethical alternative to existing efforts towards increasing the available pool of organs. However, people who die from an out-of-hospital cardiac arrest are currently being denied the opportunity to be organ donors except in those few locations where out-of-hospital UDCD programs are active, such as in Paris, Madrid, and Barcelona. Societies have the medical and moral obligation to develop UDCD programs.

Pediatric nerve agent poisoning: medical and operational considerations for emergency medical services in a large American city.

Most published recommendations for treatment of pediatric nerve agent poisoning are based on standard resuscitation doses for these agents. However, certain medical and operational concerns suggest that an alternative approach may be warranted for treatment of children by emergency medical personnel after mass chemical events. (1) There is evidence both that suprapharmacological doses may be warranted and that side effects from antidote overdosage can be tolerated. (2) There is concern that many emergency medical personnel will have difficulty determining both the age of the child and the severity of the symptoms. Therefore, the Regional Emergency Medical Advisory Committee of New York City and the Fire Department, City of New York, Bureau of Emergency Medical Services, in collaboration with the Center for Pediatric Emergency Medicine of the New York University School of Medicine and the Bellevue Hospital Center, have developed a pediatric nerve agent antidote dosing schedule that addresses these considerations. These doses are comparable to those being administered to adults with severe symptoms and within limits deemed tolerable after inadvertent nerve agent overdose in children. We conclude that the above approach is likely a safe and effective alternative to weight-based dosing of children, which will be nearly impossible to attain under field conditions.

Impact of a citywide blackout on an urban emergency medical services system.

INTRODUCTION: On 14 August 2003, New York City and a large portion of the northeastern United States experienced the largest blackout in the history of the country. An analysis of such a widespread disaster on emergency medical service (EMS) operations may assist in planning for and managing such disasters in the future. METHODS: A retrospective review of all EMS activity within New York City's 9-1-1 emergency telephone system during the 29 hours during which all or parts of the city were without power (16:11 hours (h) on 14 August 2003 until 21:03 h on 15 August 2003) was performed. Control periods were established utilizing identical time periods during the five weeks preceding the blackout. RESULTS: Significant increases were identified in the overall EMS demand (7,844 incidents vs. 3,860 incidents; p < 0.001) as well as in 20 of the 62 call-types of the system, including cardiac arrests (119 vs. 76, p = 0.043). Significant decreases were found only among calls related to psychological emergencies (114 vs. 221; p = 0.006) and drug- or alcohol-related emergencies (78 vs. 146; p = 0.009). Though median response times increased by only 60 seconds, median call-processing times within the 9-1-1 emergency telephone system EMS dispatch center of the city increased from 1.1 to 5.5 minutes. CONCLUSIONS: The citywide blackout resulted in dramatic changes in the demands upon the EMS system of New York City, the types of patients for whom EMS providers were assigned to provide care, and the dispositions for those assignments. During this time of increased, system-wide demand, the use of cross-trained firefighter and first-responder engine companies resulted in improved response times to cardiac arrest patients. Finally, the ability of the EMS dispatch center to process the increased requests for EMS assistance proved to be the rate-limiting step in responding to these emergencies. These findings will prove useful in planning for future blackouts or any disaster that may broadly impact the infrastructure of a city.

Facilitating EMS turnaround intervals at hospitals in the face of receiving facility overcrowding.

The escalating national problem of oversaturated hospital beds and emergency departments (EDs) has resulted in serious operational impediments within patient-receiving facilities. It has also had a growing impact on the 9-1-1 emergency care system. Beyond the long-standing difficulties arising from ambulance diversion practices, many emergency medical services (EMS) crews are now finding themselves detained in EDs for protracted periods, unable to transfer care of their transported patients to ED staff members. Key factors have included a lack of beds or stretcher space, and, in some cases, EMS personnel are used transiently for ED patient care services. In other circumstances, ED staff members no longer prioritize rapid turnaround of EMS-transported patients because of the increasing volume and acuity of patients already in their care. The resulting detention of EMS crews confounds concurrent ambulance availability problems, creates concrete risks for delayed EMS responses to impending critical cases, and incurs regulatory jeopardy for hospitals. Communities should take appropriate steps to ensure that delivery intervals (time elapsing from entry into the hospital to physical transfer of patient care to ED staff) remain extremely brief (less than a few minutes) and that they rarely exceed 10 minutes. While recognizing that the root causes of these issues will require far-reaching national health care policy changes, EMS and local government officials should still maintain ongoing dialogues with hospital chief administrators to mitigate this mutual crisis of escalating service demands. Federal and state health officials should also play an active role in monitoring progress and compliance.