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

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

Designing, development and validation of an app to reduce the response time of the emergency medical services.

INTRODUCTION: Delays in prehospital care attributable to the call-taking process can often be traced back to miscommunication, including uncertainty around the call location. Geolocation applications have the potential to streamline the call-taking process by accurately identifying the caller's location. OBJECTIVE: To develop and validate an application to geolocate emergency calls and compare the response time of calls made via the application with those of conventional calls made to the Brazilian Medical Emergency System (Serviço de Atendimento Médico de Urgência-SAMU). METHODS: This study was conducted in two stages. First, a geolocating application for SAMU emergency calls (CHAMU192) was developed using a mixed methods approach based on design thinking and subsequently validated using the System Usability Scale (SUS). In the second stage, sending time of the geolocation information of the app was compared with the time taken to process information through conventional calls. For this, a hypothetical case control study was conducted with SAMU in the Maringá, Paraná, Brazil. A control group of 350 audio recordings of emergency calls from 2019 was compared to a set of test calls made through the CHAMU192 app. The CHAMU192 group consisted of 201 test calls in Maringá. In test calls, the location was obtained by GPS and sent to the SAMU communication system. Comparative analysis between groups was performed using the Mann-Whitney test. RESULTS: CHAMU192 had a SUS score of 90, corresponding to a "best imaginable" usability rating. The control group had a median response time of 35.67 seconds (26.00-48.12). The response time of the CHAMU192 group was 0.20 (0.15-0.24). CONCLUSION: The use of the CHAMU192 app by emergency medical services could significantly reduce response time. The results demonstrate the potential of app improving the quality and patient outcomes related to the prehospital emergency care services.

Incorporation of Drone Technology Into the Chain of Survival for OHCA: Estimation of Time Needed for Bystander Treatment of OHCA and CPR Performance.

BACKGROUND: Drone-delivered automated external defibrillators (AEDs) hold promises in the treatment of out-of-hospital cardiac arrest. Our objective was to estimate the time needed to perform resuscitation with a drone-delivered AED and to measure cardiopulmonary resuscitation (CPR) quality. METHODS: Mock out-of-hospital cardiac arrest simulations that included a 9-1-1 call, CPR, and drone-delivered AED were conducted. Each simulation was timed and video-recorded. CPR performance metrics were recorded by a Laerdal Resusci Anne Quality Feedback System. Multivariable regression modeling examined factors associated with time from 9-1-1 call to AED shock and CPR quality metrics (compression rate, depth, recoil, and chest compression fraction). Comparisons were made among those with recent CPR training (≤2 years) versus no recent (>2 years) or prior CPR training. RESULTS: We recruited 51 research participants between September 2019 and March 2020. The median age was 34 (Q1-Q3, 23-54) years, 56.9% were female, and 41.2% had recent CPR training. The median time from 9-1-1 call to initiation of CPR was 1:19 (Q1-Q3, 1:06-1:26) minutes. A median time of 1:59 (Q1-Q3, 01:50-02:20) minutes was needed to retrieve a drone-delivered AED and deliver a shock. The median CPR compression rate was 115 (Q1-Q3, 109-124) beats per minute, the correct compression depth percentage was 92% (Q1-Q3, 25-98), and the chest compression fraction was 46.7% (Q1-Q3, 39.9%-50.6%). Recent CPR training was not associated with CPR quality or time from 9-1-1 call to AED shock. Younger age (per 10-year increase; ß, 9.97 [95% CI, 4.63-15.31] s; P<0.001) and prior experience with AED (ß, -30.0 [95% CI, -50.1 to -10.0] s; P=0.004) were associated with more rapid time from 9-1-1 call to AED shock. Prior AED use (ß, 6.71 [95% CI, 1.62-11.79]; P=0.011) was associated with improved chest compression fraction percentage. CONCLUSION: Research participants were able to rapidly retrieve an AED from a drone while largely maintaining CPR quality according to American Heart Association guidelines. Chest compression fraction was lower than expected.

Barriers and facilitators for developing a prehospital emergency care system evaluation tool (PEC-SET) for low-resource settings: a qualitative analysis.

OBJECTIVES: Strengthening of emergency care systems, including prehospital systems, can reduce death and disability. We aimed to identify perspectives on barriers and facilitators relating to the development and implementation of a prehospital emergency care system assessment tool (PEC-SET) from prehospital providers representing several South and Southeast (SE) Asian countries. DESIGN: We conducted a qualitative study using focus group discussions (FGD) informed by the Consolidated Framework for Implementation Research (CFIR). FGDs were conducted in English, audioconferencing/videoconferencing was recorded, transcribed verbatim and coded using an inductive and deductive approach. Participants suggested specific elements to be measured within three main 'pillars' of disease conditions proposed by the research team of the tool being developed (cardiovascular, trauma and perinatal emergencies). SETTING: We explored the perspectives of medical directors in six low-income and middle-income countries (LMICs) in South and SE Asia. PARTICIPANTS: A total of 16 participants were interviewed (1 Vietnam, 4 Philippines, 4 Thailand, 5 Malaysia, 1 Indonesia and 1 Pakistan) as a part of 4 focus groups. RESULTS: Themes identified within the four CFIR constructs included: (1) Intervention characteristics: importance of developing an contextually specific tool, need for generalisability, trialling in one geographical area or with one pillar before expanding; (2) Inner setting: data transfer barriers, workforce shortages; (3) Outer setting: underdevelopment of EMS nationally; need for further EMS system development prior to implementing a tool and (4) Individual characteristics: lack of buy-in by prehospital personnel. Elements proposed by participants included both process and outcome measures. CONCLUSIONS: Through the CFIR framework, we identified several themes which can provide a basis for codeveloping a PEC-SET for LMICs with local stakeholders. This work may inform development of quality improvement tools in LMIC PEC systems.

AI-based approach for transcribing and classifying unstructured emergency call data: A methodological proposal.

Emergency care-sensitive conditions (ECSCs) require rapid identification and treatment and are responsible for over half of all deaths worldwide. Prehospital emergency care (PEC) can provide rapid treatment and access to definitive care for many ECSCs and can reduce mortality in several different settings. The objective of this study is to propose a method for using artificial intelligence (AI) and machine learning (ML) to transcribe audio, extract, and classify unstructured emergency call data in the Serviço de Atendimento Móvel de Urgência (SAMU) system in southern Brazil. The study used all "1-9-2" calls received in 2019 by the SAMU Novo Norte Emergency Regulation Center (ERC) call center in Maringá, in the Brazilian state of Paraná. The calls were processed through a pipeline using machine learning algorithms, including Automatic Speech Recognition (ASR) models for transcription of audio calls in Portuguese, and a Natural Language Understanding (NLU) classification model. The pipeline was trained and validated using a dataset of labeled calls, which were manually classified by medical students using LabelStudio. The results showed that the AI model was able to accurately transcribe the audio with a Word Error Rate of 42.12% using Wav2Vec 2.0 for ASR transcription of audio calls in Portuguese. Additionally, the NLU classification model had an accuracy of 73.9% in classifying the calls into different categories in a validation subset. The study found that using AI to categorize emergency calls in low- and middle-income countries is largely unexplored, and the applicability of conventional open-source ML models trained on English language datasets is unclear for non-English speaking countries. The study concludes that AI can be used to transcribe audio and extract and classify unstructured emergency call data in an emergency system in southern Brazil as an initial step towards developing a decision-making support tool.

A qualitative assessment of stakeholder perspectives on barriers and facilitators to emergency care delays in Northern Tanzania through the Three Delays.

Introduction: Emergency conditions cause a significant burden of death and disability, particularly in developing countries. Prehospital and Emergency Medical Services (EMS) are largely nonexistent throughout Tanzania and little is known about the community's barriers to accessing emergency care. The objective of this study was to better understand local community stakeholder perspectives on barriers, facilitators, and potential solutions surrounding emergency care in the Kilimanjaro region through the Three Delays Model framework. Methods: A qualitative assessment of local stakeholders was conducted through semi-structured focus group discussions (FGDs) from February to June 2021 with five separate groups: hospital administrators, emergency hospital workers, police personnel, fire brigade personnel, and community health workers. FGDs were conducted in Kiswahili, audio recorded, and translated to English verbatim. Two research analysts separately coded the first two FGDs using both inductive and deductive thematic analysis. A final codebook was then created to analyze the remaining FGDs. Results: A total of 24 participants were interviewed. Thematic analysis revealed that participants identified significant barriers within the Three Delays Model as well as identified an additional delay centered on community members and first aid provision. Perceived delays in the decision to seek care, the first delay, were financial constraints and the lack of community education on emergency conditions. Limited infrastructure and reduced transportation access were thought to contribute to the second delay. Potential barriers to receiving timely appropriate care, the third delay, included upfront payments required by hospitals and emergency department intake delays. Suggested solutions focused on increasing education and improving communication and infrastructure. Conclusion: The findings outline barriers to accessing emergency care from a stakeholder perspective. These themes can support recommendations for further strengthening of the prehospital and emergency care system. Due to logistical constraints, emergency care workers interviewed were all from one hospital and patients were not included.

Built environment influence on the incidence of elderly pedestrian collisions in a medium-large city in southern Brazil: a spatial analysis.

Trauma disproportionately affects vulnerable road users, especially the elderly. We analyzed the spatial distribution of elderly pedestrians struck by vehicles in the urban area of Maringa city, from 2014 to 2018. Hotspots were obtained by kernel density estimation and wavelet analysis. The relationship between spatial relative risks (RR) of elderly run-overs and the built environment was assessed through Qualitative Comparative Analysis (QCA). Incidents were more frequent in the central and southeast regions of the city, where the RR was up to 2.58 times higher. The QCA test found a significant association between elderly pedestrian victims and the presence of traffic lights, medical centers/hospitals, roundabouts and schools. There is an association between higher risk of elderly pedestrians collisions and specific elements of built environments in Maringa, providing fundamental data to help guide public policies to improve urban mobility aimed at protecting vulnerable road users and planning an age-friendly city.

Emergency unit capacity in Northern Tanzania: a cross-sectional survey.

INTRODUCTION: Emergency medicine (EM) is a growing field in Sub-Saharan Africa. Characterising the current capacity of hospitals to provide emergency care is important in identifying gaps and future directions of growth. This study aimed to characterise the ability of emergency units (EU) to provide emergency care in the Kilimanjaro region in Northern Tanzania. METHODS: This was a cross-sectional study conducted at 11 hospitals with emergency care capacity in three districts in the Kilimanjaro region of Northern Tanzania assessed in May 2021. An exhaustive sampling approach was used, whereby all hospitals within the three-district area were surveyed. Hospital representatives were surveyed by two EM physicians using the Hospital Emergency Assessment tool developed by the WHO; data were analysed in Excel and STATA. RESULTS: All hospitals provided emergency services 24 hours a day. Nine had a designated area for emergency care, four had a core of fixed providers assigned to the EU, two lacked a protocol for systematic triage. For Airway and Breathing interventions, oxygen administration was adequate in 10 hospitals, yet manual airway manoeuvres were only adequate in six and needle decompression in two. For Circulation interventions, fluid administration was adequate in all facilities, yet intraosseous access and external defibrillation were each only available in two. Only one facility had an ECG readily available in the EU and none was able to administer thrombolytic therapy. For trauma interventions, all facilities could immobilise fractures, yet lacked interventions such as cervical spinal immobilisation and pelvic binding. These deficiencies were primarily due to lack of training and resources. CONCLUSION: Most facilities perform systematic triage of emergency patients, though major gaps were found in the diagnosis and treatment of acute coronary syndrome and initial stabilisation manoeuvres of patients with trauma. Resource limitations were primarily due to equipment and training deficiencies. We recommend the development of future interventions in all levels of facilities to improve the level of training.

Disparities in Emergency Medical Services Care Delivery in the United States: A Scoping Review.

BACKGROUND: Emergency medical services (EMS) often serve as the first medical contact for ill or injured patients, representing a critical access point to the health care delivery continuum. While a growing body of literature suggests inequities in care within hospitals and emergency departments, limited research has comprehensively explored disparities related to patient demographic characteristics in prehospital care. OBJECTIVE: We aimed to summarize the existing literature on disparities in prehospital care delivery for patients identifying as members of an underrepresented race, ethnicity, sex, gender, or sexual orientation group. METHODS: We conducted a scoping review of peer-reviewed and non-peer-reviewed (gray) literature. We searched PubMed, CINAHL, Web of Science, Proquest Dissertations, Scopus, Google, and professional websites for studies set in the U.S. between 1960 and 2021. Each abstract and full-text article was screened by two reviewers. Studies written in English that addressed the underrepresented groups of interest and investigated EMS-related encounters were included. Studies were excluded if a disparity was noted incidentally but was not a stated objective or discussed. Data extraction was conducted using a standardized electronic form. Results were summarized qualitatively using an inductive approach. RESULTS: One hundred forty-five full-text articles from the peer-reviewed literature and two articles from the gray literature met inclusion criteria: 25 studies investigated sex/gender, 61 studies investigated race/ethnicity, and 58 studies investigated both. One study investigated sexual orientation. The most common health conditions evaluated were out-of-hospital cardiac arrest (n = 50), acute coronary syndrome (n = 36), and stroke (n = 31). The phases of EMS care investigated included access (n = 55), pre-arrival care (n = 46), diagnosis/treatment (n = 42), and response/transport (n = 40), with several studies covering multiple phases. Disparities were identified related to all phases of EMS care for underrepresented groups, including symptom recognition, pain management, and stroke identification. The gray literature identified public perceptions of EMS clinicians' cultural competency and the ability to appropriately care for transgender patients in the prehospital setting. CONCLUSIONS: Existing research highlights health disparities in EMS care delivery throughout multiple health outcomes and phases of EMS care. Future research is needed to identify structured mechanisms to eliminate disparities, address clinician bias, and provide high-quality equitable care for all patient populations.

Predictors of Non-Transport for Older Adult EMS Patients Encountered for Falls.

BACKGROUND: Emergency medical services (EMS) encounters for falls among older adults have been linked to poor outcomes when the patient is not transported by EMS to a hospital. However, little is known regarding characteristics of this patient population. Our primary objective was to describe characteristics associated with non-transport among older adult EMS patients encountered for falls. METHODS: We performed a national retrospective cross-sectional study of 9-1-1 patient contacts from the 2019 ESO Data Collaborative. We included patients who had 9-1-1 encounters for ground-level falls and were aged 60 years or older. Patients residing in congregate living facilities, interfacility transports, cardiac arrests, and suspected drowning patients were excluded. Potential predictors of non-transport included patient demographics, initial vital signs, who requested 9-1-1 service, incident location, alcohol/substance use, and urbanicity. We used multivariable logistic regression to determine associations between non-transport and potential predictors. RESULTS: We identified 195,204 EMS encounters for older adults who fell in 2019, including 27,563 (14.1%) non-transports. Most patients were female (62.4%), non-Hispanic White (85.4%), and fell at a home or residence (80.4%). Greater odds of non-transport were identified among males (OR 1.37, 95% CI 1.32-1.42) and Hispanic/Latino patients (OR 1.24, 95% CI 1.14-1.35). Older age was associated with greater odds of non-transport compared to patients aged 60-69 years (70-79 [OR 1.42, 95% CI 1.35-1.49], 80-89 [OR 1.51, 95% CI 1.42-1.59], ≥90 [OR 1.45, 95% CI 1.35-1.55]). Patients residing in Census tracts with larger percentages of the population living in poverty had lower odds of non-transport compared to those in areas with ≤5% in poverty (6-15% poverty [OR 0.82, 95% CI 0.78-0.84), 15-25% poverty [OR 0.78, 95% CI 0.73-0.82], and >25% poverty [OR 0.78, 95% CI 0.72-0.84]). CONCLUSION: Males, older age groups, and Hispanic/Latino patients had higher odds of non-transport among this population of community-dwelling adults age 60 or greater. These findings may inform development of future targeted falls-related mobile integrated health or community paramedic services and referrals to community intervention programs. Future work is needed to understand underlying patient and clinician perspectives driving non-transport decisions among these patients to better equip EMS clinicians with tools and information on tailored risk/benefit discussions.

Shame and Guilt in EMS: A Qualitative Analysis of Culture and Attitudes in Prehospital Emergency Care.

STUDY OBJECTIVES: The shame reaction is a highly negative emotional reaction shown to have long-term deleterious effects on the mental health of clinicians. Prior studies have focused on in-hospital personnel, but very little is known about what drives shame reactions in emergency medical services (EMS), a field with very high rates of post-traumatic stress disorder, burnout, anxiety, and depression. The objective of this study was to describe emotions, processes, and resilience associated with self-identified adverse events in the work of prehospital clinicians. METHODS: We conducted a qualitative study using a modified critical incident technique. Participants were recruited from two EMS agencies in North Carolina: one urban and one rural. They provided an open-ended, written reflection in which they were asked to self-identify particular events in their EMS careers that felt emotionally difficult. In-person or video in-depth interviews about these events were then conducted in a semi-structured fashion using an iterative interview guide. The codebook was developed through a mix of inductive and deductive analysis strategies and discussed within the research team and a content expert for validation. Interviews were transcribed and data were analyzed following a thematic content analysis approach for types of cases identified as emotionally difficult, common emotional responses and coping mechanisms, and the lingering effects of these experiences on study subjects. RESULTS: Eight interviews were conducted with EMS personnel: five from an urban agency and three from a rural agency. Participants commonly identified complex medical cases as being emotionally difficult, which led to the most robust shame reactions. Shame reactions were more common when EMS clinicians committed self-perceived errors in patient care, whereas guilt reactions were more common when patient outcomes seemed "inevitable" despite any intervention. Common themes related to coping mechanisms included both personal mechanisms, which tended to be less successful compared to interpersonal mechanisms, particularly when emotions were shared with colleagues. This reflected a perceived culture change within EMS in which sharing emotions with colleagues was seen as a departure from the "old school" where emotions tended to be kept to oneself. Feelings of inadequacy, low self-worth, and being "not good enough" were frequently identified as lingering emotions after difficult cases that were hard to move on from, corresponding to longstanding shame in these clinicians. Recovery and resilience varied but tended to be positively associated with a culture in which sharing with colleagues was encouraged, along with personal introspection on root causes for the sentinel event. CONCLUSION: EMS clinicians often identify complex patient cases as those leading to emotions such as shame and guilt, with shame reactions being more common when a perceived error was committed. Coping mechanisms were varied, but individuals often relied on their coworkers in a sharing environment to adequately process their negative feelings, which was seen as a departure from past practices in EMS personnel. Our hope is that future studies will be able to use these findings to identify targets for intervention on negative mental health outcomes in EMS personnel.

Diversity, Equity, and Inclusion in the United States Emergency Medical Services Workforce: A Scoping Review.

OBJECTIVE: Emergency medical services (EMS) workforce demographics in the United States do not reflect the diversity of the population served. Despite some efforts by professional organizations to create a more representative workforce, little has changed in the last decade. This scoping review aims to summarize existing literature on the demographic composition, recruitment, retention, and workplace experience of underrepresented groups within EMS. METHODS: Peer-reviewed studies were obtained from a search of PubMed, CINAHL, Web of Science, ProQuest Thesis and Dissertations, and non-peer-reviewed ("gray") literature from 1960 to present. Abstracts and included full-text articles were screened by two independent reviewers trained on inclusion/exclusion criteria. Studies were included if they pertained to the demographics, training, hiring, retention, promotion, compensation, or workplace experience of underrepresented groups in United States EMS by race, ethnicity, sexual orientation, or gender. Studies of non-EMS fire department activities were excluded. Disputes were resolved by two authors. A single reviewer screened the gray literature. Data extraction was performed using a standardized electronic form. Results were summarized qualitatively. RESULTS: We identified 87 relevant full-text articles from the peer-reviewed literature and 250 items of gray literature. Primary themes emerging from peer-reviewed literature included workplace experience (n = 48), demographics (n = 12), workforce entry and exit (n = 8), education and testing (n = 7), compensation and benefits (n = 5), and leadership, mentorship, and promotion (n = 4). Most articles focused on sex/gender comparisons (65/87, 75%), followed by race/ethnicity comparisons (42/87, 48%). Few articles examined sexual orientation (3/87, 3%). One study focused on telecommunicators and three included EMS physicians. Most studies (n = 60, 69%) were published in the last decade. In the gray literature, media articles (216/250, 86%) demonstrated significant industry discourse surrounding these primary themes. CONCLUSIONS: Existing EMS workforce research demonstrates continued underrepresentation of women and nonwhite personnel. Additionally, these studies raise concerns for pervasive negative workplace experiences including sexual harassment and factors that negatively affect recruitment and retention, including bias in candidate testing, a gender pay gap, and unequal promotion opportunities. Additional research is needed to elucidate recruitment and retention program efficacy, the demographic composition of EMS leadership, and the prevalence of racial harassment and discrimination in this workforce.

Evaluation of telephone-assisted cardiopulmonary resuscitation recommendations for out-of-hospital cardiac arrest.

AIM OF THE STUDY: While out-of-hospital cardiac arrest (OHCA) is associated with poor survival, early bystander CPR (B-CPR) and telephone CPR (T-CPR) improves survival from OHCA. American Heart Association (AHA) Scientific Statements outline recommendations for T-CPR. We assessed these recommendations and hypothesized that meeting performance standards is associated with increased likelihood of survival. Additional variables were analyzed to identify future performance measurements. METHODS: We conducted a retrospective cohort study of non-traumatic, adult, OHCA using the Singapore Pan-Asian Resuscitation Outcomes Study. The primary outcome was likelihood of survival; secondary outcomes were pre-hospital Return of Spontaneous Circulation (ROSC) and B-CPR. RESULTS: From 2012 to 2016, 2,574 arrests met inclusion criteria. Mean age was 68 ± 15; of 2,574, 1,125 (44%) received T-CPR with 5% (135/2574) survival. T-CPR cases that met the Lerner et al. performance metrics analyzed, demonstrated no statistically significant association with survival. Cases which met the Kurz et al. criteria, "Time for Dispatch to Recognize Need for CPR" and "Time to First Compression," had adjusted odds ratios of survival of 1.01 (95% CI:1.00, 1.02; p = <0.01) and 0.99 (95% CI:0.99, 0.99; p = <0.01), respectively. Identified barriers to CPR decreased the odds of T-CPR and B-CPR being performed. Patients with prehospital ROSC had higher odds of B-CPR being performed. EMS response time < 8 minutes was associated with increased survival among patients receiving T-CPR. CONCLUSION: AHA scientific statements on T-CPR programs serve as ideal starting points for increasing the quality of T-CPR systems and patient outcomes. More work is needed to identify other system performance measures.

The association of indoor heat exposure with diabetes and respiratory 9-1-1 calls through emergency medical dispatch and services documentation.

BACKGROUND: People with pre-existing medical conditions, who spend a large proportion of their time indoors, are at risk of emergent morbidities from elevated indoor heat exposures. In this study, indoor heat of structures wherein exposed people received Grady Emergency Services based care in Atlanta, GA, U.S., was measured from May to September 2016. METHOD: ology: In this case-control study, analyses were conducted to investigate the effect of indoor heat on the odds of 9-1-1 calls for diabetic (n = 90 cases) and separately, for respiratory (n = 126 cases), conditions versus heat-insensitive emergencies (n = 698 controls). Generalized Additive Models considered both linear and non-linear indoor heat and health outcome associations using thin-plate regression splines. RESULTS: Hotter and more humid indoor conditions were non-linearly associated with an increasing likelihood of receiving emergency care for complications of diabetes and severe respiratory distress. Higher heat indices were associated with increased odds of a diabetes (odds ratio for change from 30 to 31 °C: 1.12, 95% CI: 1.08-1.16) or respiratory 9-1-1 medical call versus control (odds ratio for change from 34 to 35 °C: 1.18, 95% CI: 1.09-1.28) call. Both diabetic and respiratory distress patients were more likely to be African-American and/or have comorbidities. CONCLUSIONS: In this study, the statistical association of indoor heat exposure with emergency morbidities (diabetic, respiratory) was demonstrated. The study also showcased the value and utility of data gathered by emergency medical dispatch and services from inaccessible private indoor sources (i.e., domiciles) for environmental health.

Medical transport-associated infection: Review and commentary making a case for its legitimacy.

The purpose of this article is to summarize existing literature about healthcare-associated infection (HAI) in the medical transport environment and to define the term medical transport-associated infection (MTAI) to unify all previous work under a single umbrella with the objective of providing a standardized definition for future research. A review of the literature yielded 34 relevant articles. These studies show that there are pathogens in the ambulance environment, that emergency medical services (EMS) personnel do not regularly comply with hygiene practices, and that patients are potentially affected by HAI as a direct result of ambulance exposure. Prospective studies must be conducted to truly understand the impact that ambulance exposure has on HAIs. MTAI is a subset of HAI and is defined as any infection acquired as a direct effect of exposure in a medical transport setting.

Barriers to accessing follow up care in post-hospitalized trauma patients in Moshi, Tanzania: A mixed methods study.

Disproportionately high injury rates in Sub-Saharan Africa combined with limited access to care in both the acute injury phase and for injury patients requiring continued care after hospital discharge remains a challenge. We aimed to characterize barriers to transportation and access to care in a cohort of post-hospitalized injury patients in Moshi, Tanzania. This was a mixed-methods study of a prospective cohort of trauma registry patients presenting to Kilimanjaro Christian Medical Center between August 2018 and January 2020. We conducted standardized patient/family surveys and in-depth interviews at a 2-week follow up visit after hospital discharge, and focus groups with healthcare providers. Quantitative results were analyzed using descriptive statistics and multivariable logistic regression using R statistical software. Qualitative results were analyzed using thematic analysis through an iterative process using NVivo software. A total of 1,365 patients were enrolled in the trauma registry, with 169 patients followed up at 2 weeks. Over half of patients at follow-up, 101 (59.8%), reported challenges in traveling. The majority of patients were male (80.3%). Difficulty in traveling since injury was associated with female gender (aOR 5.85 [95% CI 1.20-33.59]) and a need for non-family members escorts for travel (aOR 7.10 [95% CI 1.43-41.66]). Those who reported assault or fall as the mechanism of injury as compared to road traffic injury and had health insurance were less likely to report challenges in traveling (aOR 0.19 [95% CI 0.03-0.90]), 0.11 [95% CI 0.01-0.61], 0.14 [95% 0.02-0.80]). Transportation barriers that emerged from qualitative data included inability to use regular means of transportation, financial challenges, physical barriers, rigid compliance to physician orders, access to healthcare, and social support barriers. Our findings demonstrate several areas to address transportation barriers for post-injury patients in Tanzania. Educational interventions such as clarification of doctors' orders of strict bedrest, provision of vouchers to support financial challenges and alternate means of transportation given physical barriers and reliance on social support may address some of these barriers.

A hypothetical implementation of 'Termination of Resuscitation' protocol for out-of-hospital cardiac arrest.

BACKGROUND: Out-of-hospital cardiac arrests with negligible chance of survival are routinely transported to hospital and many are pronounced dead thereafter. This leads to some potentially avoidable costs. The 'Termination of Resuscitation' protocol allows paramedics to terminate resuscitation efforts onsite for medically futile cases. This study estimates the changes in frequency of costly events that might occur when the protocol is applied to out-of-hospital cardiac arrests, as compared to existing practice. METHODS: We used Singapore data from the Pan-Asian Resuscitation Outcomes Study, from 1 Jan 2014 to 31 Dec 2017. A Markov model was developed to summarise the events that would occur in two scenarios, existing practice and the implementation of a Termination of Resuscitation protocol. The model was evaluated for 10,000 hypothetical patients with a cycle duration of 30 days after having a cardiac arrest. Probabilistic sensitivity analysis accounted for uncertainties in the outcomes: number of urgent transports and emergency treatments, inpatient bed days, and total number of deaths. RESULTS: For every 10,000 patients, existing practice resulted in 1118 (95% Uncertainty Interval 1117 to 1119) additional urgent transports to hospital and subsequent emergency treatments. There were 93 (95% Uncertainty Interval 66 to 120) extra inpatient bed days used, and 3 fewer deaths (95% Uncertainty Interval 2 to 4) in comparison to using the protocol. CONCLUSION: The findings provide some evidence for adopting the Termination of Resuscitation protocol. This policy could lead to a reduction in costs and non-beneficial hospital admissions, however there may be a small increase in the number of avoidable deaths.

Predictors of ambulance transport to first health facility among injured patients in southern Sri Lanka.

BACKGROUND: Injuries account for about 13% of all registered deaths in Sri Lanka and are the leading cause of admission to public hospitals. Prehospital trauma care is new to Sri Lanka, and in 2016, a free ambulance service was launched in the Western and Southern provinces. OBJECTIVE: The aim of this study was to identify the proportion of admitted injury patients at a tertiary hospital who used an ambulance to get to the first health facility and examine patient demographics, injury event, and injury type as predictors of ambulance transport. METHODS: A cross-sectional survey was administered to 405 patients who were admitted to the emergency trauma center at Teaching Hospital Karapitiya (THK) in Galle, Sri Lanka. Descriptive statistics were tabulated to summarize prehospital transportation variables. Logistic regression models were created to examine predictors of ambulance transport, and ArcGIS Pro was used to calculate the distance between injury location and first facility and THK. RESULTS: The proportion of patients with injuries who used an ambulance to get to the first health facility was 20.5%. Factors that were significantly associated with ambulance use were older age, injury mechanism, alcohol use prior to injury, location type, open wound, abrasion, and chest/abdomen injury. Distance from injury location to THK or nearest health facility were not significantly associated with ambulance transport to the first health facility. CONCLUSION: Among lower acuity injury patients in southern Sri Lanka, 20.5% traveled in an ambulance to the first health facility, while over half used a tuk tuk. Older age and injuries at home were associated with lower odds of ambulance transport. Future studies on predictors of ambulance transport should include patients with more severe injuries, gather detailed data on care provided while in transport and examine the association between prehospital care and clinical outcomes.

Helicopter Transportation of Brazilian Trauma Patients: A Comparison of Times to Care.

OBJECTIVE: The purpose of this study was to analyze helicopter emergency medical service (HEMS) transport with secondary land ambulance transfer, comparing landings performed inside and outside the hospital complex to the emergency department. METHODS: This was a cross-sectional observational study of HEMS transports of trauma patients between 2016 and 2018 in southern Brazil. Patients were attended by the HEMS team at the trauma site or stabilized in hospitals nearby and subsequently referred to trauma centers. In this region, no trauma centers have their own helipads so helicopters land in remote areas close to the hospital, which may be inside or outside the hospital complex. Both landings require ground emergency medical service transport, with off-site landings necessitating ground emergency medical service transport via public access roads to reach the hospital. Data were analyzed using descriptive statistics, and on-site and off-site transport times were compared using a t-test for independent samples. RESULTS: Of 176 transports, 28.5% resulted in on-site landings, whereas 71.5% occurred off-site. The ground transport time when the landing zone was off-site was 5 minutes longer than on-site (P < .001). CONCLUSION: Off-site landings result in longer transports to the emergency room. The construction of helipads in trauma centers can reduce transport time, in addition to reducing the costs and sequelae of trauma.