Five-Year Follow-up of a Severe Case of Pertussis in Oregon, 2012.

Oregon continues to face epidemics of pertussis, and infants younger than 2 months of age have the highest incidence and rates of hospitalization and complications. We describe the medical course and sequelae of an infant's severe pertussis illness through age 5½ years. The child has failed to meet developmental milestones, requires substantial medical care, and bears the burdens of chronic lung disease, stroke, epilepsy, impaired neurodevelopment, and problems with vision. The medical and social burden of pertussis among infants too young to be vaccinated underscores the importance of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccination during pregnancy.

Causes of Prehospital Misinterpretations of ST Elevation Myocardial Infarction.

OBJECTIVES: To determine the causes of software misinterpretation of ST elevation myocardial infarction (STEMI) compared to clinically identified STEMI to identify opportunities to improve prehospital STEMI identification. METHODS: We compared ECGs acquired from July 2011 through June 2012 using the LIFEPAK 15 on adult patients transported by the Los Angeles Fire Department. Cases included patients ≥18 years who received a prehospital ECG. Software interpretation of the ECG (STEMI or not) was compared with data in the regional EMS registry to classify the interpretation as true positive (TP), true negative (TN), false positive (FP), or false negative (FN). For cases where classification was not possible using registry data, 3 blinded cardiologists interpreted the ECG. Each discordance was subsequently reviewed to determine the likely cause of misclassification. The cardiologists independently reviewed a sample of these discordant ECGs and the causes of misclassification were updated in an iterative fashion. RESULTS: Of 44,611 cases, 50% were male (median age 65; inter-quartile range 52-80). Cases were classified as 482 (1.1%) TP, 711 (1.6%) FP, 43371 (97.2%) TN, and 47 (0.11%) FN. Of the 711 classified as FP, 126 (18%) were considered appropriate for, though did not undergo, emergent coronary angiography, because the ECG showed definite (52 cases) or borderline (65 cases) ischemic ST elevation, a STEMI equivalent (5 cases) or ST-elevation due to vasospasm (4 cases). The sensitivity was 92.8% [95% CI 90.6, 94.7%] and the specificity 98.7% [95% CI 98.6, 98.8%]. The leading causes of FP were ECG artifact (20%), early repolarization (16%), probable pericarditis/myocarditis (13%), indeterminate (12%), left ventricular hypertrophy (8%), and right bundle branch block (5%). There were 18 additional reasons for FP interpretation (<4% each). The leading causes of FN were borderline ST-segment elevations less than the algorithm threshold (40%) and tall T waves reducing the ST/T ratio below threshold (15%). There were 11 additional reasons for FN interpretation occurring ≤3 times each. CONCLUSION: The leading causes of FP automated interpretation of STEMI were ECG artifact and non-ischemic causes of ST-segment elevation. FN were rare and were related to ST-segment elevation or ST/T ratio that did not meet the software algorithm threshold.

A Decade of Progress in Regional ST-Segment Elevation Myocardial Infarction Systems of Care: A Tale of Two Cities.

Over the past 20 years, care for patients with ST-elevation myocardial infarction (STEMI) has rapidly evolved, not just in terms of how patients are treated, but where patients are treated. The advent of regional STEMI systems of care has decreased the number of "eligible but untreated" patients while improving access to primary percutaneous coronary intervention for patients. These regional STEMI systems of care have consistently demonstrated that rapid transport of STEMI patients is safe and effective, and have shown marked improvements in a variety of clinical outcomes. However, no two STEMI systems are alike, and each must be tailored to the unique geographic, political, and socioeconomic challenges of the region. This article takes an in-depth look at two of the earliest STEMI systems within the United States: the Minneapolis Heart Institute and the Los Angeles County STEMI receiving network.

Effect of Therapeutic Hypothermia on Survival and Neurologic Outcome in the Elderly.

Old age is considered a negative prognostic factor after out-of-hospital cardiac arrest (OHCA). The purpose of this study was to assess the benefit of therapeutic hypothermia (TH) on survival and neurologic outcome in the elderly. This is a retrospective study of patients treated for OHCA from April 2011 to August 2013 in a regional cardiac system. Patients with return of spontaneous circulation (ROSC) are directed to designated cardiac receiving centers with established TH protocols. The decision to initiate TH is determined by the treating physician. All patients 65 years or older were identified. Patients were excluded if awake and responsive in the emergency department, died before hospital admission, or had preexisting coma. The adjusted odds ratio for survival with good neurologic outcome (defined as cerebral performance category [CPC] 1 or 2) was calculated for patients who received TH compared to a reference group without TH. There were 1612 patients, of whom 552 (34%) received TH. Median age was 78 (inter-quartile range [IQR] 71-85); 56% was male. 493 (31%) patients survived to hospital discharge, 266 (17%) with CPC of 1 or 2. Of 1292 patients considered for TH, 192 (25%) of 552 patients who received TH survived to hospital discharge and 97 (18%) with good neurologic outcome compared to 150 (20%) and 57 (8%), respectively, without TH. The adjusted odds ratio for survival with good neurologic outcome for TH was 2.0 (95% CI 1.3-3.3). TH is associated with improved neurologic outcome in the elderly population.

Should we still use motor vehicle intrusion as a sole triage criterion for the use of trauma center resources?

BACKGROUND: Motor vehicle intrusion (MVI) is one of the field triage criteria recommended by the American College of Surgeons Committee of Trauma (ACS-COT) and Centers for Disease Control and Prevention (CDC). However, the evidence supporting its validity is scarce. The purpose of this study was to evaluate the validity of this criterion and assess its impact on overtriage or undertriage. PATIENTS AND METHODS: This was a retrospective study based on the Los Angeles County Trauma and Emergency Medicine Information System (TEMIS) Trauma database. Included in the analysis were patients with MVI as the sole criterion for trauma center triage. Physiological characteristics, severity of injury, and outcomes of the MVI patients were compared between different age groups. Further, a logistic regression model was used to identify factors significantly associated with the need for trauma center resources. RESULTS: During the period 2002-2012, a total of 10,554 trauma patients involved in motor vehicle crashes had documentation of MVI. A subgroup of 3998 patients (37.9%) did not meet any other criteria that require immediate transportation to a designated trauma center. Only 0.7% of these patients had hypotension and 0.1% had deterioration of the Glasgow Coma Scale on admission to the emergency room. Overall, 18.8% of patients required trauma center resources defined as intubation in the emergency room, certain surgical procedures, in-hospital death, or intensive care unit admission. Age ≥65 years, male gender, prehospital heart rate >100/min, and systolic blood pressure <110 mmHg were significantly associated with the need for trauma center resources. CONCLUSIONS: The MVI itself did not appear to be a strong indicator for the use of trauma center resources and is associated with excessive overtriage. However, age >65 years, systolic blood pressure <110 mmHg, and heart rate >100/min were significant predictors for the need of trauma center resources. The MVI criterion should be refined for better utilization of trauma center resources.

Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care.

OBJECTIVE: Therapeutic hypothermia (TH) improves neurologic outcome in patients resuscitated from ventricular fibrillation. The purpose of this study was to evaluate TH effects on neurologic outcome in patients resuscitated from a non-shockable out-of-hospital cardiac arrest rhythm. DESIGN AND SETTING: This is a retrospective cohort study of data reported to a registry in an emergency medical system in a large metropolitan region. Patients achieving field return of spontaneous circulation are transported to designated hospitals with TH protocols. PATIENTS: Patients with an initial non-shockable rhythm were identified. Patients were excluded if awake in the Emergency Department or if TH was withheld due to preexisting coma or death prior to initiation. The decision to initiate TH was determined by the treating physician. MEASUREMENTS: The primary outcome was survival with good neurologic outcome defined by a cerebral performance category of 1 or 2. MAIN RESULTS: Of the 2772 patients treated for cardiac arrest during the study period, there were 1713 patients resuscitated from cardiac arrest with an initial non-shockable rhythm and 1432 patients met inclusion criteria. The median age was 69 years [IQR 59-82]; 802 (56%) male. TH was induced in 596 (42%) patients. Survival with good neurologic outcome was 14% in the group receiving TH, compared with 5% in those not treated with TH (risk difference = 8%, 95% CI 5-12%). The adjusted OR for a CPC 1 or 2 with TH was 2.9 (95% CI 1.9-4.4). CONCLUSION: Analyzing the data collected from the registry of the standard practice in a large metropolitan region, TH is associated with improved neurologic outcome in patients resuscitated from initial non-shockable rhythms in a regionalized system for post-resuscitation care.

Variability in Criteria for Emergency Medical Services Routing of Acute Stroke Patients to Designated Stroke Center Hospitals.

INTRODUCTION: Comprehensive stroke systems of care include routing to the nearest designated stroke center hospital, bypassing non-designated hospitals. Routing protocols are implemented at the state or county level and vary in qualification criteria and determination of destination hospital. We surveyed all counties in the state of California for presence and characteristics of their prehospital stroke routing protocols. METHODS: Each county's local emergency medical services agency (LEMSA) was queried for the presence of a stroke routing protocol. We reviewed these protocols for method of stroke identification and criteria for patient transport to a stroke center. RESULTS: Thirty-three LEMSAs serve 58 counties in California with populations ranging from 1,175 to nearly 10 million. Fifteen LEMSAs (45%) had stroke routing protocols, covering 23 counties (40%) and 68% of the state population. Counties with protocols had higher population density (1,500 vs. 140 persons per square mile). In the six counties without designated stroke centers, patients meeting criteria were transported out of county. Stroke identification in the field was achieved using the Cincinnati Prehospital Stroke Screen in 72%, Los Angeles Prehospital Stroke Screen in 7% and a county-specific protocol in 22%. CONCLUSION: California EMS prehospital acute stroke routing protocols cover 68% of the state population and vary in characteristics including activation by symptom onset time and destination facility features, reflecting matching of system design to local geographic resources.

Suffer the Infants: A Severe Case of Pertussis in Oregon, 2012.

Pertussis remains a public health concern in Oregon, especially among young infants. The disease can be severe in this age group and is associated with a high inpatient cost. This report describes an Oregon infant who was hospitalized with pertussis for 90 days, required extracorporeal oxygenation for 43 days, suffered complications including stroke, and had hospital charges totaling $1.5 million. Pertussis morbidity among young infants argues for vaccination of women during each pregnancy and of infants beginning promptly at two months of age.

Routing Ambulances to Designated Centers Increases Access to Stroke Center Care and Enrollment in Prehospital Research.

BACKGROUND AND PURPOSE: Emergency medical services routing of patients with acute stroke to designated centers may increase the proportion of patients receiving care at facilities meeting national standards and augment recruitment for prehospital stroke research. METHODS: We analyzed consecutive patients enrolled within 2 hours of symptom onset in a prehospital stroke trial, before and after regional Los Angeles County Emergency Medical Services implementation of preferentially routing patients with acute stroke to approved stroke centers (ASCs). From January 2005 to mid-November 2009, patients were transported to the nearest emergency department, whereas from mid-November 2009 to December 2012, patients were preferentially transported to first 9, and eventually 29, ASCs. RESULTS: There were 863 subjects enrolled before and 764 after emergency medical service preferential routing, with implementation leading to an increase in the proportion cared for at an ASC from 10% to 91% (P<0.0001), with a slight decrease in paramedic on-scene to emergency department arrival time (34.5 [SD, 9.1] minutes versus 33.5 [SD, 10.3] minutes; P=0.045). The effects of routing were immediate and included an increase in proportion of receiving ASC care (from 17% to 88%; P<0.001) and a greater number of enrollments (18.6% increase) when comparing 12 months before and after regional stroke system implementation. CONCLUSIONS: The establishment of a regionalized emergency medical services system of acute stroke care dramatically increased the proportion of patients with acute stroke cared for at ASCs, from 1 in 10 to >9 in 10, with no clinically significant increase in prehospital care times and enhanced recruitment of patients into a prehospital treatment trial. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059332.

The Utility of Prehospital ECG Transmission in a Large EMS System.

BACKGROUND: Prehospital identification of STEMI and activation of the catheterization lab can improve door-to-balloon (D2B) times but may lead to decreased specificity and unnecessary resource utilization. The purpose of this study was to examine the effect of electrocardiogram (ECG) transmission on false-positive (FP) cath lab activations and time to reperfusion. METHODS: This is a retrospective cohort from a registry in a large metropolitan area with regionalized cardiac care and emergency medical services (EMS) with ECG transmission capabilities. Thirty-four designated STEMI receiving centers (SRC) contribute to this registry, from which patients with a prehospital ECG software interpretation of myocardial infarction (MI) indicated by ****Acute MI****, or manufacturer equivalent, were identified between April 2011 and September 2013. Frequency of FP field activations (defined as not resulting in emergent percutaneous coronary intervention [PCI] or referral for CABG during hospital admission) for patients with ECG transmission received by the SRC was compared to a reference group without successful ECG transmission. FP field activations were compared to the baseline frequency of FP ED activations. We hypothesized that successful transmission would reduce FP field activation to ED activation levels. Door-to-balloon and first medical contact-to-balloon (FMC2B) times were compared. The protocol for field cath lab activation varied by institution. RESULTS: There were 7,768 patients presenting with a prehospital ECG indicating MI. The ECG was received by the SRC for 2,156 patients (28%). Regardless of transmission, the cath lab was activated 77% of the time; this activation occurred from the field in 73% and 74% of the activations in the transmission and reference group, respectively. The overall proportion of FP activation was 57%. Among field activations, successful ECG transmission reduced the FP activation rate compared to without ECG transmission, 55% vs. 61% (RD = -6%, 95%CI -9, -3%). This led to an overall system reduction in FP activations of 5% (95%CI 2, 8%). ECG transmission had no effect on D2B and FMC2B time. CONCLUSION: Prehospital ECG transmission is associated with a small reduction in false-positive field activations for STEMI and had no effect on time to reperfusion in this cohort.

Preoxygenation reduces desaturation events and improves intubation success.

OBJECTIVE: Oxygen desaturation occurs frequently in the course of prehospital rapid sequence intubation (RSI) and is associated with increased morbidity and mortality. Preoxygenation with positive pressure ventilation by bag valve mask may delay the onset of desaturation. The purpose of this study was to evaluate implementation of a targeted preoxygenation protocol including the use of positive pressure ventilation on desaturation events and intubation success during air medical RSI. METHODS: The RSI air medical program airway training model was modified to target an oxygen saturation as measured by pulse oximetry value of ≥ 93% before initial laryngoscopy. A review of oxygen saturation as measured by pulse oximetry tracings was performed for 2 years before and 2 years after implementation of this protocol. The incidence of desaturation events and overall intubation success rates were compared before and after the intervention. RESULTS: One hundred fifty-five RSI procedures were evaluated over the study period. Desaturation events decreased from 58% in the 2 years before algorithm changes to 28% in the first year and 14% in the second year after implementation (P < .01). Intubation success rates increased from 89% to 98% (P < .01). There were no self-reports of aspiration events during the study period. CONCLUSION: A preoxygenation protocol dramatically reduced the incidence of desaturation events and increased intubation success without an increase in the number of reported aspiration events.

Treatment and outcomes of ST segment elevation myocardial infarction and out-of-hospital cardiac arrest in a regionalized system of care based on presence or absence of initial shockable cardiac arrest rhythm.

The aim of this study was to evaluate the treatment and outcomes of patients with ST-segment elevation myocardial infarctions complicated by out-of-hospital cardiac arrest in a regional system of care. In this retrospective study, the effect of the absence of an initial shockable arrest rhythm was analyzed. The primary end point of survival with good neurologic outcome in patients with and without an initial shockable arrest rhythm was adjusted for age, witnessed arrest, bystander cardiopulmonary resuscitation, and treatment with therapeutic hypothermia and percutaneous coronary intervention. One-hundred sixty-eight of 348 patients (49%) survived to hospital discharge. Patients with a shockable initial rhythm were more likely to receive therapeutic hypothermia (48% vs 37%, risk ratio 1.2, 95% confidence interval [CI] 1.0 to 1.5) and to be treated in the cardiac catheterization laboratory (80% vs 43%, risk ratio 2.8, 95% CI 2.0 to 3.8). The likelihood of survival with good neurologic outcome in patients with a shockable initial rhythm compared with those presenting without a shockable rhythm was 4.8 (95% CI 2.7 to 8.7). In patients who underwent percutaneous coronary intervention, the likelihood of survival with good neurologic outcome was higher (risk ratio 2.7, 95% CI 1.1 to 6.8) in those with a shockable rhythm. In conclusion, the absence of an initial shockable rhythm in patients with ST-segment elevation myocardial infarctions plus out-of-hospital cardiac arrest is associated with significantly worse survival and neurologic outcome. These differences persist despite application of therapies including therapeutic hypothermia and percutaneous coronary intervention within a regionalized system of care.

Implementation of a titrated oxygen protocol in the out-of-hospital setting.

Oxygen is one of the most frequently-used therapeutic agents in medicine and the most commonly administered drug by prehospital personnel. There is increasing evidence of harm with too much supplemental oxygen in certain conditions, including stroke, chronic obstructive pulmonary disease (COPD), neonatal resuscitations, and in postresuscitation care. Recent guidelines published by the British Thoracic Society (BTS) advocate titrated oxygen therapy, but these guidelines have not been widely adapted in the out-of-hospital setting where high-flow oxygen is the standard. This report is a description of the implementation of a titrated oxygen protocol in a large urban-suburban Emergency Medical Services (EMS) system and a discussion of the practical application of this out-of-hospital protocol.

Re-examining outcomes after unsuccessful out-of-hospital resuscitation in the era of field termination of resuscitation guidelines and regionalized post-resuscitation care.

BACKGROUND: Dismal prognosis after failed out-of-hospital resuscitation has previously been demonstrated. Changes in resuscitation and post-resuscitation care may affect patient outcomes. We describe characteristics and outcomes of patients with out-of-hospital cardiac arrest (OOHCA) transported to specialty cardiac centers after failure of out-of-hospital interventions. METHODS: In Los Angeles (LA) County, patients with non-traumatic OOHCA with return of spontaneous circulation (ROSC) are transported to specialized cardiac care centers. Outcomes are reported to a registry maintained by the LA County Emergency Medical Services (EMS) Agency. We report patient characteristics and outcomes for the subset of patients treated at these specialty centers in whom initial ROSC was achieved in the ED. The primary outcome was neurologically intact survival, defined by a cerebral performance category (CPC) score of 1 or 2. RESULTS: 105 patients transported to the SRC after failure to achieve ROSC with out-of-hospital resuscitation were successfully resuscitated in the ED. The median age was 68 years (IQR 57-78); 74 (70%) were male. The presenting rhythm was ventricular fibrillation or ventricular tachycardia in 40 patients (38%) and 86 (82%) were witnessed. Twenty-two patients (21%) survived to hospital discharge. Of the 103 patients with known CPC scores, 13 (13% [95% CI 7-21%]) survived to hospital discharge with a CPC score of 1 or 2. No patient who survived with good neurologic outcome met criteria for termination of resuscitation in the field. CONCLUSION: Failure of out-of-hospital resuscitation is not universally predictive of poor neurologic outcome.

Survival and neurologic outcome after out-of-hospital cardiac arrest: results one year after regionalization of post-cardiac arrest care in a large metropolitan area.

BACKGROUND: Post-resuscitation care of cardiac arrest patients at specialized centers may improve outcome after out-of-hospital cardiac arrest (OOHCA). This study describes experience with regionalized care of resuscitated patients. METHODS: Los Angeles (LA) County established regionalized cardiac care in 2006. Since 2010, protocols mandate transport of nontraumatic OOHCA patients with field return of spontaneous circulation (ROSC) to a STEMI Receiving Center (SRC) with a hypothermia protocol. All SRC report outcomes to a registry maintained by the LA County Emergency Medical Services (EMS) Agency. We report the first year's data. The primary outcome was survival with good neurologic outcome, defined by a Cerebral Performance Category (CPC) score of 1 or 2. RESULTS: The SRC treated 927 patients from April 2011 through March 2012 with median age 67; 38% were female. There were 342 patients (37%) who survived to hospital discharge. CPC scores were unknown in 47 patients. Of the 880 patients with known CPC scores, 197 (22%) survived to hospital discharge with a CPC score of 1 or 2. The initial rhythm was VF/VT in 311 (34%) patients, of whom 275 (88%) were witnessed. For patients with an initial shockable rhythm, 183 (59%) survived to hospital discharge and 120 (41%) had survival with good neurologic outcome. Excluding patients who were alert or died in the ED, 165 (71%) patients with shockable rhythms received therapeutic hypothermia (TH), of whom 67 (42%) had survival with good neurologic outcome. Overall, 387 patients (42%) received TH. In the TH group, the adjusted OR for CPC 1 or 2 was 2.0 (95%CI 1.2-3.5, p = 0.01), compared with no TH. In contrast, the proportion of survival with good neurologic outcome in the City of LA in 2001 for all witnessed arrests (irrespective of field ROSC) with a shockable rhythm was 6%. CONCLUSION: We found higher rates of neurologically intact survival from OOHCA in our system after regionalization of post-resuscitation care as compared to historical data.

Effect of prehospital cardiac catheterization lab activation on door-to-balloon time, mortality, and false-positive activation.

BACKGROUND: Reperfusion of ST elevation myocardial infarction (STEMI) is most effective when performed early. Notification of the cardiac catheterization laboratory (cath lab) prior to hospital arrival based on paramedic-performed ECGs has been proposed as a strategy to decrease time to reperfusion and mortality. The purpose of this study was to compare the effects of cath lab activation prior to patient arrival versus activation after arrival at the emergency department (ED). METHODS: We performed a retrospective cohort study (n = 1933 cases) using Los Angeles County STEMI database from May 1, 2008 through August 31, 2009. The database includes patients arriving at a STEMI Receiving Center (SRC) by ambulance who were diagnosed with STEMI either before or after hospital arrival. We compared the cohort of patients with prehospital cath lab activation to those activated from the ED within 5 minutes of first ED ECG. Outcomes measured were mortality, door-to-balloon time, percent door-to-balloon time <90 min, and percentage of false-positive activations. RESULTS: Prehospital cath lab activations had mean door-to-balloon times 14 minutes shorter (95% CI 11-17), in-hospital mortality 1.5% higher (95% CI -1.0-5.2), and false-positive activation 7.8%, (95% CI 2.7-13.3) higher than ED activation. For prehospital activation, 93% (95% CI 91-94%) met a door-to-balloon target of 90 minutes versus 85% (95% CI 80-88%) for ED activations. CONCLUSION: Prehospital cath lab activation based on the prehospital ECG was associated with decreased door-to-balloon times but did not affect hospital mortality. False-positive activation was common and occurred more often with prehospital STEMI diagnosis.

Emergency medical services as a strategy for improving ST-elevation myocardial infarction system treatment times.

BACKGROUND: Reducing delays in time to treatment is a key goal of ST-elevation myocardial infarction (STEMI) emergency care. Emergency medical services (EMS) are a critical component of the STEMI chain of survival. STUDY OBJECTIVE: We sought to assess the impact of the careful integration of EMS as a strategy for improving systemic treatment times for STEMI. METHODS: We conducted a study of all 747 nontransfer STEMI patients who underwent primary percutaneous coronary intervention (PCI) in Dallas County, Texas from October 1, 2010 through December 31, 2011. EMS leaders from 24 agencies and 15 major PCI receiving hospitals collected and shared common, de-identified patient data. We used 15 months of data to develop a generalized linear regression to assess the impact of EMS on two treatment metrics-hospital door to balloon (D2B) time, and symptom onset to arterial reperfusion (SOAR) time, a new metric we developed to assess total treatment times. RESULTS: We found statistically significant reductions in median D2B (11.1-min reduction) and SOAR (63.5-min reduction) treatment times when EMS transported patients to the receiving facility, compared to self-transport. In addition, when trained EMS paramedics field-activated the cardiac catheterization laboratory using predefined specified protocols, D2B times were reduced by 38% (43 min) after controlling for confounding variables, and field activation was associated with a 21.9% reduction (73 min) in the mean SOAR time (both with p < 0.001). CONCLUSION: Active EMS engagement in STEMI treatment was associated with significantly lower D2B and total coronary reperfusion times.

Time of day variation in door-to-balloon time for STEMI patients in Los Angeles County: does time of day make a difference?

OBJECTIVE: Evaluate treatment times and clinical outcome in a consecutive series of ST segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) in Los Angeles County. BACKGROUND: Primary PCI for STEMI is beneficial if performed in a timely manner. Conflicting data exist regarding potential treatment delays for primary PCI performed during off hours. METHODS: The Emergency Medical Services STEMI Receiving Center Database was queried from 2007 to 2009 to identify patients with a pre-hospital ECG showing STEMI who underwent PCI. On-hour PCI (On-hour Group, n = 1324) was defined as PCI occurring from 8 am to 5 pm and off-hour PCI (Off-hour Group, n = 922) was defined as occurring from 5 pm to 8 am. Treatment times, length of stay, vascular complications, achievement of TIMI 3 flow and in-hospital mortality were evaluated. RESULTS: Off-hours PCI occurred in 41% of patients. Medical contact to door time was similar in the Off-hour Group compared to the On-hour Group, 20.7 ± 14.6 versus 20.3 ± 12.3 min, respectively, P = 0.47. In patients with available data (n = 1366), the door-to-catheterization laboratory (CL) activation time was significantly shorter in the On-hour Group as compared to the Off-hour Group, -4.9 ± 11.9 versus -0.2 ± 27.5 min, respectively, P < 0.0001. Door-to-balloon time was significantly longer in the Off-hour Group compared to the On-hour Group, 74 ± 35 versus 60 ± 26 min respectively, P < 0.0001. Length of stay, vascular complications, final TIMI 3 flow and in-hospital mortality were similar between both groups. CONCLUSIONS: In STEMI patients receiving primary PCI in Los Angeles County, off-hour PCI was common. Short-term clinical outcomes were similar despite longer door-to-balloon time in patients receiving off-hour PCI. The longer door-to-balloon time in the off-hour PCI patients were partly explained by longer door-to-CL activation time.

Developing an ST-elevation myocardial infarction system of care in Dallas County.

BACKGROUND: The American Heart Association Caruth Initiative (AHACI) is a multiyear project to increase the speed of coronary reperfusion and create an integrated system of care for patients with ST-elevation myocardial infarction (STEMI) in Dallas County, TX. The purpose of this study was to determine if the AHACI improved key performance metrics, that is, door-to-balloon (D2B) and symptom-onset-to-balloon times, for nontransfer patients with STEMI. METHODS: Hospital patient data were obtained through the National Cardiovascular Data Registry Action Registry-Get With The Guidelines, and prehospital data came from emergency medical services (EMS) agencies through their electronic Patient Care Record systems. Initial D2B and symptom-onset-to-balloon times for nontransfer primary percutaneous coronary intervention (PCI) STEMI care were explored using descriptive statistics, generalized linear models, and logistic regression. RESULTS: Data were collected by 15 PCI-capable Dallas hospitals and 24 EMS agencies. In the first 18 months, there were 3,853 cases of myocardial infarction, of which 926 (24%) were nontransfer patients with STEMI undergoing primary PCI. D2B time decreased significantly (P < .001), from a median time of 74 to 64 minutes. Symptom-onset-to-balloon time decreased significantly (P < .001), from a median time of 195 to 162 minutes. CONCLUSION: The AHACI has improved the system of STEMI care for one of the largest counties in the United States, and it demonstrates the benefits of integrating EMS and hospital data, implementing standardized training and protocols, and providing benchmarking data to hospitals and EMS agencies.

The development and implementation of a Hospital Emergency Response Team (HERT) for out-of-hospital surgical care.

Over the past two decades, Los Angeles County has implemented a Hospital Emergency Response Team (HERT) to provide on-scene, advanced surgical care of injured patients as an element of the local Emergency Medical Services (EMS) system. Since 2008, the primary responsibility of the team has been to perform surgical procedures in the austere field setting when prolonged extrication is anticipated. Following the maxim of "life over limb," the team is equipped to provide rapid amputation of an entrapped extremity as well as other procedures and medical care, such as anxiolytics and advanced pain control. This report describes the development and implementation of a local EMS system HERT.