Years of Potential Life Lost and Mean Age of Adults Experiencing Nontraumatic, Out-of-Hospital Cardiac Arrests - Chicago, 2014-2021.

Approximately 1,000 out-of-hospital cardiac arrests (OHCAs) are assessed by emergency medical services in the United States every day, and approximately 90% of patients do not survive, leading to substantial years of potential life lost (YPLL). Chicago emergency medical services data were used to assess changes in mean age and YPLL from nontraumatic OHCA in adults in biennial cycles during 2014-2021. Among 21,070 reported nontraumatic OHCAs during 2014-2021, approximately 60% occurred among men and 57% among non-Hispanic Black or African American (Black) persons. YPLL increased from 52,044 during 2014-2015 to 88,788 during 2020-2021 (p = 0.002) and mean age decreased from 64.7 years during 2014-2015, to 62.7 years during 2020-2021. Decrease in mean age occurred among both men (p<0.001) and women (p = 0.002) and was largest among Black men. Mean age decreased among patients without presumed cardiac etiology from 56.3 to 52.5 years (p<0.001) and among patients with nonshockable rhythm from 65.5 to 62.7 years (p<0.001). Further study is needed to assess whether similar trends are occurring elsewhere, and to understand the mechanisms that underlie these trends in Chicago because these mechanisms could help guide prevention efforts. Increased public awareness of the risk of cardiac arrest and knowledge of how to intervene as a bystander could help decrease associated mortality.

Work-Life Balance and Academic Productivity Among College of Medicine Faculty During the Evolution of the COVID-19 Pandemic: The New Normal.

Background: Work and home stress, productivity, and self-care of academic medicine faculty in Spring 2021 was contrasted to faculty's experience in the Spring of 2020, both of which were relatively compared with the prepandemic period. Methods: A 93-question survey was sent to academic medicine faculty at an urban public university medical center in March 2020 and again in March 2021. Demographic, family, and academic characteristics, work distribution and productivity before and during the pandemic, perceived stress related to work and home activities, and self-care data compared with the prepandemic period were collected. Differences were assessed using chi-square or Fisher exact tests. Student t-test was used for the difference in mean values, while logistic regression was used to determine predictors of work stress. Results: Two hundred thirty-one faculty completed the survey in Spring 2020 and 118 faculty responded in Spring 2021. The proportion of faculty reporting increased work and home stress decreased in Spring 2021 compared with Spring 2020. A higher proportion of women compared with men reported increased work stress in both surveys. In Spring 2021, work stress decreased significantly for men but not for women. Home stress decreased significantly for women in Spring 2021 but remained stable for the men faculty. Research productivity increased for both genders in Spring 2021, but a greater percentage of women reported disturbed sleep and diet. There were no differences in home stress levels between genders when caring for young children. Conclusions: Men faculty are more likely to adapt to the "new normal" by lowering work stressors and increasing productivity, whereas women's continued high work stress and increased productivity may occur at the expense of decreased self-care. The challenges associated with having young children continue to affect the productivity and well-being of all faculty.

Interhospital variability in Out-of-Hospital cardiac arrest survival in a large metropolitan area.

Background: Out-of-hospital cardiac arrest (OHCA) survival varies widely across the United States. The impact of hospital OHCA volume and ST-elevation myocardial infarction (STEMI) Receiving Center (SRC) designation on survival is not fully understood. Methods: This was a retrospective analysis of adult OHCA who survived to hospital admission reported to the Chicago Cardiac Arrest Registry to Enhance Survival (CARES) database from May 1, 2013 to December 31, 2019. Hierarchical logistic regression models were generated and adjusted by hospital characteristics. Survival to hospital discharge (SHD) and cerebral performance category (CPC) 1-2 at each hospital were calculated after adjusting for arrest characteristics. Hospitals were assigned quartiles (Q1-Q4) based on total arrest volume to allow for comparison of SHD and CPC 1-2 between quartiles. Results: 4,020 patients met inclusion criteria. 21 of the 33 Chicago hospitals included in this study were designated SRCs. Adjusted SHD and CPC 1-2 rates ranged from 27.3% to 37.0% and from 8.9% to 25.1%, respectively, by hospital. SRC designation did not significantly affect SHD (OR 0.96; 95% CI, 0.71-1.30) nor CPC 1-2 (OR 1.17; 95% CI, 0.74-1.84). OHCA volume quartiles did not significantly affect SHD (Q2: OR 0.94; 95% CI, 0.54-1.60; Q3: OR 1.30; 95% CI, 0.78-2.16; Q4: OR 1.25; 95% CI, 0.74-2.10) nor CPC 1-2 (Q2: OR 0.75; 95% CI, 0.36-1.54; Q3: OR 0.94; 95% CI, 0.48-1.87; Q4: OR 0.97; 95% CI, 0.48-1.97). Conclusion: Interhospital variability in both SHD and CPC 1-2 cannot be explained by hospital arrest volume nor SRC status. Further research is warranted to explore reasons for interhospital variability.

Velocity-Time Integral: A Bedside Echocardiography Technique Finding a Place in the Emergency Department.

BACKGROUND: Point-of-care ultrasound is a fundamental tool in the emergency department when managing the critically ill patient. Determining a patient's hemodynamic status at the bedside can better guide resuscitation efforts. The left ventricular outflow tract velocity-time integral (VTI) is a validated, noninvasive, and rapidly acquired echocardiographic measurement that is analogous to stroke volume. DISCUSSION: VTI can be used to determine fluid responsiveness and to risk stratify patients, particularly in pulmonary embolism, heart failure, and sepsis. Emergency physicians with limited experience can successfully measure VTI in a timely and accurate manner. However, VTI measurement is not commonly taught in emergency medicine residency and, as a result, it is an underused tool. CONCLUSIONS: VTI is an objective tool for clinicians to assess the hemodynamic status of critically ill patients. Understanding the acquisition of VTI and proper application in the context of the patient's history, clinical examination, and other bedside ultrasound findings, should be reviewed within the emergency medicine residency ultrasound curriculum. This article provides a simple four-step protocol, as well as bedside applications and potential limitations for VTI in the ED.

Race and ethnicity data in the cardiac arrest registry to enhance survival: Insights from medicare self-reported data.

BACKGROUND: For out-of-hospital cardiac arrest (OHCA), assignment of race/ethnicity data can be challenging. Validation of race/ethnicity in registry data with patients' self-reported race/ethnicity would provide insights regarding misclassification. METHODS: Using recently linked 2013-2019 Cardiac Arrest Registry to Enhance Survival (CARES) data with Medicare files, we examined the concordance of race/ethnicity in CARES with self-reported race/ethnicity in Medicare. Among patients with unknown race/ethnicity in CARES, race/ethnicity data from Medicare files were reported. RESULTS: Of 26,875 patients in the linked data, 5757 (21.4%) had unknown race/ethnicity in CARES. Of the remaining 21,118 patients, 14,284 (67.6%) were identified in CARES as non-Hispanic White, 4771 (22.6%) as non-Hispanic Black, 1213 (5.7%) as Hispanic, 760 (3.6%) as Asian or Pacific Islander, and 90 (0.4%) as American Indian or Alaskan Native. The concordance rate for race/ethnicity between CARES and Medicare was 93.4% for patients reported as non-Hispanic White in CARES, 89.1% for non-Hispanic Blacks, 74.6% for Hispanics, 69.6% for Asians and Pacific Islanders, and 37.8% for American Indian or Alaskan Natives. For the 5757 patients with unknown race/ethnicity in CARES, 3973 (69.0%) self-reported in Medicare as non-Hispanic White, 617 (10.7%) as non-Hispanic Black, 425 (7.4%) as Hispanic, 491 (8.5%) as Asian or Pacific Islander, and 52 (0.9%) as American Indian or Alaskan Native. Race/ethnicity remained unknown in 199 (3.5%) of patients. CONCLUSION: Race/ethnicity in CARES was highly concordant with self-reported race/ethnicity in Medicare, especially for non-Hispanic White and Black individuals. For patients with unknown race/ethnicity data in CARES, the vast majority were of White race.

Utilizing community level factors to improve prediction of out of hospital cardiac arrest outcome using machine learning.

OBJECTIVES: To evaluate the impact of community level information on the predictability of out-of-hospital cardiac arrest (OHCA) survival. METHODS: We used the Cardiac Arrest Registry to Enhance Survival (CARES) to geocode 9,595 Chicago incidents from 2014 to 2019 into community areas. Community variables including crime, healthcare, and economic factors from public data were merged with CARES. The merged data were used to develop ML models for OHCA survival. Models were evaluated using Area Under the Receiver Operating Characteristic curve (AUROC) and features were analyzed using SHapley Additive exPansion (SHAP) values. RESULTS: Baseline results using CARES data achieved an AUROC of 84%. The final model utilizing community variables increased the AUROC to 88%. A SHAP analysis between high and low performing community area clusters showed the high performing cluster is positively impacted by good health related features and good community safety features positively impact the low performing cluster. CONCLUSION: Utilizing community variables helps predict neurologic outcomes with better performance than only CARES data. Future studies will use this model to perform simulations to identify interventions to improve OHCA survival.

Work-Life Balance and Productivity Among Academic Faculty During the COVID-19 Pandemic: A Latent Class Analysis.

Background: For faculty in academic health sciences, the balance between research, education, and patient care has been impeded by the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to identify personal and professional characteristics of faculty to understand the impact of the pandemic on faculty and consequent policy implications. Methods: A 93-question survey was sent to faculty at a large urban public university and medical center. Demographic, family, and academic characteristics, work distribution and productivity before and during the pandemic, stress, and self-care data information were collected. Latent class analysis (LCA) was performed to identify classes of faculty sharing similar characteristics. Comparisons between latent classes were performed using analysis of variance and chi-square analyses. Results: Of 497 respondents, 60% were women. Four latent classes of faculty emerged based on six significant indicator variables. Class 1 individuals were more likely women, assistant professors, nontenured with high work and home stress; Class 2 faculty were more likely associate professors, women, tenured, who reported high home and work stress; Class 3 faculty were more likely men, professors, tenured with moderate work, but low home stress; and Class 4 faculty were more likely adjunct professors, nontenured, and had low home and work stress. Class 2 reported significantly increased administrative and clinical duties, decreased scholarly productivity, and deferred self-care. Conclusions: The pandemic has not affected faculty equally. Early and mid-career individuals were impacted negatively from increased workloads, stress, and decreased self-care. Academic leaders need to acknowledge these differences and be inclusive of faculty with different experiences when adjusting workplace or promotion policies.

Sex differences in outcomes for out-of-hospital cardiac arrest in the United States.

BACKGROUND: Approximately 1000 out-of-hospital cardiac arrest (OHCA) occur each day in the United States. Although sex differences exist for other cardiovascular conditions such as stroke and acute myocardial infarction, they are less well understood for OHCA. Specifically, the extent to which neurological and survival outcomes after OHCA differ between men and women remains poorly characterized in the U.S. METHODS AND RESULTS: Within the national Cardiac Arrest Registry to Enhance Survival (CARES) registry, we identified 326,138 adults with an OHCA from 2013 to 2019. Using multivariable logistic regression, we evaluated for sex differences in rates of survival to hospital admission, survival to hospital discharge, and favorable neurological survival (i.e., without severe neurological disability), adjusted for demographics, cardiac arrest characteristics and bystander interventions. Overall, 117,281 (36%) patients were women. Median age was 62 and 65 years for men and women, respectively. An initial shockable rhythm (25.1% vs 14.7%, standardized difference of 0.26) and an arrest in a public location (22.2% vs. 11.3%; standardized difference of 0.30) were more common in men, but there were no meaningful sex differences in rates of witnessed arrests, bystander cardiopulmonary resuscitation, intra-venous access, or use of mechanical devices for delivering cardiopulmonary resuscitation. Overall, the unadjusted rates of all survival outcomes were similar between men and women: survival to hospital admission (27.0% for men vs. 27.9% for women, standardized difference of -0.02), survival to hospital discharge (10.5% for men vs. 8.6% for women, standardized difference of 0.07), and favorable neurological survival (9.0% for men vs. 6.6% for women, standardized difference of 0.09). After multivariable adjustment, however, men were less likely to survive to hospital admission (adjusted OR = 0.75, 95% CI: 0.73, 0.77), survive to hospital discharge (adjusted OR = 0.83, 95% CI: 0.80, 0.85), or have favorable neurological survival (adjusted OR = 0.88, 95% CI: 0.85, 0.91). CONCLUSIONS: Compared to women, men with OHCA have more favorable cardiac arrest characteristics but were less likely to survive to hospital admission, survive to discharge, nor have favorable neurological survival.

Sudden Cardiac Arrest Survivorship: A Scientific Statement From the American Heart Association.

Cardiac arrest systems of care are successfully coordinating community, emergency medical services, and hospital efforts to improve the process of care for patients who have had a cardiac arrest. As a result, the number of people surviving sudden cardiac arrest is increasing. However, physical, cognitive, and emotional effects of surviving cardiac arrest may linger for months or years. Systematic recommendations stop short of addressing partnerships needed to care for patients and caregivers after medical stabilization. This document expands the cardiac arrest resuscitation system of care to include patients, caregivers, and rehabilitative healthcare partnerships, which are central to cardiac arrest survivorship.

When the Female Heart Stops: Sex and Gender Differences in Out-of-Hospital Cardiac Arrest Epidemiology and Resuscitation.

Sex- and gender-based differences are emerging as clinically significant in the epidemiology and resuscitation of patients with out-of-hospital cardiac arrest (OHCA). Female patients tend to be older, experience arrest in private locations, and have fewer initial shockable rhythms (ventricular fibrillation/ventricular tachycardia). Despite standardized algorithms for the management of OHCA, women are less likely to receive evidence-based interventions, including advanced cardiac life support medications, percutaneous coronary intervention, and targeted temperature management. While some data suggest a protective mechanism of estrogen in the heart, brain, and kidney, its role is incompletely understood. Female patients experience higher mortality from OHCA, prompting the need for sex-specific research.

Strain analysis for the identification of hypertensive cardiac end-organ damage in the emergency department.

Hypertensive emergency is a life-threatening state. End-organ damage affecting the heart accounts for up to 52% of hypertensive emergencies commonly encountered in the emergency department. Recent evidence indicates that strain echocardiography with computerized speckle-tracking is more sensitive at identifying hypertension induced changes in the left ventricle (LV) mechanical function than traditional 2-D echocardiography. We present a case demonstrating the use of emergency physician performed point-of-care strain echocardiography to identify and quantify LV mechanical dysfunction during a hypertensive crisis and to monitor improvement over 6 h.

Implementing a STEMI system of care in urban Bangalore: Rationale and Study Design for heart rescue India.

BACKGROUND: A system of care designed to measure and improve process measures such as symptom recognition, emergency response, and hospital care has the potential to reduce mortality and improve quality of life for patients with ST-elevation myocardial infarction (STEMI). OBJECTIVE: To document the methodology and rationale for the implementation and impact measurement of the Heart Rescue India project on STEMI morbidity and mortality in Bangalore, India. STUDY DESIGN: A hub and spoke STEMI system of care comprised of two interventional, hub hospitals and five spoke hospitals will build and deploy a dedicated emergency response and transport system covering a 10 Km. radius area of Bangalore, India. High risk patients will receive a dedicated emergency response number to call for symptoms of heart attack. A dedicated operations center will use geo-tracking strategies to optimize response times including first responder motor scooter transport, equipped with ECG machines to transmit ECG's for immediate interpretation and optimal triage. At the same time, a dedicated ambulance will be deployed for transport of appropriate STEMI patients to a hub hospital while non-STEMI patients will be transported to spoke hospitals. To enhance patient recognition and initiation of therapy, school children will be trained in basic CPR and signs and symptom of chest pain. Hub hospitals will refine their emergency department and cardiac catheterization laboratory protocols using continuous quality improvement techniques to minimize treatment delays. Prior to hospital discharge, secondary prevention measures will be initiated to enhance long-term patient outcomes.

Bedside ultrasound as a predictive tool for acute chest syndrome in sickle cell patients.

BACKGROUND: Acute chest syndrome (ACS) is the leading cause of death for patients with sickle cell disease (SCD). Early recognition of ACS improves prognosis. OBJECTIVE: Investigate the use of bedside lung ultrasound (BLU) in identification of early pulmonary findings associated with ACS in SCD patients. METHODS: Prospective, observational study of a convenience sample of SCD patients presenting to the Emergency Department (ED) for a pain crisis. BLU interpretations were made by an emergency physician blinded to the diagnosis of ACS, and were validated by a second reviewer. The electronic medical record was reviewed at discharge and at 30 days. RESULTS: Twenty SCD patients were enrolled. Median age was 31 years, median hemoglobin was 7.7 g/dL. Six patients developed ACS. Five patients in the ACS group had lung consolidations on BLU (83%) compared to 3 patients in the non-ACS group (21%), p = 0.0181, (OR = 12.05, 95% CI 1.24 to 116.73). The ACS group was also more likely to have a pleural effusion and B-lines on BLU than the non-ACS group, p = 0.0175; 0.1657, respectively. In the ACS group, peripheral and frank consolidations on BLU was 83% and 50% sensitive, 79% and 100% specific for ACS, respectively; whereas an infiltrate on initial chest X-ray (CXR) was only 17% sensitive. BLU identified lung abnormalities sooner than CXR (median 3.6 vs. 31.8 h). CONCLUSIONS: Pulmonary abnormalities on BLU of an adult SCD patient presenting to the ED for a painful crisis appear before CXR, and highly suggest ACS. BLU is a promising predictive tool for ACS.

Emergency physician use of tissue Doppler bedside echocardiography in detecting diastolic dysfunction: an exploratory study.

INTRODUCTION: This study evaluates the agreement between emergency physician (EP) assessment of diastolic dysfunction (DD) by a simplified approach using average peak mitral excursion velocity (e'A) and an independent cardiologist's diagnosis of DD by estimating left atrial (LA) pressure using American Society of Echocardiography (ASE) guidelines. METHODS: This was a secondary analysis of 48 limited bedside echocardiograms (LBE) performed as a part of a research study of patients presenting to the Emergency Department (ED) with elevated blood pressure but without decompensated heart failure. EPs diagnosed DD based on e'A < 9 cm/s alone. A blinded board-certified cardiologist reviewed LBEs to estimate LA filling pressures following ASE guidelines. An unweighted kappa measure was calculated to determine agreement between EP and cardiologist. RESULTS: Six LBEs were deemed indeterminate by the cardiologist and excluded from the analysis. Agreement was reached in 41 out of 48 cases (85.4%). The unweighted kappa coefficient was 0.74 (95% CI 0.57-0.92). EPs identified 18 out of 20 LBEs diagnosed with diastolic dysfunction by the cardiologist. CONCLUSION: There is a good agreement between (e'A) by EP and cardiologist interpretation of LBEs. Future studies should investigate this simplified approach as a one-step method of screening for LV diastolic dysfunction in the ED.

A hypertension emergency department intervention aimed at decreasing disparities: Design of a randomized clinical trial.

Effective interventions to identify and treat uncontrolled hypertension (HTN), particularly in underrepresented populations that use the emergency department (ED) for primary care, are critically needed. Uncontrolled HTN contributes significantly to cardiovascular morbidity and mortality and is more frequently encountered among patients presenting to the ED as compared to the primary care setting. EDs serve as the point of entry into the health care system for high-risk patient populations, including minority and low-income patients. Previous studies have demonstrated that the prevalence of uncontrolled/undiagnosed HTN in patients presenting to the ED is alarmingly high. Thus ED engagement and early risk assessment/stratification is a feasible innovation to help close health disparity gaps in HTN. A Hypertension Emergency Department Intervention Aimed at Decreasing Disparities (AHEAD2) trial, funded by the National Heart, Lung, and Blood Institute (NHLBI) is a three-arm single site randomized clinical pilot trial of adults presenting to the ED with Stage 2 hypertension (blood pressure [BP]>160/100) comparing (1) an ED-initiated Screening, Brief Intervention, and Referral for Treatment (SBIRT) focused on HTN, (2) the same ED-initiated SBIRT coupled with a Post-Acute Care Hypertension Transition Consultation by ED Clinical Pharmacists, and (3) usual care. The primary outcome is mean BP differences between study arms. Secondary outcomes are proportion of participants with BP control (BP<140/90mmHg), and improvements in HTN knowledge and medication adherence scores between study arms. The objective of this report is to describe the development of the AHEAD2 trial, including the methods, research infrastructure, and other features of the randomized clinical trial design.