Search

Introduction: In October 2017, the American Association of Blood Bankers (AABB; Bethesda, Maryland USA) approved a petition to allow low-titer group O whole blood as a standard product without the need for a waiver. Around that time, a few Texas, USA-based Emergency Medical Services (EMS) systems incorporated whole blood into their ground ambulances. The purpose of this project was to describe the epidemiology of ground ambulance patients that received a prehospital whole blood transfusion. The secondary aim of this project was to report an accounting analysis of these ground ambulance prehospital whole blood programs., Methods: The dataset came from the Harris County Emergency Service District 48 Fire Department (HCESD 48; Harris County, Texas USA) and San Antonio Fire Department (SAFD; San Antonio, Texas USA) whole blood Quality Assurance/Quality Improvement (QA/QI) databases from September 2017 through December 2018. The primary outcome of this study was the prehospital transfusion indication. The secondary outcome was the projected cost per life saved during the first 10 years of the prehospital whole blood initiative., Results: Of 58 consecutive prehospital whole blood administrations, the team included all 58 cases. Hemorrhagic shock from a non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. In the non-traumatic hemorrhagic shock cohort, gastrointestinal hemorrhage was the underlying etiology of hemorrhagic shock in 66.7% (95% CI, 47.8%-81.4%) of prehospital whole blood transfusion recipients. The projected average cost to save a life in Year 10 was US$5,136.51 for the combined cohort, US$4,512.69 for HCESD 48, and US$5,243.72 for SAFD EMS., Conclusion: This retrospective analysis of ground ambulance patients that receive prehospital whole blood transfusion found that non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. Additionally, the accounting analysis suggests that by Year 10 of a ground ambulance whole blood transfusion program, the average cost to save a life will be approximately US$5,136.51.

Introduction The Public Health England (PHE; United Kingdom) Real-Time Syndromic Surveillance Team (ReSST) currently operates four national syndromic surveillance systems, including an emergency department system. A system based on ambulance data might provide an additional measure of the "severe" end of the clinical disease spectrum. This report describes the findings and lessons learned from the development and preliminary assessment of a pilot syndromic surveillance system using ambulance data from the West Midlands (WM) region in England. Hypothesis/Problem Is an Ambulance Data Syndromic Surveillance System (ADSSS) feasible and of utility in enhancing the existing suite of PHE syndromic surveillance systems?, Methods: An ADSSS was designed, implemented, and a pilot conducted from September 1, 2015 through March 1, 2016. Surveillance cases were defined as calls to the West Midlands Ambulance Service (WMAS) regarding patients who were assigned any of 11 specified chief presenting complaints (CPCs) during the pilot period. The WMAS collected anonymized data on cases and transferred the dataset daily to ReSST, which contained anonymized information on patients' demographics, partial postcode of patients' location, and CPC. The 11 CPCs covered a broad range of syndromes. The dataset was analyzed descriptively each week to determine trends and key epidemiological characteristics of patients, and an automated statistical algorithm was employed daily to detect higher than expected number of calls. A preliminary assessment was undertaken to assess the feasibility, utility (including quality of key indicators), and timeliness of the system for syndromic surveillance purposes. Lessons learned and challenges were identified and recorded during the design and implementation of the system., Results: The pilot ADSSS collected 207,331 records of individual ambulance calls (daily mean=1,133; range=923-1,350). The ADSSS was found to be timely in detecting seasonal changes in patterns of respiratory infections and increases in case numbers during seasonal events., Conclusions: Further validation is necessary; however, the findings from the assessment of the pilot ADSSS suggest that selected, but not all, ambulance indicators appear to have some utility for syndromic surveillance purposes in England. There are certain challenges that need to be addressed when designing and implementing similar systems. Todkill D , Loveridge P , Elliot AJ , Morbey RA , Edeghere O , Rayment-Bishop T , Rayment-Bishop C , Thornes JE , Smith G . Utility of ambulance data for real-time syndromic surveillance: a pilot in the West Midlands region, United Kingdom. Prehosp Disaster Med. 2017;32(6):667-672.

Introduction Previous studies have found that older adults are more likely to use Emergency Medical Services (EMS) than younger adults, but the reasons for this remain understudied. Hypothesis/Problem This study aimed to determine if older age is associated with using EMS for transportation to an emergency department (ED) after controlling for confounding variables., Methods: A cross-sectional survey study was conducted at a large academic medical center. Data on previous medical history, chief complaint, self-perceived illness severity, demographic information, and mode of arrival to the ED were collected on all subjects. Those who arrived to the ED via EMS also were asked reasons why they opted to call an ambulance for their illness/injury. Descriptive statistics were used to quantify survey responses, and multivariable regression was used to assess the independent effect of age on mode of ED arrival., Results: Data from 1,058 subjects were analyzed, 449 (42%) of whom arrived to the ED via EMS. Compared to adults<55 years, the unadjusted prevalence ratio for the association between age and EMS use was 1.18 (95% CI, 0.96-1.45) for subjects 55-79 years and 1.54 (95% CI, 1.18-2.02) for subjects ≥80 years. After adjustment for confounding variables, age remained a statistically significant risk factor for EMS use (P<.05)., Conclusion: Older age is an independent risk factor for transportation to the ED via ambulance; however, this effect is attenuated by number of chronic medical conditions and history of depression. Additional research is needed to account for confounders unmeasured in this study and to elucidate reasons for the increased frequency of EMS use among older adults. Jones CMC , Wasserman EB , Li T , Amidon A , Abbott M , Shah MN . The effect of older age on EMS use for transportation to an emergency department. Prehosp Disaster Med. 2017;32(3):261-268.

Introduction Comprehensive studies on the relationship between patient demographics and subsequent treatment and disposition at a single mass-gathering event are lacking. The Sydney Royal Easter Show (SRES; Sydney Olympic Park, New South Wales, Australia) is an annual, 14-day, agricultural mass-gathering event occurring around the Easter weekend, attracting more than 800,000 patrons per year. In this study, patient records from the SRES were analyzed to examine relationships between weather, crowd size, day of week, and demographics on treatment and disposition. This information would help to predict factors affecting patient treatment and disposition to guide ongoing training of first responders and to evaluate the appropriateness of staffing skills mix at future events. Hypothesis Patient demographics, environmental factors, and attendance would influence the nature and severity of presentations at the SRES, which would influence staffing requirements., Methods: A retrospective analysis of 4,141 patient record forms was performed for patients who presented to St John Ambulance (Australian Capital Territory, Australia) at the SRES between 2012 and 2014 inclusive. Presentation type was classified using a previously published minimum data set. Data on weather and crowd size were obtained from the Australian Bureau of Meteorology (Melbourne, Victoria, Australia) and the SRES, respectively. Statistical analyses were performed using SPSS v22 (IBM; Armonk, New York USA)., Results: Between 2012 to 2014, over 2.5 million people attended the SRES with 4,141 patients treated onsite. As expected, the majority of presentations were injuries (49%) and illnesses (46%). Although patient demographics and presentation types did not change over time, the duration of treatment increased. A higher proportion of patients were discharged to hospital or home compared to the proportion of patients discharged back to the event. Patients from rural/regional locations (accounting for 15% of all patients) were more likely to require advanced treatment, health professional review, and were more likely to be discharged to hospital or home rather than discharged back to the event. Extremes of temperature were associated with a lower crowd size and higher patient presentation rate (PPR), but had no impact on transfer or referral rates to hospital., Conclusion: This study demonstrated that analyses of patient presentations at an agricultural show provide unique insights on weather, attendance, and demographic features that correlated with treatment and disposition. These data can help guide organizers with information on how to better staff and train health care providers at future mass-gathering events of this type. Crabtree N , Mo S , Ong L , Jegathees T , Wei D , Fahey D , Liu J . Retrospective analysis of patient presentations at the Sydney (Australia) Royal Easter Show from 2012 to 2014. Prehosp Disaster Med. 2017;32(2)187-194.

Introduction: The goal of an Emergency Medical Services (EMS) system is to prevent needless death or disability from time-sensitive disease processes. Despite growing evidence that these processes contribute significantly to mortality in low- and middle- income countries (LMICs), there has been little focus on the development of EMS systems in poor countries. Problem The objective of this study was to understand the utilization pattern of a newly-implemented EMS system in Ruhiira, Uganda., Methods: An EMS system based on community priorities was implemented in rural Uganda in 2009. Six months of ambulance logs were reviewed. Patient, transfer, and clinical data were extracted and analyzed., Results: In total, 207 cases were reviewed. Out of all transfers, 66% were for chief complaints that were obstetric related, while 12% were related to malaria. Out of all activations, 77.8% were for female patients. Among men, 34% and 28% were related to malaria and trauma, respectively. The majority of emergency transfers were from district to regional hospitals, including 52% of all obstetric transfers, 65% of malaria transfers, and 62% of all trauma transfers. There was no significant difference in the call to arrival on scene time, the time to scene or the scene to treatment time during the day and night (P > .05). Cost-benefit analysis revealed a cost of $89.95 per life saved with an estimated $0.93/capita to establish the system and $0.09/capita/year to maintain the system., Conclusion: Contrary to current belief, EMS systems in rural Africa can be affordable and highly utilized, particularly for life-threatening, nontrauma complaints. Construction of a simple but effective EMS system is feasible, acceptable, and an essential component to the primary health care system of LMICs.

Introduction: While several reports discuss controversies regarding ambulance diversion from acute care hospitals and the mortality, financial, and resource effects, there is scant literature related to the effect of hospital characteristics., Hypothesis/problem: The objective of this study was to describe specific paramedic receiving center characteristics that are associated with ambulance diversion rates in an Emergency Medical Services system., Methods: A retrospective observational study design was used. The study was performed in a suburban EMS system with 27 paramedic receiving centers studied; one additional hospital present at the beginning of the study period (2000-2008) was excluded due to lack of recent data. Hospital-level and population-level characteristics were gathered, including diversion rate (hours on diversion/total hours open), for-profit status, number of specialty services (including trauma, burn, cardiovascular surgery, renal transplant services, cardiac catheterization capability [both interventional and diagnostic], and burn surgery), average inpatient bed occupancy rate (total patient days/licensed bed days), annual emergency department (ED) volume (patients per year), ED admission rate (percent of ED patients admitted), and percent of patients leaving without being seen. Demographic characteristics included percent of persons in each hospital's immediate census tract below the 100% and 200% poverty lines (each considered separately), and population density within the census tract. Bivariate and regression analyses were performed., Results: Diversion rates for the 27 centers ranged from 0.3%-14.5% (median 4.5%). Average inpatient bed occupancy rate and presence of specialty services were correlated with an increase in diversion rate; occupancy rate showed a 0.08% increase in diversion hours per 1% increase in occupancy rate (95% CI, 0.01%-0.16%), and hospitals with specialty services had, on average, a 4.1% higher diversion rate than other hospitals (95% CI, 1.6%-6.7%). Other characteristics did not show a statistically significant effect. When a regression was performed, only the presence of specialty services was related to the ambulance diversion rate., Conclusions: Hospitals in this study providing specialty services were more likely to have higher diversion rates. This may result in increased difficulty getting patients requiring specialty care to centers able to provide the needed level of service. Major limitations include the retrospective nature of the study, as well as reliance on multiple data systems.

Introduction: Heat waves pose a serious public health risk to particular patient populations, especially in urban areas. Emergency Medical Services (EMS) in many urban areas constitute the first line of regional preparation and response to major heat wave events; however, little is known on heat wave operational impact to the EMS system, such as call volume or demand., Objective: To examine the effect of heat wave periods on overall urban EMS system call volume and transport volume as well as the nature of the call types., Methods: Retrospective review of all emergency medical calls to an urban, two-tiered EMS system performed over a 5-year period from 2006-2010. Heat wave days (HWD) defined as two or more consecutive days of hot weather >32.2°C (90°F) were compared with similar non-heat wave days (nHWD) of the previous year to also include two calendar days prior to and after the heat wave. National Weather Service (NWS) temperature data, daily EMS call volume data, and call type codes were collected and underwent descriptive analysis., Results: Thirty-one HWD were identified and compared with 93 nHWD. The mean maximum temperature for HWD was 34°C (93.2°F) compared with 25.3°C (77.6°F) for nHWD (P < .001). Average daily medical emergency calls (318.4 vs 296.3, P < .001) and actual patients transported per day (247.5 vs 198.3, P < .001) were significantly higher during HWD. There was no difference in daily medical emergency call volume or EMS transports between weekdays or weekend days. No significant differences on various call types were observed between HWD and nHWD except for "heat" related calls (7.7 vs 0.5, P < .001)., Conclusion: Emergency Medical Services call volumes were significantly increased during heat waves, however there was minimal change in the types of calls received.

Unlabelled: Introduction Heat waves have significant impacts on mortality and morbidity. However, little is known regarding effects on pre-admission health outcomes such as ambulance attendances, particularly in subtropical regions. Problem This study investigated both main temperature effects and the added effects of heat waves on ambulance attendances in Brisbane, a subtropical city in Australia., Methods: Daily data relating to 783,935 ambulance attendances, along with data on meteorological variables and air pollutants, were collected for the period 2000-2007. Ambient temperature (main) effects were assessed using a distributed lag nonlinear approach that accounted for delayed effects of temperature, while added heat wave effects were incorporated separately using a local heat wave definition. Effect estimates were obtained for total, cardiovascular and respiratory attendances, and different age groups., Results: Main effects of temperature were found for total attendances, which increased by 50.6% (95% CI, 32.3%-71.4%) for a 9.5°C increase above a reference temperature of 29°C. An added heat wave effect on total attendances was observed (18.8%; 95% CI, 6.5%-32.5%). Significant effects were found for both respiratory and cardiovascular attendances, particularly for those aged 65 and above., Conclusion: Ambulance attendances can be significantly impacted by sustained periods of high temperatures, and are a valid source of early detection of the effects of extreme temperatures on the population. The planning of ambulance services may need to be adapted as a consequence of increasing numbers of heat waves in the future. Ambulance attendance data also should be utilized in the development of heat warning systems and climate change adaptation strategies.

Introduction: Timely access to acute medical treatment can be critical for patients suffering from severe stroke. Little information is available about the impact of prehospital delays on the clinical conditions of stroke patients, but it is possible that prehospital delays lead to neurological deterioration. The aim of this study was to examine the impact of prehospital delays related to emergency medical services on the level of consciousness at admission in patients with severe stroke., Methods: This retrospective study assessed 712 consecutive patients diagnosed with cerebrovascular diseases who were admitted to an intensive care unit in Tokyo, Japan, from April 1998 through March 2008. Data, including the time from the call to the ambulance service to the arrival of the ambulance at the patient location (on-scene), and the time from the arrival of the ambulance on-scene to its arrival at the emergency center were obtained. The following demographic and clinical information also were obtained from medical records: sex, age, and Glasgow Coma Scale (GCS) score at admission., Results: The mean time from ambulance call to arrival on-scene was 7 (SD=3) minutes, and the mean time from ambulance call to arrival at the center was 37 (SD=8) minutes. A logistic regression model for predicting GCS scores of 3 and 4 at admission was produced. After adjusting for sex, age, and time from arrival on-scene to arrival at the center, a longer call-to-on-scene time was significantly associated with poor GCS scores (OR = 1.056/min; 95% confidence interval, [CI] = 1.008-1.107). After adjusting for sex and age, a longer call-to-arrival at the center time also was significantly associated with poor GCS scores (OR = 1.020; 95% CI = 1.002-1.038)., Conclusions: Prehospital delays were significantly associated with decreased levels of consciousness at admission in patients suffering from a stroke. As level of consciousness is the strongest predictor of outcome, reducing prehospital delays may be necessary to improve the outcomes in patients with severe stroke.

Introduction: Estimating the number of ambulances needed in trauma-related Multiple Casualty Events (MCEs) is a challenging task., Hypothesis/problem: Emergency medical services (EMS) regions in the United States have varying "best practices" for the required number of ambulances in MCE, none of which is based on metric criteria. The objective of this study was to estimate the number of ambulances required to respond to the scene of trauma-related MCE in order to initiate treatment and complete the transport of critical (T1) and moderate (T2) patients. The proposed model takes into consideration the different transport times and capacities of receiving hospitals, the time interval from injury occurrence, the number of patients per ambulance, and the pre-designated time frame allowed from injury until the transfer care of T1 and T2 patients., Methods: The main theoretical framework for this model was based on prehospital time intervals described in the literature and used by EMS systems to evaluate operational and patient care issues. The North Atlantic Treaty Organization (NATO) triage categories (T1-T4) were used for simplicity., Results: The minimum number of ambulances required to respond to the scene of an MCE was modeled as being primarily dependent on the number of critical patients (T1) present at the scene any particular time. A robust quantitative model was also proposed to dynamically estimate the number of ambulances needed at any time during an MCE to treat, transport and transfer the care of T1 and T2 patients., Conclusion: A new quantitative model for estimation of the number of ambulances needed during the prehospital response in trauma-related multiple casualty events has been proposed. Prospective studies of this model are needed to examine its validity and applicability.

Introduction: Recreational use of gamma-hydroxybutyrate (GHB) is increasingly common at mass-gathering dance events in Australia. Overdose often occurs in clusters, and places a significant burden on the surrounding health care infrastructure., Objective: To describe the clinical presentation, required interventions and disposition of patrons with GHB intoxication at dance events, when managed by dedicated medical assistance teams., Methods: Retrospective analysis of all patrons attending St. John Ambulance medical assistance teams at dance events in the state of Victoria (Australia), from January 2010 through May 2011. Main outcome measures Clinical presentation, medical interventions and discharge destination., Results: Sixty-one patients with GHB intoxication attended medical teams during the study period. The median age was 22 years, and 64% were male. Altered conscious state was present in 89% of attendances, and a GCS <9 in 44%. Hypotension, bradycardia and hypothermia were commonly encountered. Endotracheal intubation was required in three percent of patrons. Median length of stay onsite was 90 minutes. Ambulance transport to hospital was avoided in 65% of presentations., Conclusions: The deployment of medical teams at dance events and music festivals successfully managed the majority of GHB intoxications onsite and avoided acute care ambulance transfer and emergency department attendance.

Introduction: Annual ambulance diversion hours in Boston increased more than six-fold from 1997 to 2006. Although interventions and best practices were implemented, there was no reduction in the number of diversion hours., Objectives: A consortium of Boston teaching hospitals instituted a two-week moratorium on citywide diversion from 02 October 2006 to 15 October 2006. The hypothesis was that there would be no significant difference in measures of hospital and emergency medical services (EMS) efficiency compared with the two weeks immediately prior., Methods: A total of nine hospitals and the municipal emergency medical services in Boston submitted data for analysis. The following mean daily hospital measures were studied: (1) emergency department volume; (2) number of emergency department admissions; (3) length of stay (LOS) for all patients; and (4) number of elopements. Mean EMS at-hospital time by destination and the percent of all Boston EMS transports to each hospital destination were calculated. The median differences (MD) were calculated as "before" minus "during" the study period and were compared with paired, Wilcoxon, non-parametric tests. Additional mean EMS measures for all destinations included: (1) to hospital time; (2) number of responses with transport initiated per day; (3) incident entry to arrival; and (4) at-hospital time., Results: The LOS for admitted patients (MD = 0.30 hours; IQR 0.10,1.30; p = 0.03) and number of daily admissions (MD = -1.50 patients; IQR -1.50, -0.10; p = 0.04) were significantly different statistically. The results for LOS for all patients, LOS for discharged patients, ED volume, EMS time at hospital by destination, number of elopements, and percent of Boston EMS transports to each hospital revealed no statistically significant differences. The difference between the study and control periods for mean EMS to hospital time, at-hospital time, and incident entry to arrival was a maximum of 0.6 minutes. The vast majority of EMS respondents to an online survey believed that the "no diversion" policy should be made routine practice., Conclusions: The LOS for admitted patients decreased by 18 minutes, and the number of admissions increased by 1.5 patients per day during the study period. The "no diversion" policy resulted in minimal changes in EMS efficiency and operations. Diversion was temporarily eliminated in a major city without significant detrimental changes in ED, hospital, or EMS efficiency.

Objective: To identify the factors that lead to increased use of emergency medical services (EMS) by patients 65 years of age and older in an urban EMS system., Methods: Retrospective, case-control study of frequent EMS use among elderly patients transported during one year in an urban EMS system. Three distinct groups were examined for transports that took place in 1999: (1) 1-3 transports per year (low use); (2) 4-9 times per year (high use); and (3) those transported 10+ times (very high use). This frequency-use indicator variable is the primary outcome measurement. Predictors included age, gender, preexisting medical diseases, ethnicity, number of medications, number of medical problems, primary physician, psychiatric diagnosis, and homelessness. Analysis of predictors was done using ordinal logistic regression model, and a global test of interaction terms., Results: Male gender, black ethnicity, homelessness, and a variety of types of medical problems were associated with increased use of EMS resources. The strongest single predictor of case status remained homelessness, which was nearly eight times as commonly associated with frequent EMS use than for the controls. The number of medical problems and medications also were significantly associated with EMS use in this patient population. There was a lack of association of alcohol, substance abuse, and psychiatric disorders with EMS use. Patients with asthma who did not have a primary care physician were more likely to use EMS services than were those who had a physician., Conclusions: This analysis highlights homelessness as being strongly associated with frequent EMS use among the elderly and downplays other associated factors, such as psychiatric disease and substance use. Medical illness severity, particularly asthma when no primary care physician is available, also appears to drive frequent EMS use. Both findings have implications in terms of targeting of public resources; providing housing to medically ill elderly and primary care to asthmatics in particular, may provide dividends not only in terms of social welfare and medical care, but in preventing frequent EMS use by the elderly.

Introduction: Until early 2003, the Consultative Committee on Road Traffic Fatalities (CCRTF) in Victoria, Australia was the main body investigating and publishing data about prehospital errors resulting from road traffic fatalities. The objective of this study was to identify and interpret prehospital error rate trends associated with road traffic fatalities during a 10-year period of the CCRTF reports., Methods: This study is a review of the prehospital errors defined in Victorian CCRTF reports of preventable deaths of road traffic fatalities over a 10-year period., Results: Six CCRTF reports contained prehospital data for errors associated with road traffic fatalities. From 1992 to 1998, system errors decreased. However, over the same timeframe, management, technical, and diagnostic errors increased. There was a marked jump in system, technique, and diagnosis errors from 1998 to 2001-2003. However, management errors declined over the same timeframe. The jump in errors in the 1998 to 2001-2003 timeframe coincided with the introduction of advanced life support (ALS) for Victorian paramedics in 2000.The number of preventable deaths decreased from 1992 to 1998, however, there was an increase from 1999 onwards, coinciding with the introduction of the state trauma system and ALS for paramedics., Conclusions: This study demonstrates that there has been an increase in prehospital error rates, especially from 2000, which coincided with the introduction of ALS for paramedics and the state trauma system in Victoria, even though the state trauma system had an overall decrease in error rates.

Objectives: This study utilizes a [US] national sample of emergency medical services (EMS) professionals to explore the hypothesis that demographic and work-related characteristics are associated with involvement in ambulance crashes., Methods: In 2004, a cohort of nationally registered EMS professionals was surveyed to determine ambulance crash involvement during a 12-month period. Involvement in an ambulance crash was the outcome variable of interest. Demographics such as age, community size, service type, call volume, time spent in an ambulance, and current sleep problems were analyzed as independent variables. A multivariate logistic regression model identified variables associated with involvement in an ambulance crash within the past year., Results: Surveys were received from 1,775/5,565 (32.0%) participants; 1,297 (73.1%) met the inclusion criteria. A total of 111 (8.6%) of participants reported being involved in an ambulance crash within the past 12 months. When controlling for call volume and time in an ambulance, the odds of involvement in an ambulance crash within the past year were significantly higher for younger EMS professionals and those reporting sleep problems., Conclusions: Results from this analysis suggest age and sleep problems are associated with involvement in an ambulance crash. Future studies should investigate interventions to minimize the effects of these associations.

Introduction: International mass gatherings can cause great challenges to local healthcare system and emergency medical services (EMS). Traditionally, planning has been based on retrospective reports of previous events, but there still is a need for prospective studies in order to make the process more evidence-based. The aim of this study was to analyze the success of medical preparedness, ambulance patient characteristics, emergency care, and the use of pre-hospital resources during the 2005 World Championship Games in Athletics in Helsinki, Finland., Methods: The study was a prospective, observational study conducted within the Helsinki EMS. Data from all emergency calls at the sport venues and Games village between 05 and 14 August 2005 were collected. Data from the organizations responsible for the health care and first aid of spectators and accredited persons (e.g., athletes, coaches, the press, very important persons and personnel working in the Games area) also were collected. The Institutional Review Board of Helsinki University Central Hospital approved the study plan., Results: A total of 479,000 persons visited the Games. The ambulance call incidence at the Olympic Stadium was 0.50 per 10,000 people and 0.7 per 10,000 when the Games Village was included. The overall need for ambulance transportation to the emergency department was 0.52 per 10,000. No patients needed cardiopulmonary resuscitation or other immediate, life-saving procedures on-site. First aid was provided to 554 spectators (0.17 per 10,000 people). The three medical organizations cared for 1,586 patients of which 25 (1.6%) were transported to a hospital by an ambulance. The number of patients needing transportation and the overall patient load for the healthcare system was well-anticipated. Accredited persons sought health care a total of 1,009 times. The number of patients treated was associated closely with the number of spectators (p = 0.05). The number of ambulance calls in the city increased 5.9 % as compared to the corresponding time period in the five previous years., Conclusions: The medical preparedness and resources for the Games proved to be sufficient. The EMS personnel were able to provide quality emergency care. This prospective study provided new, detailed data for the medical aspects of mass gatherings and confirmed many previous observations.

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

Introduction: Mass-gathering events are dynamic and challenge traditional medical management systems. To improve the system for the provision of first aid at mass-gathering events, an evaluation of two models that assist in forecasting the number of patients presenting for first-aid services was conducted., Method: A prospective evaluation of a recurrent, mass-gathering event was undertaken comparing predicted patient presentations and ambulance transfers generated by a predictive model developed by Arbon et al and a retrospective review of seven years of historical, event data as described by Zeitz et al., Results: Patient presentation rate (per 1,000 patrons) for this event was 1.6 and the transport to hospital rate (per 1,000 patrons) was 0.07. The retrospective review closely predicted the actual overall attendance. Both methods forecast the number of patients presenting on a daily basis. The prediction proved to be more accurate, on a day-by-day basis, using the Zeitz method., Conclusion: The Arbon method is particularly useful for events where there is no or limited information about previous medical work. Retrospective review of data generated from specific events (Zeitz method) considers the unique and individual variability that can occur from event to event and is more accurate at predicting patient presentations when the data are available. Both methods have the potential to be used more frequently to adequately and efficiently plan for the resources required for specific events.

Objective: To assess the religious spirituality of EMS personnel and their perception of the spiritual needs of ambulance patients., Methods: Emergency medical technicians (EMTs) and paramedics presenting to an urban, academic emergency department (ED) were asked to complete a three-part survey relating to demographics, personal practices, and perceived patient needs. Their responses were compared to those of ambulance patients presenting to an ED during a previous study period and administered a similar survey., Results: A total of 143 EMTs and 89 paramedics returned the surveys. There were 161 (69.4%) male and 71 (30.6%) female respondents with a median age range of 26-35 years old. Eighty-seven percent believed in God, 82% practiced prayer or meditation, 62% attended religious services occasionally, 55% belonged to a religious organization, 39% felt that their beliefs affected their job, and 18% regularly read religious material. This was similar to the characteristics of ambulance patients. However, only 43% felt that occasionally ambulance patients presented with spiritual concerns and 78% reported never or rarely discussing spiritual issues with patients. Contrastingly, > 40% of ambulance patients reported spiritual needs or concerns at the time of ED presentation, and > 50% wanted their providers to discuss their beliefs. Twenty-six percent of respondents reported praying or meditating with patients, while 50% reported praying or meditating for patients. Females were no more religious or spiritual than males, but were more likely to engage in prayer with (OR = 2.38, p = 0.0049) or for (OR = 6.45, p < 0.0001) patients than their male counterparts., Conclusion: EMTs and paramedics did not perceive spiritual concerns as often as reported by ambulance patients, nor did they commonly inquire about the religious/spiritual needs of patients.

Background: The purpose of this study was to describe the regional locations of cardiac arrest, and to identify public locations and the annual incidence of arrests within the identified locations, in order to help to determine optimal placement of Automatic External Defibrillators (AEDs) under the regional Public Access Defibrillation (PAD) Program. This is a retrospective study., Methods: The locations of cardiac arrest were abstracted from Ambulance Call Reports (ACRs) collected by the Essex-Kent Base Hospital Centre from regional ambulance services throughout the City of Windsor, and the Counties of Essex and Kent, Ontario, Canada, from 01 January 1994 through 31 December 2000. Arrest locations were grouped into five categories, and then the number of public venues was determined. Public Sites were grouped into 28 Public Locations. Also included in the Public Sites were both General Industry and Outdoors categories. Categories identified but excluded from Public Sites were Institutions and Private Residences., Results: During the study, 2,295 arrests occurred, 152 cases were excluded, 2,142 arrests were categorized, (average annual incidence of 306 +/- 50.4 cardiac arrests), 329 (15.4%) of which were in Public Sites. Nineteen public venues had an average of > 1 arrest/year, and nine public venues had an average of < or = 1 arrest/year during the study, period. Calculations of the annual incidence of arrests for each public location were completed., Conclusions: These findings have significant prehospital emergency cardiac care implications for communities that wish to strengthen/improve their responses to out-of-hospital cardiac arrests. Public Access Defibrillation Programs should identify the site-specific incidence of arrest within their communities in order to provide legitimacy for funding and planning of programs. Training and availability of AEDs will reduce the time to first shock, thus strengthening the chain-of-survival and will save more lives.

Introduction: This descriptive research used a large, urban population-based data set for prehospital, emergency medical transports to examine racial/ethnic patterns of access and utilization for several broad categories of emergency medical transport services., Methods: Fire department files of approximately 39,000 reports on service provision were used to establish rates of transport utilization per 1,000 population in 1990, the most recent year for which reliable city-level census data were available. Data were categorized by three age groups (< 25 years, 25-64 years, > or = 65 years), three racial/ethnic groups (non-Hispanic whites, African-Americans, Hispanics), and gender. Transport rates were computed for total utilization, trauma incidents, and incidents due to medical conditions. Racial/ethnic rates were analyzed for each age and gender group and age- and gender-standardized rates were analyzed and presented in a graphical comparison. Statistical analyses of racial/ethnic differences were conducted using Tukey-type tests of multiple comparisons of proportions, with significant differences evaluated at the p = 0.001 level of significance., Results: Significant differences between racial/ethnic groups in the utilization of emergency transport services existed for all pair-wise comparisons including comparisons by each of the three age groups and gender. For total utilization, unadjusted rates are highest for African-Americans (65.9/1,000) and lowest for Hispanics (25.8/1.000). Likewise, African-American rates were substantially higher for both gender groups and across all age groups. Categorized by gender and age group under age > or = 65 years, non-Hispanic whites are observed to have the lowest rates for both males and females under the age 65 years, while Hispanics have the lowest rates in the group 65 years old However, when rates are age- and gender-standardized, compared to African-Americans and Hispanics, rates for non-Hispanic whites are significantly lower for total transports and for trauma and medically related transports (p = 0.001)., Conclusion: Age- and gender-standardized rates for emergency medical transport were found to be lowest for non-Hispanic, whites, moderately higher for Hispanics, and substantially higher for African-Americans, who experienced transport rates nearly three times higher than were the rates for non-Hispanic whites. Further research is required to establish the extent to which racial/ethnic differences observed in this geographically restricted study reflect variations between racial/ethnic groups in the underlying need for services.

Introduction: A comprehensive state-wide emergency medical services and helicopter transport system has been developed in the State of Maryland on the principle that early definitive care improves patient outcomes. The purpose of this study was to determine if empirical data exist to support the theory that air medical transportation services provided by the Maryland State Police (MSP) Aviation Division contribute to an improved trauma patient survival rate in Maryland., Methods: A retrospective study was conducted on the records of all patients transported by helicopter or ground ambulance and admitted to the R Adams Cowley Shock Trauma Center (STC) of the University of Maryland Medical System. Data were obtained from the Maryland Institute of Emergency Medical Services Systems (MIEMSS) Shock Trauma Clinical Registry for the period January 1988 through July 1995, covering 23,002 patients. Patients included those transported directly from the scene of injury to the STC as well as those from interfacility transfers. All patients were stratified by injury severity and compared by outcome (mortality) using Mantel-Haenszel statistics., Results: During the study period, 11,379 patients were transported by ground and 11,623 were transported by MSP helicopter. The mean Injury Severity Score (ISS) for patients transported by ground was 12.7 (SD = 12.52) and the mean ISS for patients transported by air was 14.6 (SD = 13.42), p < 0.001. Among patients classified as having a high index of injury severity, the mortality rate was lower among those transported by MSP helicopter than among those transported by ambulance. The mortality rate was significantly lower for air transported patient with an ISS higher than 31., Conclusion: The State of Maryland has demonstrated a commitment to its citizenry and invested heavily in its public safety air medical service. This study suggests the rapid air transport of victims of traumatic events by specialized personnel in Maryland has a positive effect on the outcome of severely injured patients. Further research is necessary to clarify the causal relationships in order to more fully elucidate the value of this resource.

Introduction: Determining the predictors of demand for emergency prehospital care can assist ambulance services in undertaking policy and planning activities., Hypothesis: Demand for prehospital care can be explained by demographic, health status, and economic determinants., Methods: The study used a cross-sectional design to investigate the association of demographic, health status, and insurance factors with the use of prehospital, ambulance care. Core data items including age, gender, marital status, country of origin, triage score, diagnosis, time of presentation, method of arrival, and patient disposition were collected for every patient who presented at the Emergency Department of the study hospital over a four-month period. Ambulance usage was analysed using Poisson regression., Results: For the 10,229 patients surveyed, only a small number were triaged as having the highest level of urgent medical need (0.8%), but the majority of these used prehospital emergency medical care (90.2%). Predictors of ambulance use included age > 65 years (Prevalence Ratio [PR] = 2.92; 95% confidence interval [CI]: 2.35-3.63), being married or in a de-facto relationship (PR = 0.69; 95% CI: 0.60-0.79) or divorced, separated, or widowed (PR = 0.83; 95% CI: 0.70-0.98), triage score level 1 or 2 (PR = 1.95; 95% CI: 1.68-2.28), or triage score level 3 (PR = 1.54; 95% CI: 1.38-1.72), diagnosis involving either mental (PR = 4.29; 95% CI: 1.84-10.01), nervous (PR = 2.74; 95% CI: 1.19-6.31) or trauma (PR = 2.33; 95% CI: 1.03-5.27) conditions, and insurance status (PR = 1.54; 95% CI: 1.40-1.71). Ethnicity, gender, and time of day were not associated with usage., Conclusion: Demand for ambulance services can be predicted by a number of demographic, medical status, and insurance variables. Age and triage levels are key influences on demand for ambulance services. Ambulance insurance status provides an economic incentive to use ambulance services regardless of the urgency of the medical condition.

Introduction: Emergency medical vehicle collisions (EMVCs) occurring during initial response and with patient transport have been a long-standing problem for emergency medical services (EMS) systems. Experience suggests "wake-effect" collisions occur as a result of an EMS vehicle's transit, but do not involve the emergency medical vehicle (EMV). Substantiating the existence and magnitude of wake-effect collisions may have major implications regarding the manner of EMV response., Hypothesis: Paramedics will report that wake-effect collisions do occur and that they occur more frequently than do EMVCs., Design: Survey analysis., Participants: Thirty paramedics employed by the Salt Lake City (Utah) Fire Department and 45 paramedics employed by Salt Lake County Fire Department. Geographic Area: Service area has population of 650,000 and is urban, suburban, and rural., Measurements: The survey consisted of three open-ended questions concerning years on the job, EMVCs, and wake-effect collisions., Analysis: The mean value for the number of EMVCs and wake-effect EMVCs, along with the 0.95 confidence intervals (0.95 CI) were determined., Results: Seventy-three surveys were analyzed. Sixty EMVCs and 255 wake-effect collisions were reported. Overall, the mean value for the number EMVCs per respondent was 0.82 (0.60-1.05) and for wake-effect collisions 3.49 (2.42-4.55). The mean values for EMVC's for each service were 0.86 (0.50-1.38); 0.80 (0.50-11.0). For wake-effect collisions the mean values were 4.59 (2.83-6.35); and 2.76 (1.46-4.06) respectively., Conclusions: This study suggests that the wake-effect collision is real and may occur with greater frequency than do EMVCs. Significant limitations of this study are recall bias and misclassification bias. Future studies are needed to define more precisely wake-effect collision prevalence and the resulting "cost" in regards to injury and vehicle/property damage.

Objective: As the role of paramedics evolves, evaluation of their ability to accomplish an expanded scope of practice is necessary. The objective of this study was to determine whether specially trained paramedics can monitor and treat patients appropriately during interfacility transports that traditionally have required the use of supplemental, hospital-based personnel., Methods: A paramedic-staffed mobile intensive care unit was developed as a cooperative program between Huron Valley Ambulance and the Washtenaw/Livingston County Medical Control Authority. This prospective observational study involved 111 patients requiring interfacility transport, conveyed by a paramedic-staffed mobile intensive care unit. A change in the Acute Physiologic and Chronic Health Evaluation (APACHE II) score components of mean arterial pressure, heart rate, and respiratory rate at the beginning and end of the transport was used to evaluate the ability of the paramedics to accomplish the transfer appropriately., Results: APACHE II scores increased in 20 patients, decreased in 16, and were unchanged in 75. The mean value for the change in APACHE score was 0.11 (95% confidence interval: -0.11-0.33)., Conclusion: Specially trained paramedics can monitor and treat patients appropriately during interfacility transfers that traditionally would have required supplementation with additional hospital staff.