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Purpose We examined changes in annual paramedic transport incidence over the ten years prior to COVID-19 in comparison to increases in population growth and emergency department (ED) visitation by walk-in. Methods We conducted a population-level cohort study using the National Ambulatory Care Reporting System from January 1, 2010 to December 31, 2019 in Ontario, Canada. We included all patients triaged in the ED who arrived by either paramedic transport or walk-in. We clustered geographical regions using the Local Health Integration Network boundaries. Descriptive statistics, rate ratios (RR), and 95% confidence intervals were calculated to explore population-adjusted changes in transport volumes. Results Overall incidence of paramedic transports increased by 38.3% (n = 264,134), exceeding population growth fourfold (9.4%) and walk-in ED visitation threefold (13.4%). Population-adjusted transport rates increased by 26.2% (rate ratio 1.26, 95% CI 1.26–1.27) compared to 3.4% for ED visit by walk-in (rate ratio 1.03, 95% CI 1.03–1.04). Patient and visit characteristics remained consistent (age, gender, triage acuity, number of comorbidities, ED disposition, 30-day repeat ED visits) across the years of study. The majority of transports in 2019 had non-emergent triage scores (60.0%) and were discharged home directly from the ED (63.7%). The largest users were persons aged 65 or greater (43.7%). The majority of transports occurred in urbanized regions, though rural and northern regions experienced similar paramedic transport growth rates. Conclusion There was a substantial increase in the demand for paramedic transportation. Growth in paramedic demand outpaced population growth markedly and may continue to surge alongside population aging. Increases in the rate of paramedic transports per population were not bound to urbanized regions, but were province-wide. Our findings indicate a mounting need to develop innovative solutions to meet the increased demand on paramedic services and to implement long-term strategies across provincial paramedic systems.

Introduction: Time-to-treatment plays a pivotal role in survival from sudden cardiac arrest (SCA). Every minute delay in defibrillation results in a 7-10% reduction in survival. This is particularly problematic in rural and remote regions, where bystander and EMS response is often prolonged and automated external defibrillators (AED) are often not available. Our objective was to examine the feasibility of a novel AED drone delivery method for rural and remote SCA. A secondary objective was to compare times between AED drone delivery and ambulance response to various mock SCA resuscitations. Methods: We conducted 6 simulations in two different rural communities in southern Ontario. During phase 1 (4 simulations) a “mock” call was placed to 911 and a single AED drone and an ambulance were simultaneously dispatched from the same location to a pre-determined destination. Once on scene, trained first responders retrieved the AED from the drone and initiated resuscitative efforts on a manikin. The second phase (2 scenarios) were done in a similar manner save for the drone being dispatched from a regionally optimized location for drone response. Results: Phase 1: The distance from dispatch location to scene varied from 6.6 km to 8.8 km. Mean (SD) response time from 911 call to scene arrival was 11.2 (+/- 1.0) minutes for EMS compared to 8.1 (+/- 0.1) for AED drone delivery. In all four simulations, the AED drone arrived before EMS, ranging from 2.1 to 4.4 minutes faster. The mean time for trained responders to retrieve the AED and apply it to the manikin was 35 (+/- 5) sec. No difficulties were encountered in drone activation by dispatch, drone lift off, landing or removal of the AED from the drone by responders. Phase 2: The ambulance response distance was 20km compared to 9km for the drone. Drones were faster to arrival at the scene by 7 minutes and 8 minutes with AED application 6 and 7 minutes prior to ambulance respectively. Conclusion: This implementation study suggests AED drone delivery is feasible with improvements in response time during a simulated SCA scenario. These results suggest the potential for AED drone delivery to decrease time to first defibrillation in rural and remote communities. Further research is required to determine the appropriate distance for drone delivery of an AED in an integrated EMS system as well as optimal strategies to simplify bystander application of a drone delivered AED.

Introduction: Despite recent advances in resuscitation, some patients remain in ventricular fibrillation (VF) after multiple defibrillation attempts during out-of-hospital cardiac arrest (OHCA). Vector change defibrillation (VC) and double sequential external defibrillation (DSED) have been proposed as alternate therapeutic strategies for OHCA patients with refractory VF. The primary objective was to determine the feasibility, safety and sample size required for a future cluster randomized controlled trial (RCT) with crossover comparing VC or DSED to standard defibrillation for patients experiencing refractory VF. Secondary objectives were to evaluate the intervention effect on VF termination and return of spontaneous circulation (ROSC). Methods: We conducted a pilot cluster RCT with crossover in four Canadian paramedic services and included all treated adult OHCA patients who presented in VF and received a minimum of three defibrillation attempts. In addition to standard cardiac arrest care, each EMS service was randomly assigned to provide continued standard defibrillation (control), VC or DSED. Services crossed over to an alternate defibrillation strategy after six months. Prior to the launch of the trial, 2,500 paramedics received in-person training for VC and DSED defibrillation using a combination of didactic, video and simulated scenarios. Results: Between March 2018 and September 2019, 152 patients were enrolled. Monthly enrollment varied from 1.4 to 6.1 cases per service. With respect to feasibility, 89.5% of cases received the defibrillation strategy they were randomly allocated to, and 93.1% of cases received a VC or DSED shock prior to the sixth defibrillation attempt. There were no reported cases of defibrillator malfunction, skin burns, difficulty with pad placement or concerns expressed by paramedics, patients, families, or ED staff about the trial. In the standard defibrillation group, 66.6% of cases resulted in VF termination, compared to 82.0% in VC and 76.3% of cases in the DSED group. ROSC was achieved in 25.0%, 39.3% and 40.0% of standard, VC and DSED groups, respectively. Conclusion: Findings from our pilot RCT suggest the DOSE VF protocol is feasible and safe. VF termination and ROSC were higher with VC and DSED compared to standard defibrillation. The results of this pilot trial will allow us to inform a multicenter cluster RCT with crossover to determine if alternate defibrillation strategies for refractory VF may impact patient-centered, clinical outcomes

Introduction: Community paramedic programs are being implemented to leverage existing resources and contribute to a sustainable patient-centered healthcare system. Expanding the role of paramedics into home care requires new collaborative relationships with healthcare providers such as nurses and physicians. Developing effective and productive collaborative relationships will enhance and support the integration of community paramedic programs. Our objective was to describe the barriers and facilitators to effective collaboration between nurses, physicians, and paramedics within home-based community paramedicine. Methods: We conducted semi-structured interviews with nurses, physicians, paramedics, and faculty who teach in paramedic programs. We explored the attitudes, perceptions, barriers, and enablers to collaboration in home-based community paramedic programs. Participants were recruited utilizing the professional networks of the researchers as well as snowball sampling. Recruitment in each group stopped when saturation was achieved. We conducted a thematic analysis of the interviews to generate findings related to our objectives. Results: We interviewed 33 participants with a typical cross-section of age, years of experience, and education. Overall, participants felt that collaboration was important for effective integration of community paramedics into home care and for ensuring a patient-centered approach to care. Currently, collaboration mostly occurs between physicians and paramedics and community paramedicine appears to be a siloed rather than integrated service. Few collaborative relationships exist between paramedics and nurses, despite the fact that nurses are highly involved in home care. We identified several barriers to effective collaboration including lack of understanding of the contributions of the different health providers, and regulatory and funding constraints. Inter-professional education that supports collaboration and facilitates dismantling of professional and service silos can support the effective integration of paramedics into home care. Conclusion: Strengthening networks of collaboration between nurses, physicians, and paramedics can help dismantle silos and enhance inter-professional collaboration to support appropriate integration of paramedics into home care. The willingness and positive attitudes for collaboration are assets that provide an excellent foundation upon which to move forward. Continuing education to support inter-professional collaboration is needed.

Introduction: Pediatric out-of-hospital cardiac arrest (OHCA) is unique in terms of epidemiology, treatment, and outcomes. There is a paucity of literature examining predictors of survival to help guide resuscitation in this population. Objective: The primary objective was to examine predictors of survival to hospital discharge. The secondary objective was to determine the probability of return of spontaneous circulation (ROSC) over the duration of resuscitation. Methods: We performed a retrospective cohort study of non-traumatic OHCA (Results: A total of 658 patients met inclusion criteria. Survival to discharge was 10.2% with 70.1% of those children having a good neurologic outcome. The overall median time to ROSC was 23.9 min. (IQR 15.0,36.7). However, the median time to ROSC for survivors was significantly shorter than the time to ROSC for patients who died in hospital (15.9 (IQR 10.6 to 22.8) vs. 33.2 (IQR 22.0 to 48.6); P value Conclusion: Inclusion of duration of resuscitation improved the performance of our model compared to Utstein factors alone. However, our results suggest there are a number of other important factors for predicting patient outcome from pediatric OHCA.

Introduction: High-quality cardiopulmonary resuscitation (CPR) is essential for patient survival. Typically, CPR quality is only measured during the first 10 minutes of resuscitation. There is limited research examining the quality of CPR over the entire duration of resuscitation.Objective: To examine the quality of CPR over the entire duration of resuscitation and correlate the quality of CPR to patient survival. Methods: This was a retrospective observational study using data from the Toronto RescuNET Epistry-Cardiac Arrest database. We included consecutive, adult (>18) OHCA treated by EMS between January 1, 2014 and September 30, 2015. High-quality CPR was defined, in accordance with 2015 AHA Guidelines, as a chest compression rate of 100-120/min, depth of 5.0-6.0 cm and chest compression fraction (ccf) of >0.80. We further categorized high-quality resuscitation as meeting benchmarks >80% of the time, moderate-quality between 50-80% and low-quality meeting benchmarks Results: A total of 5,208 OHCA met our inclusion criteria with a survival rate of 8%. The median (IQR) duration of resuscitation was 23.0 min (15.0,32.7). Overall CPR quality was considered high-quality for ccf in 81% of resuscitation episodes, 41% for rate, and 7% for depth. The percentage of resuscitations meeting the quality benchmarks differed between survivors and non-survivors for both depth (15% vs 6%) and ccf (61% vs 83%) (P value 80% showed a trend towards improved survival (OR 1.68, 95% CI 0.96, 2.92). Other variables associated with survival were public location, initial CPR by EMS providers or bystanders, witnessed cardiac arrest (EMS or bystander), and initial shockable rhythm. Increasing age and longer duration of resuscitation were associated with decreased survival. Conclusion: Overall, EMS providers were not able to maintain rate or depth within guideline recommendations for the majority of the duration of resuscitation. Maintaining chest compression depth for greater than 80% of the resuscitation showed a trend towards increased survival from OHCA.

Introduction: Cardiopulmonary resuscitation (CPR) quality assurance and research has traditionally been limited to the first five minutes of resuscitation due to significant costs in time, resources and personnel from manual data abstraction. Moreover, CPR quality can be affected during prolonged resuscitations, which represents significant knowledge gaps. The objective of this study was to develop a software program to help automate the abstraction of CPR quality data from electronic defibrillators. Methods: We developed a software program to facilitate and help automate data abstraction from electronic defibrillator files for entire resuscitation episodes. Internal validation of the software program was performed on 50 randomly selected cardiac arrest cases with resuscitation durations of up to 60 minutes. CPR quality data variables such as number of ventilations, number of compressions, minute compression rate, minute compression depth, minute compression fraction, minute end-tidal CO2, were manually abstracted independently by two trained data abstractors and by the automated software program. Error rates and the time needed for data abstraction were measured. Results: A total of 9826 data points were abstracted. Manual data abstraction resulted in a total of six errors (0.06%) compared to zero errors by the software program. The mean time ± SD needed for manual data abstraction was 20.3 ± 2.7 minutes compared to 5.3 ± 1.4 minutes using the software program (p=0.003). Conclusion: Our CPR quality data abstraction software was 100% accurate in abstracting CPR quality data for complete resuscitation episodes and showed a significant reduction in data abstraction duration. This software will enable quality assurance programs and future cardiac arrest studies to evaluate the impact of CPR quality during prolonged resuscitations.