Search

INTRODUCTION: Estimates of the prevalence of drug-related out of hospital cardiac arrest (OHCA) vary, ranging from 1.8% to 10.0% of medical OHCA. However, studies conducted prior to the recent wave of fentanyl deaths likely underestimate the current prevalence of drug-related OHCA. We evaluated recent trends in drug-related OHCA, hypothesizing that the proportion of presumed drug-related OHCA treated by emergency medical services (EMS) has increased since 2015. METHODS: We conducted a retrospective analysis of OHCA patients treated by EMS providers in San Francisco, California between 2015 and 2023. Participants included OHCA cases in which resuscitation was attempted by EMS. The study exposure was the year of arrest. Our primary outcome was the occurrence of drug-related OHCA, defined as the EMS impression of OHCA caused by a presumed or known overdose of medication(s) or drug(s). RESULTS: From 2015 to 2023, 5044 OHCA resuscitations attended by EMS (average 561 per year) met inclusion criteria. The median age was 65 (IQR 50-79); 3508 (69.6%) were male. The EMS impression of arrest etiology was drug-related in 446/5044 (8.8%) of OHCA. The prevalence of presumed drug-related OHCA increased significantly each year from 1% in 2015 to 17.6% in 2023 (p-value for trend = 0.0001). After adjustment, presumed drug-related OHCA increased by 30% each year from 2015-2023. CONCLUSION: Drug-related OHCA is an increasingly common etiology of OHCA. In 2023, one in six OHCA was presumed to be drug related. Among participants less than 60 years old, one in three OHCA was presumed to be drug related.

Fentanyl-mixed and substituted heroin is well-documented, but less is known about unintentional fentanyl use among people using stimulants. To determine the prevalence of and racial and ethnic disparities in unintentional fentanyl use among people experiencing a medically attended opioid overdose, we reviewed 448 suspected non-fatal overdose cases attended by a community paramedic overdose response team in San Francisco from June to September 2022. We applied a case definition for opioid overdose to paramedic records and abstracted data on intended substance use prior to overdose. Among events meeting case criteria with data on intended substance use, intentional opioid use was reported by 57.3%, 98.0% of whom intended to use fentanyl. No intentional opioid use was reported by 42.7%, with most intending to use stimulants (72.6%), including methamphetamine and cocaine. No intentional opioid use was reported by 58.5% of Black, 52.4% of Latinx, and 28.8% of White individuals (p = 0.021), and by 57.6% of women and 39.5% of men (p = 0.061). These findings suggest that unintentional fentanyl use among people without opioid tolerance may cause a significant proportion of opioid overdoses in San Francisco. While intentional fentanyl use might be underreported, the magnitude of self-reported unintentional use merits further investigation to confirm this phenomenon, explore mechanisms of use and disparities by race and ethnicity, and deploy targeted overdose prevention interventions.

BackgroundCameroon is amongst the worst affected countries by road traffic injuries with an estimated 1443 disability-adjusted life years per 100,000 population. There have been very limited reports on the crucial prehospital response to road traffic injuries in Cameroon. This study aimed to identify prehospital factors associated with RTI mortality in Cameroon.MethodsWe included patients enrolled between June 2022 and March 2023 in the Cameroon Trauma Registry. Information about prehospital factors and demographic data was obtained from patients or their proxies. We examined the association of prehospital care factors like care at the crash scene and type of transportation during crash with final patient outcome. We used Chi-squared test to investigate the association between selected independent variables and mortality. A multivariable logistic regression model was built to identify independent predictors of dying from an RTI.ResultsRTIs constituted 69.5% (n = 3203) of all injuries in the Cameroon Trauma Registry. Only 20.7% (n = 102) of 4 + wheel vehicle occupants had seatbelts on and just 2.7% (n = 53) of motorcycle riders were wearing helmets during the collision. Only 4.9% (n = 156) of patients received any form of scene care. In-hospital mortality was 4.3% (n = 139) and was associated with male sex (AOR = 1.7, 95%CI = 1.08-2.80), crashing on a motorcycle (AOR = 2.08, 95%CI = 1.1-3.67) and scene care (AOR = 0.25, 95%CI = 0.04-0.80).ConclusionsReceiving any type of care at the scene such as bleeding control or being placed in the recovery position by bystanders is associated with improved survival. Improving on existing informal prehospital care responses should be a priority in Cameroon.

ImportanceThe incidence of opioid-associated out-of-hospital cardiac arrest (OA-OHCA) has grown from less than 1% of OHCA in 2000 to between 7% and 14% of OHCA in recent years; American Heart Association (AHA) protocols suggest that emergency medical service (EMS) clinicians consider naloxone in OA-OHCA. However, it is unknown whether naloxone improves survival in these patients or in patients with undifferentiated OHCA.ObjectiveTo evaluate the association of naloxone with clinical outcomes in patients with undifferentiated OHCA.Design, setting, and participantsRetrospective cohort study of EMS-treated patients aged 18 or older who received EMS treatment for nontraumatic OHCA in 3 Northern California counties between 2015 and 2023. Data were analyzed using propensity score-based models from February to April 2024.ExposureEMS administration of naloxone.Main outcomes and measuresThe primary outcome was survival to hospital discharge; the secondary outcome was sustained return of spontaneous circulation (ROSC). Covariates included patient and cardiac arrest characteristics (eg, age, sex, nonshockable rhythm, any comorbidity, unwitnessed arrest, and EMS agency) and EMS clinician determination of OHCA cause as presumed drug-related.ResultsAmong 8195 patients (median [IQR] age, 65 [51-78] years; 5540 male [67.6%]; 1304 Asian, Native Hawaiian, or Pacific Islander [15.9%]; 1119 Black [13.7%]; 2538 White [31.0%]) with OHCA treated by 5 EMS agencies from 2015 to 2023, 715 (8.7%) were believed by treating clinicians to have drug-related OHCA. Naloxone was administered to 1165 patients (14.2%) and was associated with increased ROSC using both nearest neighbor propensity matching (absolute risk difference [ARD], 15.2%; 95% CI, 9.9%-20.6%) and inverse propensity-weighted regression adjustment (ARD, 11.8%; 95% CI, 7.3%-16.4%). Naloxone was also associated with increased survival to hospital discharge using both nearest neighbor propensity matching (ARD, 6.2%; 95% CI, 2.3%-10.0%) and inverse propensity-weighted regression adjustment (ARD, 3.9%; 95% CI, 1.1%-6.7%). The number needed to treat with naloxone was 9 for ROSC and 26 for survival to hospital discharge. In a regression model that assessed effect modification between naloxone and presumed drug-related OHCA, naloxone was associated with improved survival to hospital discharge in both the presumed drug-related OHCA (odds ratio [OR], 2.48; 95% CI, 1.34-4.58) and non-drug-related OHCA groups (OR, 1.35; 95% CI, 1.04-1.77).Conclusions and relevanceIn this retrospective cohort study, naloxone administration as part of EMS management of OHCA was associated with increased rates of ROSC and increased survival to hospital discharge when evaluated using propensity score-based models. Given the lack of clinical practice data on the efficacy of naloxone in OA-OHCA and OHCA in general, these findings support further evaluation of naloxone as part of cardiac arrest care.

BACKGROUND: Pediatric patients transferred by Emergency Medical Services (EMS) from urgent care (UC) and office-based physician practices to the emergency department (ED) following activation of the 9-1-1 EMS system are an under-studied population with scarce literature regarding outcomes for these children. The objectives of this study were to describe this population, explore EMS level-of-care transport decisions, and examine ED outcomes. METHODS: This was a retrospective review of patients zero to

BACKGROUND: Globally, approximately 800 women and 6400 newborns die around the time of childbirth each day. Many of these deaths could be prevented with high-quality emergency obstetric and newborn care (EmONC). The Monitoring Emergency Obstetric Care: A handbook guides strengthening EmONC services. However, the handbook contains limited quality of care measures. Our study identified and prioritised quality of care indicators for potential inclusion in the handbook, which is undergoing revision. METHODS: We conducted a consultative scoping review, mapping, and prioritisation exercise to select a short list of indicators on facility-based maternal and newborn quality of care. Indicators were identified from literature searches and expert suggestions and organised by the categories of structure, process, and outcomes as defined in the World Health Organizations Standards for Improving Quality of Maternal and Newborn Care in Health Facilities. We focused on process indicators, encompassing the provision of care and experience of care during the intrapartum period, and developed a priority list of indicators using the selection criteria of relevance and feasibility. Experience of care indicators were also mapped against the Person-Centered Maternity Care (PCMC) scale. RESULTS: We extracted a total of 3023 quality of care indicators. After removing out-of-scope and duplicate indicators and applying our selection criteria, we identified 20 provision of care indicators for possible inclusion in the revised EmONC handbook. We recommend including a score for experience of care that could be measured with the 30-item or the 13-item PCMC scale. We also identified 29 experience of care items not covered by the PCMC scale that could be used. Provider experience, patient safety, and quality of abortion care were identified as areas for which no or few indicators were found through our scoping review. CONCLUSIONS: Through a rigorous, consultative, and multi-step process, we selected a short list of process-related, facility-based quality of care indicators for emergency obstetric and newborn care. This list could be included in the EmONC handbook or used for other monitoring purposes. Country consultations to assess the utility and feasibility of the proposed indicators and their adaptation to local contexts will support their refinement and uptake. REGISTRATION: https://osf.io/msxbd (Open Science Framework).

BackgroundLong-term follow-up for clinician-scientist training programs is sparse. We describe the outcomes of clinician-scientist scholars in the National Heart Lung and Blood Institute (NHLBI) K12 program in emergency care research up to 8.7 years after matriculation in the program.MethodsThis was a cohort study of faculty clinician-scientist scholars enrolled in a NHLBI K12 research training program at 6 sites across the US, with median follow-up 7.7 years (range 5.7-8.7 years) from the date of matriculation. Scholars completed electronic surveys in 2017 and 2019, with the 2019 survey collecting information for their current work setting, percent time for research, and grant funding from all sources. We used NIH RePorter and online resources to verify federal grants through March 2021. The primary outcome was a funded career development award (CDA) or research project grant (RPG) where the scholar was principal investigator. We included funding from all federal sources and national foundations.ResultsThere were 43 scholars, including 16 (37%) women. Over the follow-up period, 32 (74%) received an individual CDA or RPG, with a median of 36 months (range 9-83 months) after entering the program. Of the 43 scholars, 23 (54%) received a CDA and 22 (51%) received an RPG, 7 (16%) of which were R01s. Of the 23 scholars who received a CDA, 13 (56%) subsequently had an RPG funded. Time to CDA or RPG did not differ by sex (women vs. men log-rank test p = 0.27) or specialty training (emergency medicine versus other specialties, p = 0.59).ConclusionsAfter 7 years of follow-up for this NHLBI K12 emergency care research training program, three quarters of clinician-scientist scholars had obtained CDA or RPG funding, with no notable differences by sex or clinical training.

Background & Aims: Although most countries have long used female staff for prehospital emergency medical services (EMS), this is quite a recent development for the Iranian health system. It is hence necessary to analyze the perspectives of its recipients about the feasibility of assigning female staff to prehospital EMS to improve this service and compare it with other countries. This study aimed to design and evaluate the psychometric properties of a scale for assessing the feasibility of using female staff in prehospital EMS. Materials & Methods: This was a methodological study. The literature was reviewed to develop items for the scale. The scale's content validity index (CVI) was then evaluated based on expert opinions, and its face validity was examined by eliciting comments from the target group and experts. Following that, 456 EMS recipients from East Azerbaijan Province, Iran, completed the electronic version of the scale. Finally, the construct validity and reliability of this scale were determined using exploratory factor analysis (EFA) and internal consistency (Cronbach's alpha), respectively. Results: The findings confirmed the scale's high content validity and internal consistency, as well as its acceptable face validity. The EFA findings also revealed three factors, all of which were based on primary domains: the need for engagement (17 items), groundwork (14 items), and staffing (9 items). Conclusion: The study's findings suggested that the intended scale's design and psychometric properties were appropriate for Iranian culture. Therefore, it can be used to examine public opinion before, during, and after the inclusion of female personnel in prehospital EMS.

Background: A previous study on mechanical complications after central venous catheterisation demonstrated differences in complication rates between male and female operators. The objective of this subgroup analysis was to further investigate these differences. The hypothesis was that differences in distribution of predefined variables between operator genders could be identified. Methods: This was a subgroup analysis of a prospective, multicentre, observational cohort study conducted between March 2019 and December 2020 including 8 586 patients ≥ 16 years receiving central venous catheters at four emergency care hospitals. The main outcome measure was major mechanical complications defined as major bleeding, severe cardiac arrhythmia, pneumothorax, arterial catheterisation, and persistent nerve injury. Independent t-test and χ2 test were used to investigate differences in distribution of major mechanical complications and predefined variables between male and female operators. Multivariable logistic regression analysis was used to determine association between operator gender and major mechanical complications. Results: Female operators had a lower rate of major mechanical complications than male operators (0.4% vs 0.8%, P =.02), were less experienced (P <.001), had more patients with invasive positive pressure ventilation (P <.001), more often chose the internal jugular vein (P <.001) and more frequently used ultrasound guidance (P <.001). Male operators more often chose the subclavian vein (P <.001) and inserted more catheters with bore size ≥ 9 Fr (P <.001). Multivariable logistic regression analysis showed that male operator gender was associated with major mechanical complication (OR 2.67 [95% CI: 1.26–5.64]) after correction for other relevant independent variables. Conclusions: The hypothesis was confirmed as differences in distribution of predefined variables between operator genders were found. Despite being less experienced, female operators had a lower rate of major mechanical complications. Furthermore, male operator gender was independently associated with a higher risk of major mechanical complications. Future studies are needed to further investigate differences in risk behaviour between male and female operators. Trial registration: Clinicaltrials.gov identifier: NCT03782324. Date of registration: 20/12/2018. [ABSTRACT FROM AUTHOR]

Introduction: Menopause is a key workplace issue. Many women will experience symptoms through their later working life. The ambulance service constitutes an employment setting that, dependent on the roles of female staff, can impact on the severity of menopause symptoms and experiences (Prothero et al., 2021). This study aimed to explore female ambulance staff experiences of the menopause transition and suggest ways to improve support offerings. Methods: A qualitative interpretive approach was adopted, involving 12 UK ambulance services. Participants were identified via purposive sampling, and semi-structured interviews were conducted from February to July 2022 via an online platform or telephone. Recordings were transcribed verbatim and analysed using an inductive thematic approach. Results: Twenty-two female participants, aged between 42 and 62 years, were interviewed, and represented all phases of the menopause: peri-menopause (n = 9); menopause (n = 5); post-menopause (n = 3); and unsure (n = 5). Fourteen participants had front-line (patient-facing) or emergency operation centre-based roles, while seven were employed in service support roles. Ten themes were identified: impact on work role; awareness and preparedness for menopause transition; personal impact of symptoms; desired support; appropriate sickness and menopause policy; managerial development; compassion and dignity; impact of working environment; impact on safety; and lack of choice. Lack of understanding and support from colleagues and line managers were identified as the key issues. This is included under the managerial development and compassion and dignity themes. Conclusions: The varying range of menopausal symptoms and their severity impacted on women’s performance at work. The experience of working while going through the menopause could be challenging. Employers should adopt a menopause policy which includes training and awareness for all staff, and suitable for front-line as well as service support staff. There is a need to create a culture where the menopause is not taboo, and women feel able to talk about their symptoms. [ABSTRACT FROM AUTHOR]

IntroductionCoronavirus disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), has killed nearly 800,000 Americans since early 2020. The disease has disproportionately affected older Americans, men, persons of color, and those living in congregate living facilities. Sacramento County (California USA) has used a novel Mobile Integrated Health Unit (MIH) to test hundreds of patients who dwell in congregate living facilities, including skilled nursing facilities (SNF), residential care facilities (ie, assisted living facilities [ALF] and board and care facilities [BCF]), and inpatient psychiatric facilities (PSY), for SARS-CoV-2.MethodsThe MIH was authorized and rapidly created at the beginning of the COVID-19 pandemic as a joint venture between the Sacramento County Department of Public Health (SCDPH) and several fire-based Emergency Medical Services (EMS) agencies within the county to perform SARS-CoV-2 testing and surveillance in a prehospital setting at a number of congregate living facilities. All adult patients (≥18 years) who were tested for SARS-CoV-2 infection by the MIH from March 31, 2020 through April 30, 2020 and lived in congregate living facilities were included in this retrospective descriptive cohort. Demographic and laboratory data were collected to describe the cohort of patients tested by the MIH.ResultsDuring the study period, the MIH tested a total of 323 patients from 15 facilities in Sacramento County. The median age of patients tested was 66 years and the majority were female (72%). Overall, 72 patients (22%) tested positive for SARS-CoV-2 in congregate living settings, a higher rate of positivity than was measured across the county during the same time period.ConclusionThe MIH was a novel method of epidemic surveillance that succeeded in delivering effective and efficient testing to patients who reside in congregate living facilities and was able to accurately identify pockets of infection within otherwise low prevalence areas. Cooperative prehospital models are an effective model to deliver out-of-hospital testing and disease surveillance that may serve as a blueprint for community-based care delivery for a number of disease states and future epidemics or pandemics.

BackgroundPrehospital electrocardiogram(s) (ECG) can improve early detection of acute coronary syndrome (ST-segment elevation myocardial infarction [STEMI], non-STEMI, and unstable angina) and inform prehospital activation of cardiac catheterization lab; thus, reducing total ischemic time and improving patient outcomes. Less is known, however, about the association of prehospital ECG ischemic findings and long term adverse clinical events. With this in mind, this study was designed to examine the: 1) frequency of prehospital ECGs for acute myocardial ischemia (ST-elevation, ST-depression, and/or T-wave inversion); and, 2) whether any of these specific ECG features are associated with adverse clinical events within 30 day of initial presentation to the emergency department (ED).MethodsWe included consecutive patients ≥ 21 years during a five-year period (2013-2017), who were transported by ambulance to the ED with non-traumatic chest pain and/or anginal equivalent(s) and had a prehospital 12‑lead ECG. Two cardiologists (LG, EC), blinded to clinical data, interpreted the 12‑lead ECGs applying current guideline based ischemia criteria. Adverse clinical events, return to ED, and rehospitalization evaluated at 30-days.ResultsWe identified 3646 patients (mean age, 59.7 years ±15.7; 45% female) with ECGs, of which N = 3587 had data on the three ischemic markers of interest. Of these, 1762 (49.1%) had ECG evidence of ischemia. In adjusted logistic regression models, those with T-wave inversion had a higher odds (OR = 1.59) of new onset heart failure, while ST-elevation was associated with lower odds (OR = 0.69). Patients with ST-depression had higher odds of new onset heart failure and death within 30 days (OR = 1.29, 1.49 respectively), but this association attenuated after controlling for other ECG features.ConclusionsST-depression and/or T-wave inversion are independent predictors of new onset heart failure, within 30 days of initial ED presentation. Our study in a large cohort of patients, suggests that using ECG ST-elevation alone may not capture patients with ischemia who may benefit from aggressive anti-ischemic therapies to reduce myocardial damage with resultant heart failure.

BackgroundThe assessment and treatment of pediatric patients in the out-of-hospital environment often presents unique difficulties and stress for EMS practitioners.ObjectiveUse a mixed-methods approach to assess the current experience of EMS practitioners caring for critically ill and injured children, and the potential role of a simulation-based curriculum to improve pediatric prehospital skills.MethodsData were obtained from three sources in a single, urban EMS system: a retrospective review of local pediatric EMS encounters over one year; survey data of EMS practitioners' comfort with pediatric skills using a 7-point Likert scale; and qualitative data from focus groups with EMS practitioners assessing their experiences with pediatric patients and their preferred training modalities.Results2.1% of pediatric prehospital encounters were considered "critical," the highest acuity level. A total of 136 of approximately 858 prehospital providers responded to the quantitative survey; 34.4% of all respondents either somewhat disagree (16.4%), disagree (10.2%), or strongly disagree (7.8%) with the statement: "I feel comfortable taking care of a critically ill pediatric patient." Forty-seven providers participated in focus groups that resulted in twelve major themes under three domains. Specific themes included challenges in medication dosing, communication, and airway management. Participants expressed a desire for more repetition and reinforcement of these skills, and they were receptive to the use of high-fidelity simulation as a training modality.ConclusionsCritically ill pediatric prehospital encounters are rare. Over one third of EMS practitioners expressed a low comfort level in managing critically ill children. High-fidelity simulation may be an effective means to improve the comfort and skills of prehospital providers.

BackgroundPrehospital procedures (PHP) by emergency medical services (EMS) are performed regularly in penetrating trauma patients despite previous studies demonstrating no benefit. We sought to examine the influence of PHPs on outcomes in penetrating trauma patients in urban locations where transport to trauma center is not prolonged. We hypothesized that patients without PHPs would have better outcomes than those undergoing PHP.MethodsThis was an Eastern Association for the Surgery of Trauma-sponsored, multicenter, prospective, observational trial of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. The impact of PHPs and transport mechanism on in-hospital mortality were examined.ResultsOf 2,284 patients included, 1,386 (60.7%) underwent PHP. The patients were primarily Black (n = 1,527, 66.9%) males (n = 1,986, 87.5%) injured by gunshot wound (n = 1,510, 66.0%) with 34.1% (n = 726) having New Injury Severity Score of ≥16. A total of 1,427 patients (62.5%) were transported by Advanced Life Support EMS, 17.2% (n = 392) by private vehicle, 13.7% (n = 312) by police, and 6.7% (n = 153) by Basic Life Support EMS. Of the PHP patients, 69.1% received PHP on scene, 59.9% received PHP in route, and 29.0% received PHP both on scene and in route. Initial scene vitals differed between groups, but initial emergency department vitals did not. Receipt of ≥1 PHP increased mortality odds (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.01-1.83; p = 0.04). Logistic regression showed increased mortality with each PHP, whether on scene or during transport. Subset analysis of specific PHP revealed that intubation (OR, 10.76; 95% CI, 4.02-28.78; p < 0.001), C-spine immobilization (OR, 5.80; 95% CI, 1.85-18.26; p < 0.01), and pleural decompression (OR, 3.70; 95% CI, 1.33-10.28; p = 0.01) had the highest odds of mortality after adjusting for multiple variables.ConclusionPrehospital procedures in penetrating trauma patients impart no survival advantage and may be harmful in urban settings, even when performed during transport. Therefore, PHP should be forgone in lieu of immediate transport to improve patient outcomes.Level of evidencePrognostic, level III.

BackgroundDifferences in risk and protective factors (e.g., victimization, abuse, social support) have been used to explain elevated rates of suicidal ideation and suicide attempts in sexual minority youth (SMY) relative to heterosexual peers. However, little is known regarding how risk and protective factors may explain suicide risk differences among subgroups of SMY. The aims of this study were to 1) examine differences in prevalence and severity for suicide risk and protective factors among SMY, and 2) explore whether risk and protective factors are differentially associated with suicidal ideation and suicide attempts for SMY subgroups.MethodsParticipants were 6,423 adolescents (ages 12-17) recruited from 14 Emergency Departments across the United States who completed an assessment of suicide risk and protective factors. SMY were 20% of the sample (n = 1,275) and categorized as bisexual (8%), gay/lesbian (2%), mostly straight (5%), or other sexual minority (5%).ResultsBisexual youth had elevated rates of suicidal ideation and attempts, more risk factors (e.g., bullying victimization, depression), and fewer protective factors (e.g., parent-family connectedness, positive affect) relative to mostly straight and other sexual minority youth. Bisexual and gay/lesbian youth only differed in parent-family connectedness (lower among bisexual youth). Depression and parent-family connectedness had weaker associations with suicidal ideation for bisexual youth.LimitationsEmergency departments were not nationally representative. Study design was cross-sectional, preventing causal inferences.ConclusionsInterventions seeking to mitigate risk factors and promote protective factors are greatly needed for SMY and may benefit from tailoring to address unique stressors for sexual minority subgroups.

ObjectiveTo examine the use of benzodiazepines and the association between low benzodiazepine dose, breakthrough seizures, and respiratory support in patients with status epilepticus.MethodsIn this cross-sectional analysis of adult patients with status epilepticus treated by an emergency medical services agency from 2013 to 2018, the primary outcome was treatment with a second benzodiazepine dose, an indicator for breakthrough seizure. The secondary outcome was receiving respiratory support. Midazolam was the only benzodiazepine administered.ResultsAmong 2,494 patients with status epilepticus, mean age was 54.0 years and 1,146 (46%) were female. There were 1,537 patients given midazolam at any dose, yielding an administration rate of 62%. No patients received a dose and route consistent with national guidelines. Rescue therapy with a second midazolam dose was required in 282 (18%) patients. Higher midazolam doses were associated with lower odds of rescue therapy (odds ratio [OR], 0.8; 95% confidence interval [CI], 0.7-0.9) and were not associated with increased respiratory support. If anything, higher doses of midazolam were associated with decreased need for respiratory support after adjustment (OR, 0.9; 95% CI, 0.8-1.0).ConclusionsAn overwhelming majority of patients with status epilepticus did not receive evidence-based benzodiazepine treatment. Higher midazolam doses were associated with reduced use of rescue therapy and there was no evidence of respiratory harm, suggesting that benzodiazepines are withheld without clinical benefit.Classification of evidenceThis study provides Class III evidence that for patients with status epilepticus, higher doses of midazolam led to a reduced use of rescue therapy without an increased need for ventilatory support.

BackgroundIn-hospital ST-elevation myocardial infarction (STEMI) is associated with a higher mortality rate than out-of-hospital STEMI. Quality measures and universal protocols for treatment of in-hospital STEMI do not exist, likely contributing to delays in recognition and treatment.HypothesisTo analyze differences in mortality among three subsets of patients who develop in-hospital STEMI.MethodsThis was a multicenter, retrospective observational study of patients who developed in-hospital STEMI at six United States medical centers between 2008 and 2017. Patients were stratified into three groups: (1) cardiac, (2) periprocedure, or (3) noncardiac/nonpostprocedure. Outcomes examined include time from electrocardiogram (ECG) acquisition to cardiac catheterization lab arrival (ECG-to-CCL) and survival to discharge.ResultsWe identified 184 patients with in-hospital STEMI (mean age 68.7 years, 58.7% male). Group 1 (cardiac) patients had a shorter average ECG-to-CCL time (69 minutes) than group 2 (periprocedure, 215 minutes) and group 3 (noncardiac/nonpostprocedure, 199 minutes). Compared to group 1, survival to discharge was lower for group 2 (OR 0.33, P = .102) and group 3 (OR 0.20, P = .016). After adjusting for prespecified covariates, the relationship between group and survival showed a similar trend but did not reach statistical significance.ConclusionsPatients who develop in-hospital STEMI in the context of a preceding procedure or noncardiac illness appear to have longer reperfusion times and higher in-hospital mortality than patients admitted with cardiac diagnoses. Larger studies are warranted to further investigate these observations. Health systems should place an increased emphasis on developing quality metrics and implementing quality improvement initiatives to improve outcomes for in-hospital STEMI.

ObjectivesEmergency medicine in low- and middle-income countries (LMICs) is hindered by lack of research into patient outcomes. Chief complaints (CCs) are fundamental to emergency care but have only recently been uniquely codified for an LMIC setting in Uganda. It is not known whether CCs independently predict emergency unit patient outcomes.MethodsPatient data collected in a Ugandan emergency unit between 2009 and 2018 were randomized into validation and derivation data sets. A recursive partitioning algorithm stratified CCs by 3-day mortality risk in each group. The process was repeated in 10,000 bootstrap samples to create an averaged risk ranking. Based on this ranking, CCs were categorized as "high-risk" (>2× baseline mortality), "medium-risk" (between 2 and 0.5× baseline mortality), and "low-risk" (

BackgroundContinuing education is essential for healthcare workers. Education interventions can help to maintain and improve competency and confidence in the technical skills necessary to address adverse events. However, characteristics of the health provider such as age (related to more critical and reflexive attitude); sex (relationship with gender socialization), profession and work conditions might have an influence on the effect of continuing education efforts.MethodsA training in the management of obstetric and neonatal emergencies (PRONTO, Spanish acronym for Neonatal and Obstetric Rescue Program: Optimal and Timely treatment) was implemented in 14 hospitals in six Mexican states between 2013 and 2014, with a before-after evaluation design. A total of 351 health providers including physicians, interns, nurses and midwives completed the training and were included in the analytic sample. Mixed-effects regression models were fitted to model changes in knowledge and self-efficacy scores after the training for each training topic. Interaction terms of training with age, gender, profession, and shift were included to evaluate possible heterogeneities of effect. All models considered the within-hospital clustering of participants.ResultsAfter training, all participants showed a significant knowledge gain by an average of 19 percentage points for hemorrhage, 23 for neonatal resuscitation, 19 for shoulder dystocia, and 15 for preeclampsia/eclampsia (p

Background: Multiple anaphylaxis mediators have been demonstrated to provoke migraine‐like attacks following intravascular infusion, suggesting that anaphylaxis could cause headache; however, headache is rarely noted in anaphylaxis and is not included among diagnostic criteria. Objective: Our study objectives were to estimate the frequency of headache among prospectively enrolled emergency department (ED) patients with anaphylaxis and assess the association of headache with patient and anaphylaxis characteristics. Methods: A cross‐sectional study of ED patients aged ≥5 years who met anaphylaxis diagnostic criteria from January 8, 2020 to September 9, 2022 was conducted. The primary outcome of interest was headache frequency among patients who met at least one anaphylaxis criterion. We explored the association of headache with patient characteristics and anaphylaxis characteristics. Results: We included 63 patients with anaphylaxis. In all, 17 (27%, 95% confidence interval [CI] 17%–40%) patients reported the presence of a headache. Female patients had more than a nine times increased odds of having headache (odds ratio [OR] 9.3, 95% CI 1.14–77.1, p = 0.016). Presentation with headache was associated with the presence of dyspnea (OR 5.5, 95% CI 1.56–19.7, p = 0.006). Conclusion: Headache in anaphylaxis may be more common than previously recognized, especially in females. Larger prospective studies are needed to characterize headache as a marker of neurological involvement in anaphylaxis. [ABSTRACT FROM AUTHOR]

BACKGROUND: Routing patients directly to endovascular capable centers (ECCs) would decrease time to mechanical thrombectomy (MT), but may delay intravenous thrombolysis (IVT). OBJECTIVE: To study the clinical outcomes of patients with a stroke transferred directly to ECCs compared with those transferred to ECCs from non-endovascular capable centers (nECCs). METHODS: Data from the STRATIS registry were analyzed to evaluate process and clinical outcomes under five routing policies: (1) transport to nearest nECC; (2) transport to STRATIS ECC over any distance or (3) within 20 miles; (4) transport to ideal ECC (iECC), over any distance or (5) within 20 miles. RESULTS: Among 236 patients, 117 (49.6%) were transferred by ground, of whom 62 (53%) were transferred within 20 miles. Median MT start time was accelerated in all direct transport models. IVT start was prolonged with direct transport across all distances, but accelerated with direct transport to iECC ≤20 miles. With bypass limited to ≤20 miles, the median modeled EMS arrival to IVT interval decreased for both iECCs and ECCs (by 12 min and 6 min, respectively), and median EMS arrival to puncture time decreased by up to 94 min. In this cohort, no patient would have become ineligible for IVT. Bypass to iECC modeling under 20 miles showed a significant reduction in the level of disability at 3 months, with freedom from disability (modified Rankin Scale score 0-1) at 3 months increased by 12%. CONCLUSIONS: Direct routing of patients with a large vessel occlusion to ECCs, especially when within 20 miles, may lead to better clinical outcomes by accelerating the start of MT without any delay of IVT. CLINICAL TRIAL REGISTRATION NUMBER: http://www.clinicaltrials.gov. Unique identifier: NCT02239640.

BACKGROUND: We developed a culturally-adapted program (WE Stop the Bleed) to increase bleeding control knowledge and self-efficacy among Somali individuals, and to build trust between Somali individuals and first responders. METHODS: WE Stop the Bleed was piloted in the Seattle Somali community with first responders as skills coaches. The program included: 1) adapted ACS Stop the Bleed program; 2) cultural exchange. We evaluated knowledge, self-efficacy, and trust between Somali participants and first responders using a pre/post survey. RESULTS: Attendance exceeded a priori goals (27 community participants, 13 first responders). 96% of participants would recommend the training. Knowledge and self-efficacy improved pre/post (62%-72%, 65%-93% respectively). First responders indicated increased comfort with Somali individuals, and participants reported positive changes in perceptions of first responders. CONCLUSIONS: WE Stop the Bleed is a feasible and acceptable program to increase bleeding control knowledge and self-efficacy among participants and build trust between participants and first responders.

BACKGROUNDPrehospital plasma improves survival in severely injured patients transported by air ambulance. We hypothesized that prehospital plasma would be associated with a reduction in immune imbalance and endothelial damage.METHODSWe sampled blood from 405 trauma patients enrolled in the Prehospital Air Medical Plasma (PAMPer) trial upon hospital admission (0 hours) and 24 hours post admission across 6 U.S. sites. We assayed samples for 21 inflammatory mediators and 7 markers associated with endothelial function and damage. We performed hierarchical clustering analysis (HCA) of these biomarkers of the immune response and endothelial injury. Regression analysis was used to control for differences across study and to assess any association with prehospital plasma resuscitation.RESULTSHCA distinguished two patient clusters with different injury patterns and outcomes. Patients in cluster A had greater injury severity and incidence of blunt trauma, traumatic brain injury, and mortality. Cluster A patients that received prehospital plasma showed improved 30-day survival. Prehospital plasma did not improve survival in cluster B patients. In an adjusted analysis of the most seriously injured patients, prehospital plasma was associated with an increase in adiponectin, IL-1β, IL-17A, IL-23, and IL-17E upon admission, and a reduction in syndecan-1, TM, VEGF, IL-6, IP-10, MCP-1, and TNF-α, and an increase in IL-33, IL-21, IL-23, and IL-17E 24 hours later.CONCLUSIONPrehospital plasma may ameliorate immune dysfunction and the endotheliopathy of trauma. These effects of plasma may contribute to improved survival in injured patients.TRIAL REGISTRATIONNCT01818427.FUNDINGDepartment of Defense; National Institutes of Health, U.S. Army.

Background and Purpose- The prehospital setting is a promising site for therapeutic intervention in stroke, but current stroke screening tools do not account for the evolution of neurological symptoms in this early period. We developed and validated the Paramedic Global Impression of Change (PGIC) Scale in a large, prospective, randomized trial. Methods- In the prehospital FAST-MAG (Field Administration of Stroke Therapy-Magnesium) randomized trial conducted from 2005 to 2013, EMS providers were asked to complete the PGIC Scale (5-point Likert scale values: 1-much improved, 2-mildly improved, 3-unchanged, 4-mildly worsened, 5-much worsened) for neurological symptom change during transport for consecutive patients transported by ambulance within 2 hours of onset. We analyzed PGIC concurrent validity (compared with change in Glasgow Coma Scale, Los Angeles Motor Scale), convergent validity (compared with National Institutes of Health Stroke Scale severity measure performed in the emergency department), and predictive validity (of neurological deterioration after hospital arrival and of final 90-day functional outcome). We used PGIC to characterize differential prehospital course among stroke subtypes. Results- Paramedics completed the PGIC in 1691 of 1700 subjects (99.5%), among whom 635 (37.5%) had neurological deficit evolution (32% improvement, 5.5% worsening) during a median prehospital care period of 33 (IQR, 27-39) minutes. Improvement was associated with diagnosis of cerebral ischemia rather than intracranial hemorrhage, milder stroke deficits on emergency department arrival, and more frequent nondisabled and independent 3-month outcomes. Conversely, worsening on the PGIC was associated with intracranial hemorrhage, more severe neurological deficits on emergency department arrival, more frequent treatment with thrombolytic therapy, and poor disability outcome at 3 months. Conclusions- The PGIC scale is a simple, validated measure of prehospital patient course that has the potential to provide information useful to emergency department decision-making. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00059332.

ObjectiveTo test whether rapid expansion of mental health services in Federally Qualified Health Centers (FQHCs) reduces African American/white disparities in youth psychiatric emergency department (ED) visits.Data sourcesSecondary ED data for psychiatric care for 3.3 million African American and white youth in nine states, 2006-2011. We used the HCUP SEDD and SID. We obtained FQHC service data from the Uniform Data System.Study designThe psychiatric ED visit is the dependent variable. Logistic regression methods control for individual risk factors for ED use, as well as county-level health system factors and county and year fixed effects. Key independent variables include indicators of mental health service capacity in FQHCs in a county-year.Data extraction methodsWe extracted ED psychiatric visits for 3.3 million African American and white youth in nine states, 2006-2011, from the HCUP SEDD and SID, and FQHC data from the Uniform Data System.Principal findingsOverall mental health visits at FQHCs correlate positively with psychiatric ED visits among African American youth. However, increases in the number of mental health visits per FQHC patient corresponds with fewer outpatient psychiatric ED visits among African American youth, relative to white youth (odds ratio = 0.96; 95% CI = 0.94, 0.98).ConclusionsIncreases in the intensity of services offered per mental health patient at FQHCs-rather than increases in overall capacity-may reduce African American youth's overreliance on the ED for psychiatric care.

Objective: To evaluate the accuracy of emergency medical services (EMS) provider judgment for traumatic intracranial hemorrhage (tICH) in older patients following head trauma in the field. We also compared EMS provider judgment with other sets of field triage criteria. Methods: This was a prospective observational cohort study conducted with five EMS agencies and 11 hospitals in Northern California. Patients 55 years and older who experienced blunt head trauma were transported by EMS between August 1, 2015 and September 30, 2016, and received an initial cranial computed tomography (CT) imaging, were eligible. EMS providers were asked, "What is your suspicion for the patient having intracranial hemorrhage (bleeding in the brain)?" Responses were recorded as ordinal categories (5-10%, >10-50%, or >50%) and the incidences of tICH were recorded for each category. The accuracy of EMS provider judgment was compared to other sets of triage criteria, including current field triage criteria, current field triage criteria plus multivariate logistical regression risk factors, and actual transport. Results: Among the 673 patients enrolled, 319 (47.0%) were male and the median age was 75 years (interquartile range 64-85). Seventy-six (11.3%) patients had tICH on initial cranial CT imaging. The increase in EMS provider judgment correlated with an increase in the incidence of tICH. EMS provider judgment had a sensitivity of 77.6% (95% CI 67.1-85.5%) and a specificity of 41.5% (37.7-45.5%) when using a threshold of 1% or higher suspicion for tICH. Current field triage criteria (Steps 1-3) was poorly sensitive (26.3%, 95% CI 17.7-37.2%) in identifying tICH and current field trial criteria plus multivariate logistical regression risk factors was sensitive (97.4%, 95% CI 90.9-99.3%) but poorly specific (12.9%, 95% CI 10.4-15.8%). Actual transport was comparable to EMS provider judgment (sensitivity 71.1%, 95% CI 60.0-80.0%; specificity 35.3%, 95% CI 31.6-38.3%). Conclusions: As EMS provider judgment for tICH increased, the incidence for tICH also increased. EMS provider judgment, using a threshold of 1% or higher suspicion for tICH, was more accurate than current field triage criteria, with and without additional risk factors included.

BackgroundPotassium disturbances are associated with adverse prognosis in patients with chronic conditions. Its prognostic implications in stable patients attending the emergency department (ED) is poorly described.AimsThis study aimed to assess the prevalence of dyskalemia, describe its predisposing factors and prognostic associations in a population presenting the ED without unstable medical illness.MethodsPost-hoc analysis of a prospective, cross-sectional, multicenter study in the ED of 11 French academic hospitals over a period of 8 weeks. All adults presenting to the ED during this period were included, except instances of self-drug poisoning, inability to complete self-medication questionnaire, presence of an unstable medical illness and decline to participate in the study. All-cause hospitalization or deaths were assessed.ResultsA total of 1242 patients were included. The mean age was 57.2±22.3 years, 51% were female. The distribution according to potassium concentrations was: hypokalemia5mmol/L(n = 73, 0,6%). The proportion of patients with a kalemia

BackgroundPotassium disturbances are associated with adverse prognosis in patients with chronic conditions. Its prognostic implications in stable patients attending the emergency department (ED) is poorly described.AimsThis study aimed to assess the prevalence of dyskalemia, describe its predisposing factors and prognostic associations in a population presenting the ED without unstable medical illness.MethodsPost-hoc analysis of a prospective, cross-sectional, multicenter study in the ED of 11 French academic hospitals over a period of 8 weeks. All adults presenting to the ED during this period were included, except instances of self-drug poisoning, inability to complete self-medication questionnaire, presence of an unstable medical illness and decline to participate in the study. All-cause hospitalization or deaths were assessed.ResultsA total of 1242 patients were included. The mean age was 57.2±22.3 years, 51% were female. The distribution according to potassium concentrations was: hypokalemia5mmol/L(n = 73, 0,6%). The proportion of patients with a kalemia

Background and Purpose- Pilot trials suggest that glyceryl trinitrate (GTN; nitroglycerin) may improve outcome when administered early after stroke onset. Methods- We undertook a multicentre, paramedic-delivered, ambulance-based, prospective randomized, sham-controlled, blinded-end point trial in adults with presumed stroke within 4 hours of ictus. Participants received transdermal GTN (5 mg) or a sham dressing (1:1) in the ambulance and then daily for three days in hospital. The primary outcome was the 7-level modified Rankin Scale at 90 days assessed by central telephone treatment-blinded follow-up. This prespecified subgroup analysis focuses on participants with an intracerebral hemorrhage as their index event. Analyses are intention-to-treat. Results- Of 1149 participants with presumed stroke, 145 (13%; GTN, 74; sham, 71) had an intracerebral hemorrhage: time from onset to randomization median, 74 minutes (interquartile range, 45-110). By admission to hospital, blood pressure tended to be lower with GTN as compared with sham: mean, 4.4/3.5 mm Hg. The modified Rankin Scale score at 90 days was nonsignificantly higher in the GTN group: adjusted common odds ratio for poor outcome, 1.87 (95% CI, 0.98-3.57). A prespecified global analysis of 5 clinical outcomes (dependency, disability, cognition, quality of life, and mood) was worse with GTN; Mann-Whitney difference, 0.18 (95% CI, 0.01-0.35; Wei-Lachin test). GTN was associated with larger hematoma and growth, and more mass effect and midline shift on neuroimaging, and altered use of hospital resources. Death in hospital but not at day 90 was increased with GTN. There were no significant between-group differences in serious adverse events. Conclusions- Prehospital treatment with GTN worsened outcomes in patients with intracerebral hemorrhage. Since these results could relate to the play of chance, confounding, or a true effect of GTN, further randomized evidence on the use of vasodilators in ultra-acute intracerebral hemorrhage is needed. Clinical Trial Registration- URL: http://www.controlled-trials.com. Unique identifier: ISRCTN26986053.

High-occupancy hospitals may be sensitive to neighboring emergency department (ED) closures and openings, as they already operate at or near capacity. We conducted a retrospective analysis using data for the period 2001-13 to examine outcomes of and treatment received by patients with acute myocardial infarction at so-called bystander EDs that had been exposed to nearby ED closures or openings. We used changes in driving time between an ED and the next-closest one as a proxy for a closure or opening: If driving time increased, for instance, it meant that a nearby ED had closed. When a high-occupancy ED was exposed to a closure that resulted in increased driving time of thirty minutes or more to the next-closest ED, one-year mortality and thirty-day readmission rates increased by 2.39 and 2.00 percentage points, respectively, while the likelihood of receiving percutaneous coronary intervention (PCI) declined by 2.06 percentage points. Exposure to ED openings that resulted in decreased driving times of thirty minutes or more was associated with reductions in thirty-day mortality at bystander hospitals and an increased likelihood of receiving PCI. Our findings suggest that limited resources at high-occupancy bystander hospitals make them sensitive to changes in the availability of emergency care in neighboring communities.

While significant literature exists on hospital-based "code calls," there is a lack of research on calls for help in the operating room (OR). The purpose of this study was to quantify the rate and nature of calls for help in the OR of a tertiary care hospital. For a 1-year period, all calls were recorded in the main OR at The University of California, Irvine Medical Center. The average rate of calls per 1000 anesthesia hours was 1.4 (95% CI, 1.1-1.8), corresponding to a rate of 5.0 (3.8-6.5) calls per 1000 cases. Airway (44%), cardiac (32%), and hemorrhagic (11%) emergencies were the most common etiologies. Thirty-day mortality approached 11% for patients who required a call for help in the OR.

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.

BackgroundHistorically, hemorrhage has been attributed as the leading cause (40%) of early death. However, a rigorous, real-time classification of the cause of death (COD) has not been performed. This study sought to prospectively adjudicate and classify COD to determine the epidemiology of trauma mortality.MethodsEighteen trauma centers prospectively enrolled all adult trauma patients at the time of death during December 2015 to August 2017. Immediately following death, attending providers adjudicated the primary and contributing secondary COD using standardized definitions. Data were confirmed by autopsies, if performed.ResultsOne thousand five hundred thirty-six patients were enrolled with a median age of 55 years (interquartile range, 32-75 years), 74.5% were male. Penetrating mechanism (n = 412) patients were younger (32 vs. 64, p < 0.0001) and more likely to be male (86.7% vs. 69.9%, p < 0.0001). Falls were the most common mechanism of injury (26.6%), with gunshot wounds second (24.3%). The most common overall primary COD was traumatic brain injury (TBI) (45%), followed by exsanguination (23%). Traumatic brain injury was nonsurvivable in 82.2% of cases. Blunt patients were more likely to have TBI (47.8% vs. 37.4%, p < 0.0001) and penetrating patients exsanguination (51.7% vs. 12.5%, p < 0.0001) as the primary COD. Exsanguination was the predominant prehospital (44.7%) and early COD (39.1%) with TBI as the most common later. Penetrating mechanism patients died earlier with 80.1% on day 0 (vs. 38.5%, p < 0.0001). Most deaths were deemed disease-related (69.3%), rather than by limitation of further aggressive care (30.7%). Hemorrhage was a contributing cause to 38.8% of deaths that occurred due to withdrawal of care.ConclusionExsanguination remains the predominant early primary COD with TBI accounting for most deaths at later time points. Timing and primary COD vary significantly by mechanism. Contemporaneous adjudication of COD is essential to elucidate the true understanding of patient outcome, center performance, and future research.Level of evidenceEpidemiologic, level II.

Importance:In 40 of 50 US states, scheduled dialysis is withheld from undocumented immigrants with end-stage renal disease (ESRD); instead, they receive intermittent emergency-only dialysis to treat life-threatening manifestations of ESRD. However, the comparative effectiveness of scheduled dialysis vs emergency-only dialysis and the influence of treatment on health outcomes, utilization, and costs is uncertain. Objective:To compare the effectiveness of scheduled vs emergency-only dialysis with regard to health outcomes, utilization, and costs in undocumented immigrants with ESRD. Design, Setting, and Participants:Observational cohort study of 181 eligible adults with ESRD receiving emergency-only dialysis in Dallas, Texas, who became newly eligible and applied for private commercial health insurance in February 2015; 105 received coverage and were enrolled in scheduled dialysis; 76 were not enrolled in insurance for nonclinical reasons (eg, lack of capacity at a participating outpatient dialysis center) and remained uninsured, receiving emergency-only dialysis. We examined data on eligible persons during a 6-month period prior to enrollment (baseline period, August 1, 2014-January 31, 2015) until 12 months after enrollment (follow-up period, March 1, 2015-February 29, 2016), with an intervening 1-month washout period (February 2015). All participants were undocumented immigrants; self-reported data on immigration status was collected from Parkland Hospital electronic health records. Exposures:Enrollment in private health insurance coverage and scheduled dialysis. Main Outcomes and Measures:We used enrollment in health insurance and scheduled dialysis to estimate the influence of scheduled dialysis on 1-year mortality, utilization, and health care costs, using a propensity score-adjusted, intention-to-treat approach, including time-to-event analyses for mortality, difference-in-differences (DiD) negative binomial regression analyses for utilization, and DiD gamma generalized linear regression for health care costs. Results:Of 181 eligible adults with ESRD, 105 (65 men, 40 women; mean age, 45 years) received scheduled dialysis and 76 (38 men, 38 women; mean age, 52 years) received emergency-only dialysis. Compared with emergency-only dialysis, scheduled dialysis was significantly associated with reduced mortality (3% vs 17%, P = .001; absolute risk reduction, 14%; number needed to treat, 7; adjusted hazard ratio, 4.6; 95% CI, 1.2-18.2; P = .03), adjusted emergency department visits (-5.2 vs +1.1 visits/mo; DiD, -6.2; P

Statements about building walls, deportation and denying services to undocumented immigrants made during President Trump's presidential campaign and presidency may induce fear in Latino populations and create barriers to their health care access. To assess how these statements relate to undocumented Latino immigrants' (UDLI) and Latino legal residents/citizens' (LLRC) perceptions of safety and their presentations for emergency care, we conducted surveys of adult patients at three county emergency departments (EDs) in California from June 2017 to December 2018. Of 1,684 patients approached, 1,337 (79.4%) agreed to participate: 34.3% UDLI, 36.9% LLRC, and 29.8% non-Latino legal residents/citizens (NLRC). The vast majority of UDLI (95%), LLRC (94%) and NLRC (85%) had heard statements about immigrants. Most UDLI (89%), LLRC (88%) and NLRC (87%) either thought that these measures were being enacted now or will be enacted in the future. Most UDLI and half of LLRC reported that these statements made them feel unsafe living in the US, 75% (95% CI 70-80%) and 51% (95% CI 47-56%), respectively. More UDLI reported that these statements made them afraid to come to the ED (24%, 95% CI 20-28%) vs LLRC (4.4%, 95% CI 3-7%) and NLRC (3.5%, 95% CI 2-6%); 55% of UDLI with this fear stated it caused them to delay coming to the ED (median delay 2-3 days). The vast majority of patients in our California EDs have heard statements during the 2016 presidential campaign or from President Trump about measures against undocumented immigrants, which have induced worry and safety concerns in both UDLI and LLRC patients. Exposure to these statements was also associated with fear of accessing emergency care in some UDLIs. Given California's sanctuary state status, these safety concerns and ED access fears may be greater in a nationwide population of Latinos.

Study objectivePatients with acute psychiatric emergencies who receive an involuntary hold often spend hours in the emergency department (ED) because of a deficit in inpatient psychiatric beds. One solution to address the lack of prompt psychiatric evaluation in the ED has been to establish regional stand-alone psychiatric emergency services. However, patients receiving involuntary holds still need to be screened and evaluated to ensure that their behavior is not caused by an underlying and life-threatening nonpsychiatric illness. Although traditional regional emergency medical services (EMS) systems depend on the medical ED for this function, a field-screening protocol can allow EMS to directly transport a substantial portion of patients to a stand-alone psychiatric emergency service. The purpose of this investigation is to describe overall EMS use for patients receiving involuntary holds, compare patients receiving involuntary holds with all EMS patients, and evaluate the safety of field medical clearance of an established field-screening protocol in Alameda County, CA.MethodsWe obtained data for all EMS encounters between November 1, 2011, and November 1, 2016, using Alameda County's standardized data set. After unique patient identification, we describe the data at the patient level and at the encounter level. At the patient level, we compare "involuntary hold patients" (≥1 involuntary hold during the study period) with those who were "never held." Additionally, we assess the safety of out-of-hospital medical clearance by calculating the rate of failed diversion, defined as retransport of a patient to a medical ED within 12 hours of transport to the psychiatric emergency services by EMS.ResultsOf the 541,731 total EMS encounters in Alameda County during the study period, 10% (N=53,887) were identified as involuntary hold encounters. Of these involuntary hold patient encounters, 41% (N=22,074) resulted in direct transport of the patient to the stand-alone psychiatric emergency service for evaluation; 0.3% (N=60) failed diversion and required retransport within 12 hours. At the patient level, Alameda County EMS encountered 257,625 unique patients, and 10% (N=26,283) had at least one encounter for an involuntary hold during the study period. These "involuntary hold patients" were substantially younger, more likely to be men, and less likely to be insured. Additionally, they had higher overall EMS use: "involuntary hold patients" accounted for 24% of all encounters (N=128,003); 53,887 of these encounters were for involuntary holds, whereas an additional 74,116 were for other reasons. Similarly, 4% of "involuntary hold patients" had 20 or more encounters, whereas only 0.4% of "never held" patients were in this category. Last, the 7% of "involuntary hold patients" (N=1,907) who received greater than or equal to 5 involuntary holds during the study period accounted for 39% of all involuntary holds and 9% of all EMS encounters.ConclusionTen percent of all EMS encounters were for involuntary psychiatric holds. With an EMS-directed screening protocol, 41% of all such patient encounters resulted in direct transport of the patient to the psychiatric emergency service, bypassing medical clearance in the ED. Overall, only 0.3% of these patients required retransport to a medical ED within 12 hours of arrival to psychiatric emergency services. We found that 24% of all EMS encounters in Alameda County were attributable to "involuntary hold patients," reinforcing the importance of the effects of mental illness on EMS use.

BackgroundOpioid overdose deaths have increased exponentially in the United States. Bystander response to opioid overdose ideally involves administering naloxone, providing rescue breathing, and calling 911 to summon emergency medical assistance. Recently in the US, public health and public safety agencies have begun seeking to use 911 calls as a method to identify and deliver post-overdose interventions to opioid overdose patients. Little is known about the opinions of PWUDs about the barriers, benefits, or potential harms of post-overdose interventions linked to the 911 system. We sought to understand the perspectives of PWUDs about a method for using 911 data to identify opioid overdose cases and trigger a post-overdose intervention.Methods and findingsWe conducted three focus groups with 11 PWUDs in 2018. Results are organized into 4 categories: willingness to call 911 (benefits and risks of calling), thoughts about a technique to identify opioid overdoses in 911 data (benefits and concerns), thoughts about the proposed post-overdose intervention (benefits and concerns), and recommendations for developing an ideal post-overdose intervention. For most participants, calling 911 was synonymous with "calling the police" and law enforcement-related fears were pervasive, limiting willingness to engage with the 911 system. The technique to identify opioid overdoses and the proposed post-overdose intervention were identified as potentially lifesaving, but the benefits were balanced by concerns related to law enforcement involvement, intervention timing, and risks to privacy/reputation. Nearly universally, participants wished for a way to summon emergency medical assistance without triggering a law enforcement response.ConclusionsThe fact that the 911 system in the US inextricably links emergency medical assistance with law enforcement response inherently problematizes calling 911 for PWUDs, and has implications for surveillance and intervention. It is imperative to center the perspectives of PWUDs when designing and implementing interventions that rely on the 911 system for activation.

BACKGROUND:Heatwaves have been linked to increased risk of mortality and morbidity and are projected to increase in frequency and intensity due to climate change. The current study uses emergency department (ED) data from Australia, Botswana, Netherlands, Pakistan, and the United States of America to evaluate the impact of heatwaves on ED attendances, admissions and mortality. METHODS:Routinely collected time series data were obtained from 18 hospitals. Two separate thresholds (≥4 and ≥7) of the acclimatisation excess heat index (EHIaccl) were used to define "hot days". Analyses included descriptive statistics, independent samples T-tests to determine differences in case mix between hot days and other days, and threshold regression to determine which temperature thresholds correspond to large increases in ED attendances. FINDINGS:In all regions, increases in temperature that did not coincide with time to acclimatise resulted in increases in ED attendances, and the EHIaccl performed in a similar manner. During hot days in California and The Netherlands, significantly more children ended up in the ED, while in Pakistan more elderly people attended. Hot days were associated with more patient admissions in the ages 5-11 in California, 65-74 in Karachi, and 75-84 in The Hague. During hot days in The Hague, patients with psychiatric symptoms were more likely to die. The current study did not identify a threshold temperature associated with particularly large increases in ED demand. INTERPRETATION:The association between heat and ED demand differs between regions. A limitation of the current study is that it does not consider delayed effects or influences of other environmental factors. Given the association between heat and ED use, hospitals and governmental authorities should recognise the demands that heat can place on local health care systems. These demands differ substantially between regions, with Pakistan being the most heavily affected within our study sample.

ContextPain may be a potentially modifiable risk factor for expensive and burdensome emergency department (ED) visits near the end of life for older adults with dementia.ObjectivesThe objective of this study was to assess the effect of pain and unmet need for pain management on ED visits in the last month of life in older adults with dementia.MethodsThis is a mortality follow-back study of older adults with dementia in the National Health and Aging Trends Study who died between 2012 and 2014, linked to Medicare claims.ResultsTwo hundred eighty-one National Health and Aging Trends Study decedents with dementia met criteria (mean age 86 years, 61% female, 81% white). Fifty-seven percent had at least one ED visit in the last month of life, and 46.5% had an ED visit that resulted in a hospital admission. Almost three out of four (73%) of decedents experienced pain in the last month of life, and 10% had an unmet need for pain management. After adjustment for age, gender, race, educational attainment, income, comorbidities, and impairment in activities of daily living, pain was not associated with increased ED use in the last month of life (adjusted incident rate ratio 0.87, 95% CI 0.64-1.17). However, decedents with unmet need for pain management had an almost 50% higher rate of ED visits in the last month of life than those without unmet needs (adjusted incident rate ratio 1.46, 95% CI 1.07-1.99).ConclusionAmong older adults with dementia, unmet need for pain management was associated with more frequent ED visits in the last month of life.

BackgroundGlobally, an estimated 275,000 maternal deaths, 2.7 million neonatal deaths, and 2.6 million third trimester stillbirths occurred in 2015. Major improvements could be achieved by providing effective care in low- and middle-income countries, where the majority of these deaths occur. Mentoring programs have become a popular modality to improve knowledge and skills among providers in low-resource settings. Thus, a detailed understanding of interrelated factors affecting care provision and mentorship is necessary both to improve the quality of care and to maximize the impact of mentoring programs.MethodsIn partnership with the Government of Bihar, CARE India and PRONTO International implemented simulation-enhanced mentoring in 320 primary health clinics (PHC) across the state of Bihar, India from 2015 to 2017, within the context of the AMANAT mobile nurse mentoring program. Between June and August 2016, we conducted semi-structured interviews with 20 AMANAT nurse mentors to explore barriers and facilitators to optimal care provision and to implementation of simulation-enhanced mentorship in PHCs in Bihar. Data were analyzed using the thematic content approach.ResultsMentors identified numerous factors affecting care provision and mentorship, many of which were interdependent. Such barriers included human resource shortages, nurse-nurse hierarchy, distance between labor and training rooms, cultural norms, and low skill level and resistance to change among mentees. In contrast, physical resource shortages, doctor-nurse hierarchy, corruption, and violence against providers posed barriers to care provision alone. Facilitators included improved skills and confidence among providers, inclusion of doctors in training, increased training frequency, establishment of strong mentor-mentee relationships, administrative support, and nursing supervision and feedback.ConclusionsThis study has identified many interrelated factors affecting care provision and mentorship in Bihar. The mentoring program was not designed to address several barriers, including resource shortages, facility infrastructure, corruption, and cultural norms. These require government support, community awareness, and other systemic changes. Programs may be adapted to address some barriers beyond knowledge and skill deficiencies, notably hierarchy, violence against providers, and certain cultural taboos. An in-depth understanding of barriers and facilitators is essential to enable the design of targeted interventions to improve maternal and neonatal survival in Bihar and related contexts.

BackgroundHaemorrhagic shock is the leading cause of early preventable death in severe trauma. Delayed treatment is a recognized prognostic factor that can be prevented by efficient organization of care. This study aimed to develop and validate Red Flag, a binary alert identifying blunt trauma patients with high risk of severe haemorrhage (SH), to be used by the pre-hospital trauma team in order to trigger an adequate intra-hospital standardized haemorrhage control response: massive transfusion protocol and/or immediate haemostatic procedures.MethodsA multicentre retrospective study of prospectively collected data from a trauma registry (Traumabase®) was performed. SH was defined as: packed red blood cell (RBC) transfusion in the trauma room, or transfusion ≥ 4 RBC in the first 6 h, or lactate ≥ 5 mmol/L, or immediate haemostatic surgery, or interventional radiology and/or death of haemorrhagic shock. Pre-hospital characteristics were selected using a multiple logistic regression model in a derivation cohort to develop a Red Flag binary alert whose performances were confirmed in a validation cohort.ResultsAmong the 3675 patients of the derivation cohort, 672 (18%) had SH. The final prediction model included five pre-hospital variables: Shock Index ≥ 1, mean arterial blood pressure ≤ 70 mmHg, point of care haemoglobin ≤ 13 g/dl, unstable pelvis and pre-hospital intubation. The Red Flag alert was triggered by the presence of any combination of at least two criteria. Its predictive performances were sensitivity 75% (72-79%), specificity 79% (77-80%) and area under the receiver operating characteristic curve 0.83 (0.81-0.84) in the derivation cohort, and were not significantly different in the independent validation cohort of 2999 patients.ConclusionThe Red Flag alert developed and validated in this study has high performance to accurately predict or exclude SH.

Abdullah Mohammed Alobaid,1,2 Abdulmajeed Mobrad,3 Cameron Gosling,2 Lisa McKenna,4 Brett Williams2 1Prince Sultan bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Kingdom of Saudi Arabia; 2Department of Paramedicine, Faculty of Medicine, Nursing and Health Sciences Monash University, Melbourne, Victoria, Australia; 3Department of Emergency Medical Services, Prince Sultan bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Kingdom of Saudi Arabia; 4La Trobe University, School of Nursing and Midwifery, Melbourne, Victoria, AustraliaCorrespondence: Abdullah Mohammed AlobaidPrince Sultan bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Kingdom of Saudi Arabia, Tel +966533336396, Email a.alobaid33@gmail.comIntroduction: Although emergency medical services (EMS) stakeholders acknowledge the need for both male and female paramedics in the EMS field, the Saudi EMS system is currently only staffed by male paramedics and emergency medical technicians (EMTs) working in EMS organisations.Aim: To understand and explore the Saudi Arabian community’s perceptions on engaging Saudi female paramedics in the EMS workforce.Material and Methods: This was a cross-sectional survey design using convenience sampling of the public in Riyadh city by self-administered English and Arabic language questionnaires. Questionnaire validity was assessed by face and content validity.Results: Of the 3603 surveys distributed, 3132 were returned (87% completion response rate). Most respondents were aged between 18 and 29 years (n = 1308, 41%), and the sex distribution was (n = 1646, 52.6%) male and (n = 1486, 47.4%) female. Overall, 77% (n = 2412) of the respondents supported the need for female paramedics in Saudi Arabian ambulance services, and 74.8% (n = 2343) preferred that female paramedics treated female patients.Conclusion: This is the first public study to explore Saudi public perceptions about female paramedics in EMS in the Riyadh region, Saudi Arabia. The Saudi public is supportive of female paramedics being employed as paramedics in the country. Moreover, significant differences in perceptions were evidenced in the sex groups over any other factors.Keywords: emergency medical services, female, paramedic, public perception, Saudi Arabia

The ESCAPED (Examining Sickle Cell Acute Pain in the Emergency vs Day Hospital) trial is an ongoing prospective study comparing outcomes of people with sickle cell disease (SCD) seeking care for acute pain management in either an emergency department or specialty infusion clinic. The objective of this paper is to describe the baseline characteristics and health care utilization of patients in the trial. This is a multicenter study across 4 US cities that enrolled all adults with SCD living within 60 miles (96.6 km) of a study site who were expected to have acute care utilization over the study period. Twenty-one percent of participants had no acute care visits in the first 12 months of follow-up. Using negative binomial regression, we describe subject characteristics that predict acute care utilization. Three hundred ninety-one subjects have completed 12 months of follow-up with a mean age of 34.5 years (standard deviation, 11.4), 60% are female. Fifty-four percent of subjects with hemoglobin SS disease and 46% with hemoglobin SC disease had 3 or more acute visits over the study period. The prevalence of chronic pain in this cohort was 68%. Predictors of higher rates of acute care utilization included being unemployed, having chronic pain, being on chronic transfusion therapy, having a history of stroke, and being on disability or on Medicaid. This is the first prospective cohort in the modern era, and it demonstrates much higher rates of acute care utilization than reported in the Cooperative Study of Sickle Cell Disease.

While significant literature exists on hospital-based "code calls," there is a lack of research on calls for help in the operating room (OR). The purpose of this study was to quantify the rate and nature of calls for help in the OR of a tertiary care hospital. For a 1-year period, all calls were recorded in the main OR at The University of California, Irvine Medical Center. The average rate of calls per 1000 anesthesia hours was 1.4 (95% CI, 1.1-1.8), corresponding to a rate of 5.0 (3.8-6.5) calls per 1000 cases. Airway (44%), cardiac (32%), and hemorrhagic (11%) emergencies were the most common etiologies. Thirty-day mortality approached 11% for patients who required a call for help in the OR.

Although the number of older adults who are arrested and subject to incarceration in jail is rising dramatically, little is known about their emergency department (ED) use or the factors associated with that use. This lack of knowledge impairs the ability to design evidence-based approaches to care that would meet the needs of this population. This 6-month longitudinal study aimed to determine the frequency of 6-month ED use among 101 adults aged 55 or older enrolled while in jail and to identify factors associated with that use. The primary outcome was self-reported emergency department use within 6 months from baseline. Additional measures included baseline socio-demographics, physical and mental health conditions, geriatric factors (e.g., recent falls, incontinence, functional impairment, concern about post-release safety), symptoms (pain and other symptoms), and behavioral and social health risk factors (e.g., substance use disorders, recent homelessness). Chi-square tests were used to identify baseline factors associated with ED use over 6 months. Participants (average age 60) reported high rates of multimorbidity (61%), functional impairment (57%), pain (52%), serious mental illness (44%), recent homelessness (54%), and/or substance use disorders (69%). At 6 months, 46% had visited the ED at least once; 21% visited multiple times. Factors associated with ED use included multimorbidity (p = 0.01), functional impairment (p = 0.02), hepatitis C infection (p = 0.01), a recent fall (p = 0.03), pain (p

ObjectiveTo examine current trends in the characteristics of patients visiting California emergency departments (EDs) in order to better direct the allocation of acute care resources.DesignA retrospective study.SettingWe analysed ED utilisation trends between 2005 and 2015 in California using non-public patient data from California's Office of Statewide Health Planning and Development.ParticipantsWe included all ED visits in California from 2005 to 2015.Primary and secondary outcome measuresWe analysed ED visits and visit rates by age, sex, race/ethnicity, payer and urban/rural trends. We further examined age, sex, race/ethnicity and urban/rural trends within each payer group for a more granular picture of the patient population. Additionally, we looked at the proportion of patients admitted from the ED and distribution of diagnoses.ResultsBetween 2005 and 2015, the annual number of ED visits increased from 10.2 to 14.2 million in California. ED visit rates increased by 27.8% (p

BackgroundAre 9-1-1 ambulances relatively late to poorer neighborhoods? Studies suggesting so often rely on weak measures of neighborhood (e.g., postal zip code), limit the analysis to particular ambulance encounters (e.g., cardiac arrest responses), and do little to account for variations in dispatch priority or intervention severity.MethodsWe merged EMS ambulance contact records in a single California county (n = 87,554) with tract-level data from the American Community Survey (n = 300). After calculating tract-level median ambulance response time (MART), we used ordinary least squares (OLS) regression to estimate a conditional average relationship between neighborhood poverty and MART and quantile regression to condition this relationship on 25th, 50th, and 75th percentiles of MART. We also specified each of these outcomes by five dispatch priorities and by three intervention severities. For each model, we estimated the associated changes in MART per 10 percentage point increase in tract-level poverty while adjusting for emergency department proximity, population density, and population size.ResultsOur study produced three major findings. First, most of our tests suggested tract-level poverty was negatively associated with MART. Our baseline OLS model estimates that a 10 percentage point increase in tract-level poverty is associated with almost a 24 s decrease in MART (-23.55 s, 95% confidence interval [CI] -33.13 to -13.98). Results from our quantile regression models provided further evidence for this association. Second, we did not find evidence that ambulances are relatively late to poorer neighborhoods when specifying MART by dispatch priority. Third, we were also unable to identify a positive association between tract-level poverty and MART when we specified our outcomes by three intervention severities. Across each of our 36 models, tract-level poverty was either not significantly associated with MART or was negatively associated with MART by a magnitude smaller than a full minute per estimated 10 percentage point increase in poverty concentration.ConclusionOur study challenges the commonly held assumption that ambulances are later to poor neighborhoods. We scrutinize our findings before cautiously considering their relevance for ambulance response time research and for ongoing conversations on the relationship between neighborhood poverty and prehospital care.

BACKGROUND:Excessive alcohol consumption is associated with a substantial number of emergency department visits annually and is responsible for a significant number of lives lost each year in the United States. However, a minimal amount is known about the impact of alcohol on the EMS system. OBJECTIVES:The primary objective was to determine the proportion of 9-1-1 calls in Denver, Colorado in which (1) alcohol was a contributing factor or (2) the individual receiving EMS services had recently ingested alcohol. The secondary objectives were to compare the characteristics of EMS calls and to estimate the associated costs. METHODS:This was a prospective observational cohort study of EMS calls for adults from July 1, 2012, to June 30, 2014. Primary outcomes for the study were alcohol as a contributing factor to the EMS call and recent alcohol consumption by the patient receiving EMS services. Logistic regression was utilized to determine the associations between EMS call characteristics and the outcomes. Cost was estimated using historic data. RESULTS:During the study period, 169,642 EMS calls were completed by the Denver Health Paramedic Division. Of these 71% were medical and 29% were trauma-related. The median age was 45 (interquartile range [IQR] 29-59) years, and 55% were male. 50,383 calls (30%) had alcohol consumption, and 49,165 (29%) had alcohol as a contributing factor. Alcohol related calls were associated with male sex, traumatic injuries including head trauma, emergent response, use of airway adjuncts, cardiac monitoring, glucose measurement, use of restraints, use of spinal precautions, and administration of medications for sedation. Estimated costs to the EMS system due to alcohol intoxication exceeded $14 million dollars over the study period and required in excess of 37 thousand hours of paramedic time. CONCLUSIONS:Compared to 9-1-1 calls that do not involve alcohol, alcohol-related calls are more likely to involve male patients, emergent response, traumatic injuries, advanced monitoring, airway adjuncts, and medications for sedation. This represents a significant burden on the emergency system and society. Further studies are needed to evaluate whether additional interventions such as social services could be used to lessen this burden.

BACKGROUND:A significant increase in false positive ST-elevation myocardial infarction (STEMI) electrocardiogram interpretations was noted after replacement of all of the City of San Diego's 110 monitor-defibrillator units with a new brand. These concerns were brought to the manufacturer and a revised interpretive algorithm was implemented. OBJECTIVES:This study evaluated the effects of a revised interpretation algorithm to identify STEMI when used by San Diego paramedics. METHODS:Data were reviewed 6 months before and 6 months after the introduction of a revised interpretation algorithm. True-positive and false-positive interpretations were identified. Factors contributing to an incorrect interpretation were assessed and patient demographics were collected. RESULTS:A total of 372 (234 preimplementation, 138 postimplementation) cases met inclusion criteria. There was a significant reduction in false positive STEMI (150 preimplementation, 40 postimplementation; p

OBJECTIVES:This study considers whether, in an easy access single-payer health care system, patients placed on outpatient commitment-community treatment orders (CTOs) in Victoria Australia-are more likely to access acute medical care addressing physical illness than voluntary patients with and without severe mental illness. METHOD:For years 2000 to 2010, the study compared acute medical care access of 27,585  severely mentally ill psychiatrically hospitalized patients (11,424 with and 16,161 without CTO exposure) and 12,229 never psychiatrically hospitalized outpatients (individuals with less morbidity risk as they were not considered to have severe mental illness). Logistic regression was used to determine the influence of the CTO on the likelihood of receiving a diagnosis of physical illness requiring acute care. RESULTS:Validating their shared and elevated morbidity risk, 53% of each hospitalized cohort accessed acute care compared to 32% of outpatients during the decade. While not under mental health system supervision, however, the likelihood that a CTO patient would receive a physical illness diagnosis was 31% lower than for non-CTO patients, and no different from lower morbidity-risk outpatients without severe mental illness. While, under mental health system supervision, the likelihood that CTO patients would receive a physical illness diagnosis was 40% greater than non-CTO patients and 5.02 times more likely than outpatients were. Each CTO episode was associated with a 4.6% increase in the likelihood of a member of the CTO group receiving a diagnosis. CONCLUSION:Mental health system involvement and CTO supervision appeared to facilitate access to physical health care in acute care settings for patients with severe mental illness, a group that has, in the past, been subject to excess morbidity and mortality.