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How much should ethnographers involve themselves with the people, places, and processes they study? One answer has become increasingly popular: invert the standard method of participant observation into observant participation. This article draws on an ethnography of ambulance work to consider the trade-offs between these approaches. My fieldwork included "ride-alongs" with labor and management at a private ambulance firm in California (participant observation) and short-term employment as a novice emergency medical technician at the same company (observant participation). Beyond a simplistic distinction in "empirical depth," I identify three issues at stake between participant observation and observant participation: field positioning, analytic gaze, and data assembly. Where participant observation presents more opportunities for mobile positioning, outward gazing, and inscription, observant participation presents more opportunities for fixed positioning, inward gazing, and incarnation. In addition to justifying such contrasts, I consider the advantages of mixing these styles into a hybrid approach when feasible. [ABSTRACT FROM AUTHOR]

Objective: The goal of this analysis is to spatiotemporally identify and categorize areas in a large urban city according to Out-of-Hospital Cardiac Arrest (OHCA) rates and No Bystander CPR (NBCPR) risk levels.Study Area and Participants: The study comprised all cardiac arrests within the administrative geographic boundary of the City of Los Angeles. The final sample included 15,904 cases that were geolocated within 985 census tracts.Main Outcomes and Measures: The primary outcome was stratification of census tracts into risk levels of OHCA and NBCPR by observed spatiotemporal patterns.Results: Of 985 census tracts in the analytical sample, 182 census tracts (18.5%) were identified as having higher risk of OHCA and NBCPR. This assessment resulted in 129 census tracts in Tier 3 (moderate risk), 36 in Tier 2 (moderate-high risk), and 17 in Tier 1 (highest risk). Census tracts in Tiers 2 and 3 had higher amounts incident OHCA, while those in tier 1 had more OHCA events with NBCPR. These areas were largely contiguous and located in the Central and South areas of Los Angeles.Conclusions: Using a novel three-tiered neighborhood risk classification tool, specific neighborhoods have been identified in the second largest city in the U.S. with consistently high or accelerating rates of OHCA and low bystander CPR. Further study of bystander response and community-based public health campaigns are needed in these communities. [ABSTRACT FROM AUTHOR]

Background: To address the growing number of low-acuity patients in the 911-EMS system, the Los Angeles Fire Department (LAFD) launched a pilot program placing an Advanced Provider Response Unit (APRU) in the field so that a prehospital nurse practitioner (NP) could offer patients treatment/release on scene, alternative destination transport, and linkage with social services. Objective: To describe the initial 18-month experience implementing this new APRU. Methods: This is a retrospective, descriptive review of all APRU-attended patients from January 2016 to June 2017. The APRU was an ambulance staffed by an NP and a firefighter/paramedic, equipped with basic point-of-care testing capability, and linked to incidents by either being summoned by on-scene first responders or by monitoring EMS radio traffic. Descriptive statistics were used and outcome measures included counts of clients attended, treat/release rates, impact on total time in service for other LAFD resources, patient need for subsequent re-use of 911 and self-reported experience of care. Results: During its first 18 months in service, the APRU attended 812 patients, including 792 911-patient incidents. 400 of these 911-patients (50.5%) were treated and released on scene or medically cleared and transported to an alternative site for specialty care. This included 76 patients with primary psychiatric complaints who were medically-cleared and transported directly to a mental health urgent care center. An additional 18 high utilizers of 911 were attended by the APRU and connected with a social work organization, and 12 of 18 (66.7%) decreased their use of EMS in the 90-days following APRU evaluation and referral. Of the 400 911-patients that did not go to the emergency department (ED), 26 (6.5%) re-contacted 911 within 3 days: all were transported to the ED with normal vital signs and without prehospital intervention, and all were ultimately discharged home from the ED. As a result of APRU intervention, 458 other LAFD field resources were quickly placed back in service and made available for the next time-critical call. Conclusions: Advanced practice providers such as nurse practitioners can be incorporated into the prehospital setting to address a growing subset of 911-patients whose needs can be met outside of the ED. [ABSTRACT FROM AUTHOR]

Objective: Out-of-network emergency department (ED) use, or use that occurs outside the contracted network, may lead to increased care fragmentation and cost. We examined factors associated with out-of-network ED use among Medicaid beneficiaries.Data Sources and Study Setting: Enrollment, claims, and encounter data for adult Medi-Cal health plan members with 1+ ED visits and complete Medicaid eligibility during the study period from 2013 to 2014.Study Design: We analyzed the data to identify factors associated with out-of-network ED use classified by mode of arrival (ambulance vs. nonambulance).Data Extraction Methods: We extracted encounter, ambulance, and ED census data and linked them together based on ED visit date.Principal Findings: Of 11,143 ED visits, 6,808 (61.1 percent) were out-of-network. The number of hours the study ED was on ambulance diversion increased the odds of out-of-network visits for the 3,365 (30.2 percent) ED visits arriving by ambulance. For all visit types, assignment to a primary care clinic at the in-network hospital and having had any primary care visit during the study period decreased the odds of out-of-network ED care. Individuals were more likely to go out-of-network for ED care if they lived in neighborhoods containing out-of-network EDs.Conclusions: There are a number of factors related to out-of-network ED use, including the proximity and density of out-of-network EDs, race and ethnicity, a prior history of out-of-network ED use, and individuals' connection to primary care. EDs that serve Medicaid beneficiaries may need to explore alternative sites and modalities of care as alternatives to the ED, and consider their ability to absorb large numbers of out-of-network visits given already limited capacity. [ABSTRACT FROM AUTHOR]

This article reimagines poverty governance as a labor process. Extending theories of bureaucratic fields and street-level bureaucracies, the proposed model suggests that the state manages the poor through fragmented activities embedded in horizontal and vertical relations of production. I use an ethnography of 911 ambulance operations in a single California county to advance this perspective. From plugging gunshot wounds to moving sidewalk slumberers, ambulance crews interact with a mostly impoverished clientele base by transforming spaces in bodies and bodies in spaces. This two-sided governance puts the ambulance in recurrent contact with the hospital emergency department and the police squad car. Across these institutions, ambulance crews struggle with their nurse and police counterparts over the horizontal shuffling of burdensome work, shaping the life chances of their subjects in the process. At the same time, bureaucratic and capitalistic forces from above activate a lean ambulance fleet that is minimally wasteful and highly flexible. This verticality structures clientele processing through the ambulance and fuels tensions across the frontlines of governance. In an effort to advance theory and fill an empirical gap, this article proposes a new model for understanding the management of marginality and highlights an overlooked case of poverty regulation. [ABSTRACT FROM AUTHOR]

Abstract: Background: Ambulance diversion is a national problem that affects more than half of all emergency departments (EDs). Although diversion was meant to be used for short periods of time to offer temporary relief to EDs, it has evolved into a normal routine in many communities to manage the growing problem of ED and hospital crowding. Study Objectives: To assess the impact of a collaborative effort to decrease ambulance diversion. Methods: This is a pre/post study investigating ED diversion in four emergency medical services agency regions in California from September 2006 through August 2008. Hospitals developed and implemented a number of best practices revolved around patient flow initiatives, specifically looking to improve input, throughput, and output. Monthly ED diversion data are compared and reported as means and standard deviations (SD). Results: During the study period, there were a total of 31,735 diversion hours in the collaborative regions, with 17,618 during the pre-consortium period and 14,117 in the post-consortium period (19.9% decrease). The monthly average hours of diversion before the consortium was 1468 (SD = 390.6). This decreased to 1176 (SD = 605.8) after the initiation of the consortium (difference of 292 h; 95% confidence interval 99–484; p = 0.007). There was a decrease in diversion hours for every month-to-month comparison except January and February (increases of 1% and 14.6%, respectively). Conclusion: This study suggests that a decrease in ambulance diversion can be achieved through ongoing collaboration and the implementation of best practices. Continued communication and emphasis on diversion are likely needed to sustain these decreases. [Copyright &y& Elsevier]

Importance: Intravenous alteplase is an effective treatment for acute ischemic stroke and is significantly underutilized. It is known that stroke centers with accreditation are more likely to provide intravenous alteplase treatment, and therefore, policies that increase the number of certified stroke centers and the number of acute ischemic stroke patients routed to these centers may be beneficial. Objective: To determine whether increasing access to primary stroke centers (regionalization) led to an increase in intravenous alteplase use in acute ischemic stroke patients. Design: An observational, longitudinal study to examine treatment trends with log-link binomial regression modeling to compare pre-post policy implementation changes in the proportions of patients treated with intravenous alteplase in two counties. Setting: Two urban counties, Santa Clara and San Mateo, in the western region of US that regionalized acute stroke care between 2005 and 2010. Participants: Patients with primary or secondary diagnosis of stroke were identified from the statewide patient discharge database by International Classification of Diseases (ICD-9) codes. We linked ambulance and hospital data to create complete patient care records. Main outcomes and measures: Stroke treatment, defined as a documented primary procedure code for intravenous alteplase administration (ICD-9: 99.10). Results: In Santa Clara County, intravenous alteplase was administered to 35 patients (1.7%) in the pre-regionalization period and 240 patients (2.1%) in the post-regionalization period. In San Mateo County, intravenous alteplase was administered to 29 patients (1.3%) in the pre-policy period and 135 patients (3.2%) in the post-policy period. After regionalization of stroke care, intravenous alteplase increased two-fold in San Mateo County [adjusted RR 2.20, p  = 0.003, 95% CI (1.31, 3.69)] but did not show any statistically significant change in Santa Clara County [adjusted RR 1.10, p  = 0.55, 95% CI (0.80, 1.51)]. In the post-regionalization phase, when compared with Santa Clara County, we found that San Mateo County had greater change in paramedic stroke detection, higher number of transports to primary stroke centers and more frequent use of intravenous alteplase at stroke centers. Conclusions: Our findings suggest that greater post-regionalization improvements in San Mateo County contributed to significantly better county-level thrombolysis use than Santa Clara County.