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Background: The High-STEACS (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome) pathway risk stratifies emergency department patients with possible acute coronary syndrome. This study aims to determine if the High-STEACS hs-cTnT (high-sensitivity cardiac troponin T) pathway can achieve the ≥99% negative predictive value (NPV) safety threshold for 30-day cardiac death or myocardial infarction (CDMI) in a multisite US cohort of patients with and without known coronary artery disease (CAD)., Methods: A secondary analysis of the STOP-CP (High-Sensitivity Cardiac Troponin T [Gen 5 STAT Assay] to Optimize Chest Pain Risk Stratification) cohort, which enrolled adult emergency department patients with possible acute coronary syndrome at 8 US sites (January 25, 2017-September 6, 2018). Participants were classified into outpatient and admission dispositions using the High-STEACS hs-cTnT pathway. Known CAD was defined as prior MI, coronary revascularization, or ≥70% coronary stenosis. Outcomes included 30-day CDMI and efficacy, defined as the proportion identified for outpatient disposition. NPVs and negative likelihood ratios for 30-day CDMI were calculated. NPVs were compared between CAD subgroups using a Fisher exact test., Results: Among 1351 patients, 53.2% (719/1351) were male, 31.4% (424/1351) had known CAD, and the mean age was 57.4±12.8 years. At 30 days, CDMI occurred in 13.8% (187/1351). High-STEACS classified 63.4% (857/1351) to outpatient disposition, of which 2.0% (17/857) had 30-day CDMI, corresponding to an NPV of 98.0% (95% CI, 96.8-98.8) and negative likelihood ratio of 0.13 (95% CI, 0.08-0.20). In patients with CAD, 46.9% (199/424) were classified to outpatient disposition, of which 4.0% (8/199) had 30-day CDMI. Among patients without CAD, 71.0% (658/927) were classified to outpatient disposition with 1.4% (9/658) having 30-day CDMI. The NPV for 30-day CDMI was 96.0% (95% CI, 92.2-98.2) in patients with CAD versus 98.6% (95% CI, 97.4-99.4) among patients without CAD ( P =0.04). The negative likelihood ratio for 30-day CDMI among patients with CAD was 0.16 (95% CI, 0.08-0.31) and 0.12 (95% CI, 0.06-0.22) among patients without CAD., Conclusions: The High-STEACS hs-cTnT pathway had high efficacy but was unable to achieve the ≥99% NPV safety threshold for 30-day CDMI., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02984436., Competing Interests: Dr Ashburn receives funding from the National Heart, Lung, and Blood Institute (NHLBI; K23HL169929), Agency for Healthcare Quality and Research, Health Resources and Services Administration (R01HS029017), and the Emergency Medicine Foundation. Dr Snavely receives funding from NHLBI (K23HL169929), Abbott, HRSA (1H2ARH399760100), AHRQ (R01HS029017 and R21HS029234), and the Emergency Medicine Foundation. Dr Supples receives funding from the National Institutes of Health (NIH; UL1TR001420), AHRQ (R01HS029017), and the National Foundation of Emergency Medicine. Dr Mahler receives funding/support from Roche Diagnostics, Abbott Laboratories, QuidelOrtho, Siemens, Grifols, Pathfast, Beckman Coulter, Genetesis, Cytovale, National Foundation of Emergency Medicine, BlueJay Diagnostics, Duke Endowment, the Emergency Medicine Foundation, Brainbox, HRSA (1H2ARH399760100), and AHRQ (R01HS029017 and R21HS029234). He is a consultant for Roche, QuidelOrtho, Abbott, Siemens, Inflammatix, and Radiometer and is the Chief Medical Officer for Impathiq, Inc. Dr Allen receives research funding/support from Roche Diagnostics, Siemens, and Beckman Coulter. He is a consultant for Roche Diagnostics, Beckman Coulter, and Abbott. Dr Mumma has research support from the NIH (5K08HL130546) and Roche Diagnostics. Dr Wilkerson received research funding from Regeneron Pharmaceuticals, Inc, Lilly USA, LLC, BioAge Labs, Inc, Roche Diagnostics, Global Blood Therapeutics, Inc, Novartis Pharmaceuticals, Egetis Therapeutics AB, Endpoint Health, Inc, Blade Therapeutics, Janssen R&D LLC, ProvePharma, the National Foundation of Emergency Medicine, and Pfizer, Inc. He has received research funding from CoapTech, LLC through an NIH/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) grant (R44DK115325). He has received research support in the form of equipment and supplies from Cepheid and Eldon Biologicals A/s. He is an uncompensated advisor to CSL Behring. Dr Christenson is a consultant for and receives funding/support from Roche Diagnostics, Siemens Healthineers, Beckman Coulter Diagnostics, Becton Dickinson and Co, Quidel Corp, and Sphingotec GMBH. The other authors report no conflicts.

Background: Heterogeneity is observed in the care of patients with chest pain. We investigate the association of physician specialty and diagnostic testing among patients admitted for suspected acute coronary syndrome (ACS)., Methods: This is a secondary analysis of the CMR-IMPACT multicenter randomized controlled trial in which patients with suspected ACS were admitted and randomized to undergo invasive angiography or non-invasive CMR stress imaging. Admitting physician was dichotomized to interventional cardiologist (IC) or not (e.g. hospitalist). We describe adherence to protocol and angiography during the index visit by treatment arm and admitting physician specialty. A generalized estimating equation accounting for clustering within physician was used to evaluate significance and adjusted for randomization arm., Results: The 258 enrolled patients from 2013 to 2018 had a mean age of 60.7 (SD ± 10.9) years, 40.3 % (104/258 were female), and 64.7 % (167/258) were white race. ICs were the admitting physicians for 50.4 % (130/258) of the patients. Index angiography was performed more often among patients admitted by IC versus other physicians, 65.4 % (85/130) versus 53.1 % (68/128), respectively; aOR 1.75 (95 % CI 1.14-2.68). Among patients randomized to an invasive strategy, higher protocol adherence was observed in those admitted by IC [85.3 % (58/68)] versus other physicians [64.5 % (40/62)]; OR 2.82 (95 % CI 1.08-7.38). For patients randomized to the CMR-based strategy, adherence to protocol was similar for IC [67.7 % (42/62)] and other physicians [66.7 % (44/66)]; OR 0.82 (95 % CI 0.35-1.94)., Conclusion: Invasive angiography was more frequent among patients admitted by interventional cardiologists compared to other physicians., Competing Interests: Declaration of competing interest Dr. Supples receives funding from the National Foundation of Emergency Medicine, the SIREN Network, and AHRQ (R21HS029234). Dr. Snavely receives funding from Abbott Laboratories, HRSA (1H2ARH399760100), AHRQ (R01HS029017 and R21HS029234), and the Emergency Medicine Foundation. Dr. Ashburn receives funding from NHLBI (K23HL169929), AHRQ (R01HS029017), and the Emergency Medicine Foundation. Dr. Stopyra receives research funding from National Center for Advancing Translational Sciences (NCATS)/National Institutes of Health (NIH) (KL2TR001421), HRSA (H2ARH39976–01-00), NHLBI (U01HL123027), Roche Diagnostics, and Abbott Point of Care. He has provided paid consulting to Roche Diagnostics. Dr. Hiestand receives research funding from Siemens.Dr. Caterino receives research funding from National Institute on Aging (NIA)/NIH. Dr. Mahler receives funding/support from Roche Diagnostics, Abbott Laboratories, Quidel, Siemens, Grifols, Pathfast, Beckman Coulter, Genetesis, Cytovale, National Foundation of Emergency Medicine, Duke Endowment, Brainbox, BlueJay Diagnostics, Reprieve Cardiovascular, HRSA (1H2ARH399760100), and AHRQ (R01HS029017 and R21HS029234). He is a consultant for Roche, Quidel, Abbott, Siemens, Polymedco, Inflammatix, and Radiometer and is the Chief Medical Officer for Impathiq Inc. Dr. Miller received research funding from Abbott, Research Triangle Institute (RTI) International (COVID-related), and Gifols Therapeutics (COVID-related). The other authors report no conflicts., (Copyright © 2025 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: The History, Electrocardiogram, and Troponin (HET) score is a simplified alternative to the HEART score for risk stratifying emergency department (ED) patients with chest pain. This study evaluates the safety and efficacy of the HET score for 30-day cardiac death or myocardial infarction (MI)., Methods: We conducted a secondary analysis of the STOP-CP multisite cohort study. Risk score components were determined prospectively by the treating provider. Patients were classified into low-, intermediate-, and high-risk strata based on HEART and HET scores. Negative predictive value (NPV) was calculated for the primary safety outcome of cardiac death or MI at 30 days. Consistent with prior studies, the commonly accepted threshold of NPV ≥ 99 % was used to define safety. Efficacy was the proportion of patients classified as low risk. NPV and efficacy were compared between HET and HEART scores using generalized score statistic and McNemar's test, respectively., Results: Among 1460 patients, 46.3 % (676/1460) were women and the mean age was 57.6 ± 12.8 years. Cardiac death or MI at 30 days occurred in 12.7 % (186/1460). Among patients with a low-risk HET score, 1.4 % (4/286) experienced 30-day cardiac death or MI, while 2.2 % (12/534) of patients with a low-risk HEART score had 30-day cardiac death or MI. This yielded a NPV for 30-day of 98.6 % (95 % CI 96.5-99.6 %) for the HET score vs 97.8 % (95 % CI 96.1-98.8 %) for the HEART score (p = 0.29).Efficacy of the HET score was 19.6 % (286/1460, 95 % CI 17.6-21.6 %) vs 36.6 % (534/1460, 95 % CI 34.1-39.1 %) for the HEART score (p < 0.001)., Conclusion: In a multisite US cohort study, neither the HET score nor the HEART score achieved a safe NPV. The HET score had significantly lower efficacy than the HEART score., Trial Registration: High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP; ClinicalTrials.gov: NCT02984436; https://clinicaltrials.gov/ct2/show/NCT02984436)., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:, (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The American College of Cardiology (ACC) recently published an Expert Consensus Decision Pathway for chest pain., Objectives: The purpose of this study was to validate the ACC Pathway in a multisite U.S., Methods: An observational cohort study of adults with possible acute coronary syndrome was conducted. Patients were accrued from 5 U.S. Emergency Departments (November 1, 2020, to July 31, 2022). ECGs and 0- and 2-hour high-sensitivity troponin (Beckman Coulter) measures were used to stratify patients according to the ACC Pathway. The primary safety outcome was 30-day all-cause death or myocardial infarction (MI). Efficacy was defined as the proportion stratified to the rule-out zone. Negative predictive value for 30-day death or MI was assessed among the whole cohort and in a subgroup of patients with coronary artery disease (CAD) (prior MI, revascularization, or ≥70% coronary stenosis)., Results: ACC Pathway assessments were complete in 14,395 patients, of whom 51.7% (7,437 of 14,395) were women with a median age of 56 years (Q1-Q3: 44-68 years). Known CAD was present in 23.5% (3,386 of 14,395) and 30-day death or MI occurred in 8.1% (1,168 of 14,395). The ACC Pathway had an efficacy of 48.1% (95% CI: 47.3%-49.0%). Among patients in the rule-out zone, 0.3% (22 of 6,930) had death or MI at 30 days, yielding a negative predictive value of 99.7% (95% CI: 99.5%-99.8%). In patients with known CAD, 20.0% (676 of 3,386) were classified to the rule-out zone, of whom 1.5% (10 of 676) had death or MI., Conclusions: The ACC expert consensus decision pathway was safe and efficacious. However, it may not be safe for use among patients with known CAD., Competing Interests: Funding Support and Author Disclosures This study was funded internally by Wake Forest University Health Systems. The Wake Forest Clinical and Translational Science Institute, supported by the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health, through UL1TR001420. Dr Mahler has received funding/support from Roche Diagnostics, Abbott Laboratories, QuidelOrtho Clinical Diagnostics, Siemens, Grifols, Pathfast, Genetesis, Cytovale, Beckman Coulter, Brainbox, AHRQ (R01HS029017 and R21HS029234), The Duke Endowment, National Foundation of Emergency Medicine, and HRSA (1H2ARH399760100); is a consultant for Roche, Abbott, Siemens, QuidelOrtho, Genetesis, Inflammatix, and Radiometer; and is the Chief Medical Officer for Impathiq Inc. Dr Ashburn has received funding from AHRQ (R01HS029017). Dr Supples has received funding from the National Institutes of Health (UL1TR001420), HRSA (1H2ARH399760100), and the National Foundation of Emergency Medicine. Dr Snavely has received funding from Abbott Laboratories, AHRQ (R01HS029017), and HRSA (1H2ARH399760100). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The diagnostic performance of the high-sensitivity troponin T (hs-cTnT) 0/2-h algorithm is unclear among U.S. emergency department (ED) patients with acute chest pain., Methods: A preplanned subgroup analysis of the STOP-CP cohort study was conducted. Participants with 0- and 2-h hs-cTnT measures prospectively enrolled at eight U.S. EDs from January 2017 to September 2018 were stratified into rule-out, observation, and rule-in zones using the hs-cTnT 0/2-h algorithm alone and combined with the history, electrocardiogram, age, and risk factor (HEAR) score. The primary outcome was adjudicated 30-day cardiac death or myocardial infarction (CDMI). The sensitivity and negative predictive value (NPV) of the 0/2-h rule-out zone and specificity and positive predictive value (PPV) of the rule-in zone for 30-day CDMI were calculated., Results: Of the 1307 patients accrued, 53.6% (700/1307) were male and 58.6% (762/1307) were White, with a mean ± SD age of 57.5 ± 12.7 years. At 30 days, CDMI occurred in 12.9% (168/1307) of participants. The 0/2-h algorithm ruled out 61.4% (802/1307) of patients. Among rule-out patients, 1.9% (15/802) experienced 30-day CDMI, resulting in a sensitivity of 91.1% (95% confidence interval [CI] 85.7%-94.9%) and NPV of 98.1% (95% CI 96.9%-98.9%). The 0/2-h algorithm ruled in 12.4% (162/1307) patients of whom 61.7% (100/162) experienced 30-day CDMI. The rule-in zone specificity was 94.6% (95% CI 93.1%-95.8%) and PPV was 61.7% (95% CI 53.8%-69.2%) for 30-day CDMI. The 0/2-h algorithm combined with HEAR score ruled out 30.7% (401/1307) of patients with a sensitivity and NPV for 30-day CDMI of 98.2% (95% CI 94.9%-99.6%) and 99.3% (95% CI 97.8%-99.8%), respectively., Conclusions: The hs-cTnT 0/2-h algorithm ruled out most patients. With NPV of <99% for 30-day CDMI, the hs-cTnT 0/2-h algorithm, many emergency physicians may not consider it safe to use for U.S. ED patients. When combined with a low-risk HEAR score, NPV was >99% for 30-day CDMI at the cost of reduced efficacy., (© 2024 The Authors. Academic Emergency Medicine published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.)

The diagnostic performance of the high-sensitivity troponin T (hs-cTnT) European Society of Cardiology (ESC) 0/1-h algorithm in sex and race subgroups of US Emergency Department (ED) patients is unclear. A pre-planned subgroup analysis of the STOP-CP cohort study was conducted. Participants with 0- and 1-h hs-cTnT measures from eight US EDs (1/2017 to 9/2018) were stratified into rule-out, observation, and rule-in zones using the hs-cTnT ESC 0/1 algorithm. The primary outcome was adjudicated 30-day cardiac death or MI. The proportion with the primary outcome in each zone was compared between subgroups with Fisher's exact tests. The negative predictive value (NPV) of the ESC 0/1 rule-out zone for 30-day CDMI was calculated and compared between subgroups using Fisher's exact tests. Of the 1422 patients enrolled, 54.2% (770/1422) were male and 58.1% (826/1422) white with a mean age of 57.6 ± 12.8 years. At 30 days, cardiac death or myocardial infarction (MI) occurred in 12.9% (183/1422) of participants. Among patients stratified to the rule-out zone, 30-day cardiac death or MI occurred in 1.1% (5/436) of women versus 2.1% (8/436) of men (p = .40) and 1.2% (4/331) of non-white patients versus 1.8% (9/490) of white patients (p = .58). The NPV for 30-day cardiac death or MI was similar among women versus men (98.9% [95% confidence interval, CI: 97.3-99.6] vs. 97.9% [95% CI: 95.9-99.1]; p = .40) and among white versus non-white patients (98.8% [95% CI: 96.9-99.7] vs. 98.2% [95% CI: 96.5-99.2]; p = .39). NPVs <99% in each subgroup suggest the hs-cTnT ESC 0/1-h algorithm may not be safe for use in US EDs. Trial Registration: High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP; ClinicalTrials.gov: NCT02984436; https://clinicaltrials.gov/ct2/show/NCT02984436)., (© 2023 The Authors. Clinical Cardiology published by Wiley Periodicals, LLC.)

Objective: This study describes the local Emergency Medical Services (EMS) response and patient encounters corresponding to the civil unrest occurring over a four-day period in Spring 2020 in Indianapolis, Indiana (USA)., Methods: This study describes the non-conventional EMS response to civil unrest. The study included patients encountered by EMS in the area of the civil unrest occurring in Indianapolis, Indiana from May 29 through June 1, 2020. The area of civil unrest defined by Indianapolis Metropolitan Police Department covered 15 blocks by 12 blocks (roughly 4.0 square miles) and included central Indianapolis. The study analyzed records and collected demographics, scene times, interventions, dispositions, EMS clinician narratives, transport destinations, and hospital course with outcomes from receiving hospitals for patients extracted from the area of civil unrest by EMS., Results: Twenty-nine patients were included with ages ranging from two to sixty-eight years. In total, EMS transported 72.4% (21 of 29) of the patients, with the remainder declining transport. Ballistic injuries from gun violence accounted for 10.3% (3 of 29) of injuries. Two additional fatalities from penetrating trauma occurred among patients without EMS contact within and during the civil unrest. Conditions not involving trauma occurred in 37.9% (11 of 29). Among transported patients, 33.3% (7 of 21) were admitted to the hospital and there was one fatality., Conclusions: While most EMS transports did not result in hospitalization, it is important to note that the majority of EMS calls did result in a transport. There was a substantial amount of non-traumatic patient encounters. Trauma in many of the encounters was relatively severe, and the findings imply the need for rapid extraction methods from dangerous areas to facilitate timely in-hospital stabilization.

Background: Emergency medical services (EMS) clinicians demonstrate a high prevalence of chronic medical conditions that place them at risk for early mortality. Workplace health promotion programs improve health outcomes, but the availably of such programs for EMS clinicians has not been described. We investigate the availability, scope, and participation of workplace health promotion programs available to EMS clinicians in North Carolina (NC)., Methods: We administered an electronic survey based on the Centers for Disease Control and Prevention Worksite Health ScoreCard to key representatives of EMS agencies within NC that provide primarily transport-capable 9-1-1 response with ground ambulances. We collected information on agency size, rurality, elements of health promotion programs offered, incentives for participation, and participation rate. We calculated descriptive statistics using frequency and percentage for worksite and health promotion program characteristics. We compared the participation rate for agencies who did and did not incentivize participation using Fisher's exact test., Results: Complete responses were received from 69 of 92 agencies (response = 75%) that collectively employ 6679 EMS clinicians [median employees per agency 71 (IQR 50-131)]. Most agencies (88.4%, 61/69) offered at least one element of a worksite health program, but only 13.0% (9/69) offered all elements of a worksite health program. In descending order, the availability of program elements were employee assistance programs (73.9%, 51/69), supportive physical and social environment (66.7%, 46/69), health education (62.3%, 43/69), health risk assessments (52.2%, 36/69), and organization culture of health promotion (20.3%, 14/69). Of agencies with programs, few (11.5%, 7/61) required participation, but most (59.0%, 36/61) offered incentives to participate. Participation rates were <25% among nearly all of the agencies that did not offer incentives, but >50% among most agencies that did offer incentives ( p  < 0.001)., Conclusion: While most agencies offer at least one element of a worksite health promotion program, few agencies offer all elements and participation rates are low.

Background: The objective of this study is to identify patient and EMS agency factors associated with timely reperfusion of patients with ST-elevation myocardial infarction (STEMI)., Methods: We conducted a cohort study of adult patients (≥18 years old) with STEMI activations from 2016 to 2020. Data was obtained from a regional STEMI registry, which included eight rural county EMS agencies and three North Carolina percutaneous coronary intervention (PCI) centers. On each patient, prehospital and in-hospital time intervals were abstracted. The primary outcome was the ability to achieve the 90-minute EMS FMC to PCI time goal (yes vs. no). We used generalized estimating equations accounting for within-agency clustering to evaluate the association between patient and agency factors and meeting first medical contact (FMC) to PCI time goal while accounting for clustering within the agency., Results: Among 365 rural STEMI patients 30.1% were female (110/365) with a mean age of 62.5 ± 12.7 years. PCI was performed within the time goal in 60.5% (221/365) of encounters. The FMC to PCI time goal was met in 45.5% (50/110) of women vs 69.8% (178/255) of men ( p  < 0.001). The median PCI center activation time was 12 min (IQR 7-19) in the group that received PCI within the time goal compared to 21 min (IQR 10-37) in the cohort that did not. After adjusting for loaded mileage and other clinical variables (e.g., pulse rate, hypertension etc.), the male sex was associated with an improved chance of meeting the goal of FMC to PCI (aOR: 2.94; 95% CI 2.11-4.10) compared to the female sex., Conclusion: Nearly 40% of rural STEMI patients transported by EMS failed to receive FMC to PCI within 90 min. Women were less likely than men to receive reperfusion within the time goal, which represents an important health care disparity.

Background: ST-elevation myocardial infarction (STEMI) guidelines recommend an emergency medical services (EMS) first medical contact (FMC) to percutaneous coronary intervention (PCI) time of ≤90 min. The primary objective of this study was to evaluate the association between FMC to PCI time and mortality in rural STEMI patients., Methods: We conducted a cohort study of patients ≥18 years old with STEMI activations from January 2016 to March 2020. Data were obtained from a rural North Carolina Regional STEMI Data Registry, which included eight rural EMS agencies and three PCI centers, the National Cardiovascular Data Registry, and the EMS electronic health record. Prehospital and in-hospital time intervals were digitally abstracted. The outcome of index hospitalization mortality was compared between patients who did and did not meet FMC to PCI time goal using Fisher's exact tests. Negative predictive value (NPV) for index hospitalization death was calculated with 95% confidence intervals (CIs). A receiver operating characteristic curve was constructed and an optimal FMC to PCI time goal was identified by maximizing NPV to prevent index hospitalization death., Results: Among 365 rural EMS STEMI patients, 30.1% (110/365) were female with a mean ± SD age of 62.5 ± 12.7 years. PCI was performed within the 90-min time goal in 60.5% (221/365) of patients. Among these patients, 3% (11/365) died during initial STEMI hospitalization, with 1.4% (3/221) mortality in the group that met the 90-minute time goal compared to 5.6% (8/144) in patients exceeding the time goal (p = 0.03). Meeting the 90-min time goal yielded a 98.6% (95% CI 96.1%-99.7%) NPV for index death. A 78-min FMC to PCI time was the optimal cut point, yielding a NPV for index mortality of 99.3% (95% CI 96.1%-100%)., Conclusions: Death among rural patients with STEMI was four times more likely when they did not receive PCI within 90 min., (© 2023 The Authors. Academic Emergency Medicine published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.)

Introduction: Emergency department unscheduled return visits within 72-h of discharge, called a "bounceback", have been used as a metric of quality of care. We hypothesize that specific demographics and dispositions may be associated with Emergency Medical Services (EMS) 72-h bouncebacks., Methods: For all patient encounters within one calendar year from a large, urban EMS agency, we recorded demographics (name, date of birth, race, gender), primary impression, disposition, and vital signs for EMS encounters. A bounceback was defined as a patient, identified by matching first name, last name and date of birth, with more than one EMS encounter within 72 h. We performed descriptive statistics for patients that did and did not have a subsequent bounceback using median (interquartile range) and Wilcoxon Rank Sum test for age and frequency (percent) and chi square test for gender, race and run disposition. For patients with a bounceback, we describe the frequency and percentage of EMS professional primary impressions on initial encounter., Results: 98,043 encounters from January 1, 2021 to December 31, 2021, were analyzed. The median age was 50 years (IQR 32-65); 49.4% (46,147) were female and 50.7% (47,376) were White patients. 3951 encounters had a subsequent bounceback, and compared to those without bouncebacks, they were more often male patients (58.7% versus 50.2%, p < 0.001) and more commonly not transported (22.3% versus 15.5%, p < 0.001). A multivariable logistic regression model estimated the odds of bounceback were lower for females [OR 0.64 (95% CI 0.61-0.68)], Asian and Latino patients compared to White patients [OR 0.33 (95% CI 0.21-0.53) and 0.42 (95% CI 0.34-0.51)], respectively, no significant difference for Black patients compared to White patients, and higher for non-transported patients [OR 1.25 (95% CI 1.16-1.34)]. The The most common EMS primary impression for initial and subsequent encounters was mental health [576 (14.7%) and 944 (17.0%), respectively]. For subsequent encounters, the primary impression was cardiac arrest or death in 67 (1.2%) of cases., Conclusion: Bouncebacks were common in this single year study of a high-volume urban EMS agency. Male and non-transported patients most often experienced bouncebacks. The most common primary impression for encounters with bounceback was mental health related. Out-of-hospital cardiac arrest occurred in 1 % of bounceback cases. Further study is necessary to understand the effect on patient-centered outcomes., (Copyright © 2022. Published by Elsevier Inc.)

Objective: Disparities have been observed in the treatment of pain in emergency department patients. However, few studies have evaluated such disparities in emergency medical services (EMS). We describe pain medication administration for trauma indications in an urban EMS system and how it varies with patient demographics., Methods: We performed a retrospective review of the electronic medical records of adult patients transported for isolated trauma (without accompanying medical complaint) from 1/1/18 to 6/30/2020 by a third service EMS agency in a major United States metropolitan area. We performed descriptive statistics on epidemiology, type of pain medications administered, and pain scores. Kruskall-Wallis and chi-square or Fisher's exact tests were used to compare continuous and categorical variables, respectively. We constructed a logistic regression model to estimate the odds of nontreatment of pain by age, race, sex, transport interval, pain score, and Glasgow Coma Scale (GCS) score for patients with pain scores of at least four on a one to ten scale, the threshold for pain treatment per the EMS protocol., Results: Of 32,463 EMS patients with traumatic injuries included in the analysis, 40% (12,881/32,463) were African American, 50% (16,284/32,463) were female, the median age was 27 years (IQR 45-64), and the median initial pain score was 5 (IQR 2-8). Fifteen percent (4,989/32,463) received any analgesic. Initial pain scores were significantly higher for African American and female patients. African American patients were less likely to receive analgesia compared to White and Hispanic patients (19% versus 25% and 23%, respectively, p < 0.0001). Adjusting for age, pain score, transport interval, and GCS, African American compared to White, and female compared to male patients were less likely to be treated for pain, OR 1.59 (95% CI 1.47-1.72) and OR 1.20 (95% CI 1.11-1.28), respectively., Conclusion: Among patients with isolated traumatic injuries treated in a single, urban EMS system, African American and female patients were less likely to receive analgesia than White or male patients. Analgesics were given to a small percentage of patients who were eligible for treatment by protocol, and intravenous opioids were used in the vast majority patients who received treatment.

Background: Metabolic syndrome is a constellation of risk factors associated with the development of cardiovascular disease and increased all-cause mortality. Data examining the prevalence of metabolic syndrome among emergency medical services (EMS) clinicians are limited., Methods: We conducted a cross-sectional study of EMS clinicians and firefighters from three fire departments with transport-capable EMS divisions. Data were collected from compulsory annual physical exams for 2021 that included age, sex, race, body mass index (BMI), waist circumference, blood pressure, cholesterol levels, and hemoglobin A1c level. These data were used to determine the prevalence of meeting metabolic syndrome criteria. We calculated descriptive statistics of demographics, anthropometrics, and metabolic syndrome criteria for EMS clinicians and firefighters. We used chi-square tests to compare the proportion of EMS clinicians and firefighters meeting criteria for the whole group and among age groups of <40 years old, 40 to 59 years old, and ≥60 years old. We used logistic regression to estimate the odds of meeting criteria in EMS clinicians compared to firefighters, adjusted for age, sex, race, and BMI., Results: We reviewed data for 65 EMS clinicians and 239 firefighters. For the combined cohort, 13.2% (40/304) were female and 95.1% (289/304) were White. The median age for EMS clinicians was 34 years versus 45 years in firefighters (p < 0.0001). Metabolic syndrome criteria were met in 27.3% (83/304) of the entire group. The prevalence of meeting criteria among EMS clinicians and firefighters was 33.9% (22/65) and 25.5% (61/239), respectively (p = 0.18). Of the participants who were younger than age 40, 36.6% (15/41) of EMS clinicians versus 9.1% (7/74) of firefighters met criteria for metabolic syndrome (p < 0.001). EMS clinicians had significantly higher odds of meeting criteria [OR 4.62 (p = 0.001)] compared to firefighters when adjusted for age, sex, race, and BMI., Conclusion: EMS clinicians had a high prevalence of metabolic syndrome at an early age, and had a higher adjusted odds of having metabolic syndrome compared to firefighters.

Background: Rural patients with ST-elevation myocardial infarction (STEMI) may be less likely to receive prompt reperfusion therapy. This study's primary objective was to compare rural versus urban time intervals among a national cohort of prehospital patients with STEMI., Methods: The ESO Data Collaborative (Austin, TX), containing records from 1,366 emergency medical services agencies, was queried for adult 9-1-1 responses with suspected STEMI from 1/1/2018-12/31/2019. The scene address for each encounter was classified as either urban or rural using the 2010 US Census Urban Area Zip Code Tabulation Area relationship. The primary outcome was total EMS interval (9-1-1 call to hospital arrival); a key secondary outcome was the proportion of responses that had EMS intervals under 60 minutes. Generalized estimating equations were used to determine whether rural versus urban differences in interval outcomes occurred when adjusting for loaded mileage (distance from scene to hospital) and patient and clinical encounter characteristics., Results: Of 15,915,027 adult 9-1-1 transports, 23,655 records with suspected STEMI were included in the analysis. Most responses (91.6%, n = 21,661) occurred in urban settings. Median EMS interval was 37.6 minutes (IQR 30.0-48.0) in urban settings compared to 57.0 minutes (IQR 46.5-70.7) in rural settings (p < 0.01). Urban responses more frequently had EMS intervals <60 minutes (89.5%, n = 19,130), compared to rural responses (55.5%, n = 1,100, p < 0.01). After adjusting for loaded mileage, age, sex, race/ethnicity, abnormal vital signs, pain assessment, aspirin administration, and IV/IO attempt, rural location was associated with a 5.8 (95%CI 4.2-7.4) minute longer EMS interval than urban, and rural location was associated with a reduced chance of achieving EMS interval < 60 minutes (OR 0.40; 95%CI 0.33-0.49) as compared to urban location., Conclusion: In this large national sample, rural location was associated with significantly longer EMS interval for patients with suspected STEMI, even after accounting for loaded mileage.

Background: Obesity is a growing epidemic associated with higher rates of metabolic disease, heart disease and all-cause mortality. Heavier patients may require more advanced resources and specialized equipment. We hypothesize that increasing patient weight will be associated with longer prehospital on-scene times., Methods: We reviewed electronic patient care records for patients transported by two urban 9-1-1 emergency medical services (EMS) agencies. We collected age, sex, estimated patient weight, vital signs (systolic blood pressure, heart rate, pulse oximetry), provider impression, method of moving patient to ambulance, and on-scene times. We selected patients with time-sensitive diagnoses of stroke, ST-segment elevation myocardial infarction (STEMI), and trauma and compared on-scene times for patients who weighed above or below 300 pounds. We performed descriptive statistics, Mann-Whitney U tests for continuous variables and Chi-square tests for discrete variables. We constructed a generalized linear model to determine the effect of patient weight adjusted for covariates., Results: For a three-year period (May 1, 2018 to April 30, 2021) 48,203 patients were transported with an EMS impression of stroke, ST-segment elevation myocardial infarction (STEMI), and trauma. 23,654 (49.1%) patients were female, and the median age was 52 (IQR 34-68) years. The median weight was 175.0 (IQR 150.0-205.0) pounds. Patients above a dichotomous weight categorization of 300 pounds experienced a longer median scene time with any time-sensitive diagnosis (12.6 versus 11.9 min p < 0.001), STEMI (16.0 versus 13.1 min, p = 0.014) and blunt trauma (12.6 versus 11.9 min, p < 0.001)). They were more likely to be hypoxic (p < 0.001) and more likely to experience cardiac arrest (p < 0.001). They were less likely to walk to the ambulance (22.1% versus 32.2%, p < 0.001)., Conclusion: Patient weight above 300 pounds was associated with significantly longer on-scene time. These patients were more likely to be hypoxic, sustain a cardiac arrest, and less likely to walk to the ambulance., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Emergency Medical Services (EMS) professionals frequently experience job-related injuries, most commonly overexertion or movement injuries. Data on injury reduction in EMS professionals is limited. The Functional Movement Screen (FMS) is a movement analysis tool suggested to predict musculoskeletal injury, but it has not previously been evaluated for EMS professionals., Objective: To evaluate the effectiveness of the FMS to predict musculoskeletal injury among EMS professionals., Methods: In October 2014, EMS professionals employed in an urban third-service EMS agency volunteered to participate in FMS administered by certified screeners. Age, sex, height and weight were recorded. After screening, participants were instructed on exercises to correct movement deficiencies. We reviewed recorded injuries from 2013 to 2016. We performed descriptive statistics. With logistic regression modeling, we described factors that predicted musculoskeletal injury. We generated a receiver operating curve (ROC) for FMS prediction of musculoskeletal injury., Results: 147 of 240 full-time employees participated in the FMS. Participants' mean age was 33.7 years (SD = 9.6) and the majority (65%) were male. The median initial FMS score was 14 (IQR 11-16). Area under the ROC curve was 0.603 (p = 0.213) for FMS ability to predict any musculoskeletal injury within two years. Female sex was associated higher odds of injury (OR 3.98, 95% CI 1.61-9.80). Increasing age, body mass index (BMI) category, and FMS score≤14 did not predict musculoskeletal injury., Conclusion: The FMS did not predict musculoskeletal injury among EMS professionals.

Background: Emergency medical services (EMS) professionals demonstrate low adherence to physical activity guidelines and experience a high prevalence of obesity and incidence of injury. The authors investigate the barriers to participating in physical activity among EMS professionals., Methods: The EMS professionals employed by 15 North Carolina EMS agencies were surveyed with validated items. Multivariable logistic regression models were used to estimate the odds (odds ratio, 95% confidence interval) of not meeting physical activity guidelines for each barrier to being active, controlling for age, sex, body mass index category, race/ethnicity, certification and education level, and work hours., Results: A total of 1367 EMS professionals were invited to participate, and 359 complete responses were recorded. Half of the respondents (48.2%) met Centers for Disease Control and Prevention physical activity guidelines. According to standard body mass index categories, 55.9% were obese. There were increased odds of not meeting physical activity guidelines for the following barriers: lack of energy (5.32, 3.12-9.09), lack of willpower (4.31, 2.57-7.22), lack of time (3.55, 2.12-5.94), social influence (3.02, 1.66-5.48), and lack of resources (2.14, 1.12-4.11). The barriers of fear of injury and lack of skill were not associated with meeting physical activity guidelines., Conclusion: Half of EMS professionals did not meet physical activity guidelines, and the majority were obese. Significant associations exist between several modifiable barriers and not meeting physical activity guidelines.