A US National Study of the Association Between Income and Ambulance Response Time in Cardiac Arrest

Race, Ethnicity, and Gender Disparities in Acute Myocardial Infarction

Cardiovascular disease continues to be the leading cause of morbidity and mortality in the United States. Despite advancements in medical care, there remain persistent racial, ethnic, and gender disparity in the diagnosis, treatment, and prognosis of individuals with cardiovascular disease. In this review we seek to discuss differences in pathophysiology, clinical course, and risk profiles in the management and outcomes of acute myocardial infarction and related high-risk states. We also seek to highlight the demographic and psychosocial inequities that cause disparities in acute cardiovascular care.

Ambulance service recognition of health inequalities and activities for reduction: An evidence and gap map of the published literature

Background

Emergency medical services (EMS) are often patients' first point of contact for urgent and emergency care needs. Patients are triaged over the phone and may receive an ambulance response, with potential conveyance to the hospital. A recent scoping review suggested disparities in EMS patient care in the United States. However, it is unknown how health inequalities impact EMS care in other developed countries and how inequalities are being addressed.

Objectives

This rapid evidence map of published literature aims to map known health inequalities in EMS patients and describe interventions reducing health inequalities in EMS patient care.

Methods

The search strategy consisted of EMS synonyms and health inequality synonyms. The MEDLINE/PubMed database was searched from 1 January 2010 to 26 July 2022. Studies were included if they described empirical research exploring health inequalities within ambulance service patient care. Studies were mapped on to the EMS care interventions framework and Core20PLUS5 framework. Studies evaluating interventions were synthesised using the United Kingdom Allied Health Professions Public Health Strategic Framework.

Results

The search strategy yielded 771 articles, excluding duplicates, with two more studies added from hand searches. One hundred studies met the inclusion criteria after full-text review. Inequalities in EMS patient care were predominantly situated in assessment, treatment and conveyance, although triage and response performance were also represented. Studies mostly explored EMS health inequalities within ethnic minority populations, populations with protected characteristics and the core issue of social deprivation. Studies evaluating interventions reducing health inequalities (n = 5) were from outside the United Kingdom and focused on older patients, ethnic minorities and those with limited English proficiency. Interventions included community paramedics, awareness campaigns, dedicated language lines and changes to EMS protocols.

Conclusions

Further UK-based research exploring health inequalities of EMS patients would support ambulance service policy and intervention development to reduce health inequality in urgent and emergency care delivery.

Mediators of the Association Between Socioeconomic Status and Survival After Out-of-Hospital Cardiac Arrest: A Systematic Review

Low socioeconomic status (SES) is associated with poor outcomes after out-of-hospital cardiac arrest (OHCA). Patient characteristics, care processes, and other contextual factors may mediate the association between SES and survival after OHCA. Interventions that target these mediating factors may reduce disparities in OHCA outcomes across the socioeconomic spectrum. This systematic review identified and quantified mediators of the SES-survival after OHCA association. Electronic databases (MEDLINE, Embase, PubMed, Web of Science) and grey literature sources were searched from inception to July or August 2023. Observational studies of OHCA patients that conducted mediation analyses to evaluate potential mediators of the association between SES (defined by income, education, occupation, or a composite index) and survival outcomes were included. A total of 10 studies were included in this review. Income (n = 9), education (n = 4), occupation (n = 1), and composite indices (n = 1) were used to define SES. The proportion of OHCA cases that had bystander involvement, presented with an initial shockable rhythm, and survived to hospital discharge or 30 days increased with higher SES. Common mediators of the SES-survival association that were evaluated included initial rhythm (n = 6), emergency medical services response time (n = 5), and bystander cardiopulmonary resuscitation (n = 4). Initial rhythm was the most important mediator of this association, with a median percent excess risk explained of 37.4% (range 28.6%-40.0%; n = 5; 1 study reported no mediation) and mediation proportion of 41.8% (n = 1). To mitigate socioeconomic disparities in outcomes after OHCA, interventions should target potentially modifiable mediators, such as initial rhythm, which may involve improving bystander awareness of OHCA and the need for prompt resuscitation.

What factors are effective on the CPR duration of patients under extracorporeal cardiopulmonary resuscitation: a single-center retrospective study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is an alternative method for patients with reversible causes of cardiac arrest (CA) after conventional cardiopulmonary resuscitation (CCPR). However, cardiopulmonary resuscitation (CPR) duration during ECPR can vary due to multiple factors. Healthcare providers need to understand these factors to optimize the resuscitation process and improve outcomes. The aim of this study was to examine the different variables impacting the duration of CPR in patients undergoing ECPR.

METHODS

This retrospective, single-center, observational study was conducted on adult patients who underwent ECPR due to in-hospital CA (IHCA) or out-of-hospital CA (OHCA) at Hamad General Hospital (HGH), the tertiary governmental hospital of Qatar, between February 2016 and March 2020. Univariate and multivariate binary logistic regression analyses were performed to identify the prognostic factors associated with CPR duration, including demographic and clinical variables, as well as laboratory tests.

RESULTS

The mean ± standard division age of the 48 participants who underwent ECPR was 41.50 ± 13.15 years, and 75% being male. OHCA and IHCA were reported in 77.1% and 22.9% of the cases, respectively. The multivariate analysis revealed that several factors were significantly associated with an increased CPR duration: higher age (OR: 1.981, 95%CI: 1.021-3.364, P = 0.025), SOFA score (OR: 3.389, 95%CI: 1.289-4.911, P = 0.013), presence of comorbidities (OR: 3.715, 95%CI: 1.907-5.219, P = 0.026), OHCA (OR: 3.715, 95%CI: 1.907-5.219, P = 0.026), and prolonged collapse-to-CPR time (OR: 1.446, 95%CI:1.092-3.014, P = 0.001). Additionally, the study found that the initial shockable rhythm was inversely associated with the duration of CPR (OR: 0.271, 95%CI: 0.161-0.922, P = 0.045). However, no significant associations were found between laboratory tests and CPR duration.

CONCLUSION

These findings suggest that age, SOFA score, comorbidities, OHCA, collapse-to-CPR time, and initial shockable rhythm are important factors influencing the duration of CPR in patients undergoing ECPR. Understanding these factors can help healthcare providers better predict and manage CPR duration, potentially improving patient outcomes. Further research is warranted to validate these findings and explore additional factors that may impact CPR duration in this population.

Prognostic effects of cardiopulmonary resuscitation (CPR) start time and the interval between CPR to extracorporeal cardiopulmonary resuscitation (ECPR) on patient outcomes under extracorporeal membrane oxygenation (ECMO): a single-center, retrospective observational study

BACKGROUND

The impact of the chronological sequence of events, including cardiac arrest (CA), initial cardiopulmonary resuscitation (CPR), return of spontaneous circulation (ROSC), and extracorporeal cardiopulmonary resuscitation (ECPR) implementation, on clinical outcomes in patients with both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA), is still not clear. The aim of this study was to investigate the prognostic effects of the time interval from collapse to start of CPR (no-flow time, NFT) and the time interval from start of CPR to implementation of ECPR (low-flow time, LFT) on patient outcomes under Extracorporeal Membrane Oxygenation (ECMO).

METHODS

This single-center, retrospective observational study was conducted on 48 patients with OHCA or IHCA who underwent ECMO at Hamad General Hospital (HGH), the tertiary governmental hospital of Qatar, between February 2016 and March 2020. We investigated the impact of prognostic factors such as NFT and LFT on various clinical outcomes following cardiac arrest, including 24-hour survival, 28-day survival, CPR duration, ECMO length of stay (LOS), ICU LOS, hospital LOS, disability (assessed using the modified Rankin Scale, mRS), and neurological status (evaluated based on the Cerebral Performance Category, CPC) at 28 days after the CA.

RESULTS

The results of the adjusted logistic regression analysis showed that a longer NFT was associated with unfavorable clinical outcomes. These outcomes included longer CPR duration (OR: 1.779, 95%CI: 1.218-2.605, P = 0.034) and decreased survival rates for ECMO at 24 h (OR: 0.561, 95%CI: 0.183-0.903, P = 0.009) and 28 days (OR: 0.498, 95%CI: 0.106-0.802, P = 0.011). Additionally, a longer LFT was found to be associated only with a higher probability of prolonged CPR (OR: 1.818, 95%CI: 1.332-3.312, P = 0.006). However, there was no statistically significant connection between either the NFT or the LFT and the improvement of disability or neurologically favorable survival after 28 days of cardiac arrest.

CONCLUSIONS

Based on our findings, it has been determined that the NFT is a more effective predictor than the LFT in assessing clinical outcomes for patients with OHCA or IHCA who underwent ECMO. This understanding of their distinct predictive abilities enables medical professionals to identify high-risk patients more accurately and customize their interventions accordingly.

Trends of Pulmonary Embolism-Related Sudden Cardiac Death in the United States, 1999-2019

OBJECTIVES

Up-to-date population-based data on pulmonary embolism (PE)-related sudden cardiac death (SCD) mortality trends in the United States (US) are scant. We assess the current trends in PE-related SCD mortality in US over the past two decades and determine differences by sex, race, ethnicity, age, and census region.

METHODS

We extracted PE-related SCD mortality rates from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database from 1999 to 2019, in patients aged ≥ 15 years old. Age-adjusted mortality rates (AAMRs) were assessed using the Joinpoint regression modeling and expressed as estimated average annual percentage change (AAPC) with relative 95% confidence intervals (CIs).

RESULTS

Between 1999 and 2019, the AAMR from acute PE-related SCD mortality in the US linearly increased [AAPC: +2.4% (95% CI: 2.2 to 2.6), p < 0.001)]. The AAMR increase was more pronounced in men [AAPC: +2.8% (95% CI: 2.6 to 2.9), p < 0.001], Whites [AAPC: +2.7% (95% CI: 2.3 to 3.1), p < 0.001], Latinx/Hispanic patients [AAPC:+2.0% (95% CI: 1.2 to 2.8), p < 0.001], subjects younger than 65 years [AAPC: +2.4% (95% CI: 2.1 to 2.6), p < 0.001] and in residents of rural areas [AAPC: +3.6% (95% CI: 3.3 to 3.9), p < 0.001]. Moreover, higher percentages of PE-related SCD and the relative absolute number of deaths were observed in the South compared with other geographical regions.

CONCLUSIONS

PE-related SCD mortality in the US has increased over the last two decades. Stratification by race, ethnicity, urbanization, and census region demonstrates ethnoracial and regional disparities that require further investigation and remedy.

The barriers and facilitators to initiation of telephone-assisted bystander cardiopulmonary resuscitation for patients experiencing out-of-hospital cardiac arrest in a private emergency dispatch centre in South Africa

Background

The incidence of cardiovascular diseases, and with it out-of-hospital cardiac arrest (OHCA), is on the increase in low- to middle-income countries (LMICs), like South Africa. Interventions such as mass public cardiopulmonary resuscitation (CPR) training campaigns and public access defibrillators are expensive and out of reach for many LMICs. Telephone-assisted CPR (tCPR) is a cost-effective, scalable alternative. This study explored the barriers and facilitators to tCPR uptake in OHCA in a private South African emergency dispatch centre.

Methods

This qualitative study applied inductive dominant content analysis to emergency call recordings of OHCA cases into a private emergency dispatch centre. Calls were analysed to the latent level to identify barriers and facilitators. Cases were sampled randomly, until data saturation.

Results

Saturation occurred after the analysis of 25 recordings. A further three recordings were analysed to confirm saturation of the facilitators; yielding a final sample size of 28 calls. Overall, t-CPR was offered in 23 (82.1%) cases, but only initiated in 8 (34.8%) of these calls. Five barriers ("Poor Communication"; "Lack of Support"; "Caller Hesitance or Uncertainty;" "Emotionality"; and "Practical Barriers") and three facilitators ("Caller Willingness"; "Support" and "CPR in Progress") were extracted.

Conclusion

Numerous barriers limit the initiation of tCPR in the South African private sector EMS. It is crucial to address these barriers and leverage the facilitators in order to improve tCPR uptake. This study highlights the importance of using specific language techniques and developing tailored tCPR algorithms to overcome these barriers, which is underpinned by standardised training of call-takers.

Paving a Path to Equity in Cardiorenal Care

Cardiorenal syndrome encompasses a dynamic interplay between cardiovascular and kidney disease, and its prevention requires careful examination of multiple predisposing underlying conditions. The unequal distribution of diabetes, heart failure, hypertension, and kidney disease requires special attention because of the influence of these conditions on cardiorenal disease. Despite growing evidence regarding the benefits of disease-modifying agents (e.g., sodium-glucose cotransporter 2 inhibitors) for cardiovascular, kidney, and metabolic (CKM) disease, significant disparities remain in access to and utilization of these essential therapeutics. Multilevel barriers impeding their use require multisector interventions that address patient, provider, and health system-tailored strategies. Burgeoning literature also describes the critical role of unequal social determinants of health, or the sociopolitical contexts in which people live and work, in cardiorenal risk factors, including heart failure, diabetes, and chronic kidney disease. This review outlines (i) inequality in the burden and treatment of hypertension, type 2 diabetes, and heart failure; (ii) disparities in the use of key disease-modifying therapies for CKM diseases; and (iii) multilevel barriers and solutions to achieve greater pharmacoequity in the use of disease-modifying therapies. In addition, this review provides summative evidence regarding the role of unequal social determinants of health in cardiorenal health disparities, further outlining potential considerations for future research and intervention. As proposed in the 2023 American Heart Association presidential advisory on CKM health, a paradigm shift will be needed to achieve cardiorenal health equity. Through a deeper understanding of CKM health and a commitment to equity in the prevention, detection, and treatment of CKM disease, we can achieve this critical goal.

The American Heart Association Emergency Cardiovascular Care 2030 Impact Goals and Call to Action to Improve Cardiac Arrest Outcomes: A Scientific Statement From the American Heart Association

Every 10 years, the American Heart Association (AHA) Emergency Cardiovascular Care Committee establishes goals to improve survival from cardiac arrest. These goals align with broader AHA Impact Goals and support the AHA's advocacy efforts and strategic investments in research, education, clinical care, and quality improvement programs. This scientific statement focuses on 2030 AHA emergency cardiovascular care priorities, with a specific focus on bystander cardiopulmonary resuscitation, early defibrillation, and neurologically intact survival. This scientific statement also includes aspirational goals, such as establishing cardiac arrest as a reportable disease and mandating reporting of standardized outcomes from different sources; advancing recognition of and knowledge about cardiac arrest; improving dispatch system response, availability, and access to resuscitation training in multiple settings and at multiple time points; improving availability, access, and affordability of defibrillators; providing a focus on early defibrillation, in-hospital programs, and establishing champions for debriefing and review of cardiac arrest events; and expanding measures to track outcomes beyond survival. The ability to track and report data from these broader aspirational targets will potentially require expansion of existing data sets, development of new data sets, and enhanced integration of technology to collect process and outcome data, as well as partnerships of the AHA with national, state, and local organizations. The COVID-19 (coronavirus disease 2019) pandemic, disparities in COVID-19 outcomes for historically excluded racial and ethnic groups, and the longstanding disparities in cardiac arrest treatment and outcomes for Black and Hispanic or Latino populations also contributed to an explicit focus and target on equity for the AHA Emergency Cardiovascular Care 2030 Impact Goals.

Socioeconomic status is associated with greater hazard of post-discharge mortality than race, gender, and ballistic injury mechanism in a young, healthy, orthopedic trauma population

OBJECTIVES

To explore the utility of legacy demographic factors and ballistic injury mechanism relative to popular markers of socioeconomic status as prognostic indicators of 10-year mortality following hospital discharge in a young, healthy patient population with isolated orthopedic trauma injuries.

METHODS

A retrospective cohort study was performed to evaluate patients treated at an urban Level I trauma center from January 1, 2003, through December 31, 2016. Current Procedure Terminology (CPT) codes were used to identify upper and lower extremity fracture patients undergoing operative fixation. Exclusion criteria were selected to yield a patient population of isolated extremity trauma in young, otherwise healthy individuals between the ages of 18 and 65 years. Variables collected included injury mechanism, age, race, gender, behavior risk factors, Area Deprivation Index (ADI), and insurance status. The primary outcome was post-discharge mortality, occurring at any point during the study period.

RESULTS

We identified 2539 patients with operatively treated isolated extremity fractures. The lowest two quartiles of socioeconomic status (SES) were associated with higher hazard of mortality than the highest SES quartile in multivariable analysis (Quartile 3 HR: 2.2, 95% CI: 1.2-4.1, p = 0.01; Quartile 4 HR: 2.2, 95% CI: 1.1-4.3, p = 0.02). Not having private insurance was associated with higher mortality hazard in multivariable analysis (HR 2.0, 95% CI: 1.3-3.2, p = 0.002). The presence of any behavioral risk factor was associated with higher mortality hazard in univariable analysis (HR: 1.8, p < 0.05), but this difference did not reach statistical significance in multivariable analysis (HR: 1.4, 95%: 0.8-2.3, p = 0.20). Injury mechanism (ballistic versus blunt), gender, and race were not associated with increased hazard of mortality (p > 0.20).

CONCLUSION

Low SES is associated with a greater hazard of long-term mortality than ballistic injury mechanism, race, gender, and medically diagnosable behavioral risk factors in a young, healthy orthopedic trauma population with isolated extremity injury.

Association of Neighborhood-Level Socioeconomic Factors With Delay to Hospital Arrival in Patients With Acute Stroke

BACKGROUND AND OBJECTIVES

Delivery of acute ischemic stroke (AIS) therapies is contingent on the duration from last known well (LKW) to emergency department arrival time (EDAT). One reason for treatment ineligibility is delay in presentation to the hospital. We evaluate patient and neighborhood characteristics associated with time from LKW to EDAT.

METHODS

This was a retrospective observational study of patients presenting to the Yale New Haven Hospital in the AIS code pathway from 2010 to 2020. Patients presenting within 4.5 hours from LKW who were recorded in the institutional Get With the Guidelines Stroke registry were classified as early while those presenting beyond 4.5 hours were designated as late. Temporal trends in late presentation were explored by univariate logistic regression. Using variables significant in univariate analysis at p < 0.05, we developed a mixed-effect logistic regression model to estimate the probability of late presentation as a function of patient-level and neighborhood (ZIP)-level characteristics (area deprivation index [ADI] derived from the Health Resources and Services Administration), adjusted for calendar year and geographic distance from the centroid of the ZIP code to the hospital.

RESULTS

A total of 2,643 patients with AIS from 2010 to 2020 were included (63.4% presented late and 36.6% presented early). The frequency of late presentation increased significantly from 68% in 2010 to 71% in 2020 (p = 0.002) and only among non-White patients. Patients presenting late were more likely to be non-White (37.1% vs 26.9%, p < 0.0001), arrive by means other than emergency medical services (EMS) (32.7% vs 16.1%, p < 0.0001), have an NIHSS <6 (68.7% vs 55.2%, p < 0.0001), and present from a neighborhood with a higher ADI category (p = 0.0001) that was nearer to the hospital (median 5.8 vs 7.7 miles, p = 0.0032). In the mixed model, the ADI by units of 10 (odds ratio [OR] 1.022, 95% confidence interval [CI] 1.020-1.024), non-White race (OR 1.083, 95% CI 1.039-1.127), arrival by means other than EMS (OR 1.193, 95% CI 1.145-1.124), and an NIHSS <6 (OR 1.085, 95% CI 1.041-1.129) were associated with late presentation.

DISCUSSION

In addition to patient-level factors, socioeconomic deprivation of neighborhood of residence contributes to delays in hospital presentation for AIS. These findings may provide opportunities for targeted interventions to improve presentation times in at-risk communities.

The understandability and quality of telephone-guided bystander cardiopulmonary resuscitation in the Western Cape province of South Africa: A manikin-based study

Background

The incidence of cardiovascular disease is on the increase in Africa and with it, an increase in the incidence of out-of-hospital cardiac arrest (OHCA). OHCA carries a high mortality, especially in low-resource settings. Interventions to treat OHCA, such as mass cardiopulmonary resuscitation (CPR) training campaigns are costly. One cost-effective and scalable intervention is telephone-guided bystander CPR (tCPR). Little data exists regarding the quality of tCPR. This study aimed to determine quality of tCPR in untrained members of the public. Participants were also asked to provide their views on the understandability of the tCPR instructions.

Methods

This study followed a prospective, simulation-based observational study design. Adult laypeople who have not had previous CPR training were recruited at public CPR training events and asked to perform CPR on a manikin. Quality was assessed in terms of hand placement, compression rate, compression depth, chest recoil, and chest exposure. tCPR instructions were provided by a trained medical provider, via loudspeaker. Participants were also asked to complete a short questionnaire afterwards, detailing the understandability of the tCPR instructions. Data were analysed descriptively and compared to recommended quality guidance.

Results

Fifty participants were enrolled. Hand placement was accurate in 74 % (n = 37) of participants, while compression depth and chest recoil only had compliance in 20 % (n = 10) and 24 % (n = 12) of participants, respectively. The mean compression rate was within guidelines in just under half (48 %, n = 24) of all participants. Only 20 (40 %) participants exposed the manikin's chest. Only 46 % (n = 23) of participants felt that the overall descriptions offered during the tCPR guidance were understandable, while 80 % (n = 40) and 36 % (n = 18) felt that the instructions on hand placement and compression rate were understandable, respectively. Lastly, 94 % (n = 47) of participants agreed that they would be more likely to perform bystander CPR if they were provided with tCPR.

Conclusion

The quality of CPR performed by laypersons is generally suboptimal and this may affect patient outcomes. There is an urgent need to develop more understandable tCPR algorithms that may encourage bystanders to start CPR and optimise its quality.

The Minnesota first-responder AED project: Aiming to increase survival in out-of-hospital cardiac arrest

There are 350,000 out-of-hospital cardiac arrest (OHCA) cases annually in the United States of America. Using automated external defibrillators (AEDs) has increased survival in cardiac arrests (CA) with an initial shockable rhythm. Thus, guidelines recommend complete geographical coverage with AEDs. To fill in the gaps in Minnesota, the Center for Resuscitation Medicine at the University of Minnesota raised an $18.8 million grant from the Helmsley Charitable Trust to supply law enforcement first responders with AEDs and, thus, increase survival rates after OHCA by reducing the time to first shock. This report elaborates on the decision-making, fundraising, and logistic strategy required to reach statewide AED coverage.

Methods

The baseline need for AEDs was analyzed using a questionnaire sent out to state law enforcement agencies, state patrols, city and county agencies, and tribal agencies in 2021. Furthermore, OHCA cases of 2021 were reviewed. The combination of this information led to an action plan to equip and train all agencies throughout the state's eight regions with AEDs.

Results

The electronic survey was initially sent out to 358 agencies. The initial response rate was 77% (n = 276). This resulted in a total need of 8300 AEDs to be deployed over three years (2022-2025). As of 2023, over 4769 AEDs have been distributed, covering 237 sites.

Conclusion

By equipping first responders with AED systems, the Center for Resuscitation Medicine aims to shorten the gap in statewide AED coverage, thus increasing the chances of survival after OHCA.

Contextual community epinephrine prescribing: Is more always better?

OBJECTIVE

Prompt administration of epinephrine is first-line management of anaphylaxis. Although severe anaphylaxis may require more than 1 epinephrine dose, multiple epinephrine device packs may not be necessary for all patients at risk for allergic reactions.

DATA SOURCES

A narrative review was used to describe key considerations to contextualize community epinephrine prescribing.

RESULTS

Anaphylaxis has a lifetime prevalence of 1.6% to 5.1%. Meeting diagnostic criteria for anaphylaxis is not required for epinephrine treatment of a severe allergic reaction. A "1-2-3" approach to anaphylaxis treatment is important to clearly relay central management steps: promptly administer a first dose of intramuscular epinephrine with proper positioning, and activate emergency medical services if immediate symptom resolution does not occur; consider a second dose of intramuscular epinephrine with consideration of oxygen administration and intravenous fluid if initial epinephrine response is not adequate; and consider a third intramuscular epinephrine dose together with consideration of intravenous fluid support and oxygen for continued lack of appropriate response. Although multiple epinephrine doses may be required to treat severe anaphylaxis, 90% of anaphylaxis cases do not require more than 1 epinephrine dose. A universal requirement for multiple epinephrine devices in patients without a history of anaphylaxis is not cost-effective. Patients without a history of anaphylaxis may be managed without multiple device prescriptions within a patient-preference sensitive paradigm of care.

CONCLUSION

Anaphylaxis prevention involves appropriate education to avoid allergen triggers, recognize symptoms of an allergic reaction, rapidly access and administer intramuscular epinephrine, and appropriately activate emergency medical services when needed. For patients with previous anaphylaxis, particularly those who have required more than 1 dose of epinephrine to treat an allergic reaction, possessing multiple epinephrine devices is an important part of managing community anaphylaxis risk.

How do current police practices impact trauma care in the prehospital setting? A scoping review

Objective

In the United States, police are often important co-responders to 911 calls with emergency medical services for medical emergencies. To date, there remains a lack of a comprehensive understanding of the mechanisms by which police response modifies time to in-hospital medical care for traumatically injured patients. Further, it remains unclear if differentials exist within or between communities. A scoping review was performed to identify studies evaluating prehospital transport of traumatically injured patients and the role or impact of police involvement.

Methods

PubMed, SCOPUS, and Criminal Justice Abstracts databases were utilized to identify articles. English-language, US-based, peer-reviewed articles published on or prior to March 30, 2022 were eligible for inclusion.

Results

Of 19,437 articles initially identified, 70 articles were selected for full review and 17 for final inclusion. Key findings included (1) current law enforcement practices involving scene clearance introduce the potential for delayed patient transport but to date there is little research quantifying delays; (2) police transport protocols may decrease transport times; and (3) there are no studies examining the potential impact of scene clearance practices at the patient or community level.

Conclusions

Our results highlight that police are often the first on scene when responding to traumatic injuries and have an active role via scene clearance or, in some systems, patient transport. Despite the significant potential for impact on patient well-being, there remains a paucity of data examining and driving current practices.

Spatial accessibility of emergency medical services in Chongqing, Southwest China

Background

Timely access to emergency medical services (EMS) can significantly reduce mortality. In China, the evidence of the accessibility of complete EMS which considers two related trips and involves large rural areas is insufficient. This study aimed to explore the accessibility of ambulance services and complete EMS in Chongqing and its regional differences, and to provide a reference for improving spatial accessibility of EMS in Chongqing and optimizing allocation of EMS resources.

Methods

The nearest neighbor method was used to measure spatial accessibility of ambulance services and complete EMS. Spatial aggregation patterns and influencing factors of spatial accessibility of complete EMS were analyzed using Moran's I index, Pearson correlation and multiple linear regression.

Results

The medians of shortest travel time for ambulance, monitoring ambulance, primary EMS and advanced EMS in Chongqing were 7.0, 18.6, 36.2, and 47.8 min. The shortest travel time for complete EMS showed significant spatial aggregation characteristics. The Low-Low types that referred to cluster of short EMS travel time mainly distributed in city proper. The High-High types that referred to cluster of long EMS travel time mainly distributed in northeast and southeast of Chongqing. Urbanization rate was a negative influencing factor on shortest travel time for primary EMS, while average elevation and the number of settlements were positive influencing factors. GDP per capita and urbanization rate were negative influencing factors on shortest travel time for advanced EMS, while the number of settlements was a positive influencing factor.

Conclusion

This study evaluated the accessibility of EMS which considers two related trips in Chongqing. Although the accessibility of ambulances in Chongqing was relatively high, the accessibility of monitoring ambulance was relatively low. Regional and urban-rural differences in the accessibility of complete EMS integrating two related trips were obvious. It was recommended to increase financial investment in economic backward areas, increase high-quality EMS resources, enhance EMS capacity of central township health centers, strengthen road construction in mountainous areas, and provide reasonable planning of rural settlements for improving the spatial accessibility of EMS, narrowing the urban-rural gap and improving equity in getting EMS for all the people.

Trends in the likelihood of receiving percutaneous coronary intervention in a low-volume hospital and disparities by sociodemographic communities

INTRODUCTION

Over the past two decades, percutaneous coronary intervention (PCI) capacity has increased while coronary artery disease has decreased, potentially lowering per-hospital PCI volumes, which is associated with less favorable patient outcomes. Trends in the likelihood of receiving PCI in a low-volume center have not been well-documented, and it is unknown whether certain socioeconomic factors are associated with a greater risk of PCI in a low-volume facility. Our study aims to determine the likelihood of being treated in a low-volume PCI center over time and if this likelihood differs by sociodemographic factors.

METHODS

We conducted a retrospective cohort study of 374,066 hospitalized patients in California receiving PCI from January 1, 2010, to December 31, 2018. Our primary outcome was the likelihood of PCI discharges at a low-volume hospital (<150 PCI/year), and secondary outcomes included whether this likelihood varied across different sociodemographic groups and across low-volume hospitals stratified by high or low ZIP code median income.

RESULTS

The proportion of PCI discharges from low-volume hospitals increased from 5.4% to 11.0% over the study period. Patients of all sociodemographic groups considered were more likely to visit low-volume hospitals over time (P<0.001). Latinx patients were more likely to receive PCI at a low-volume hospital compared with non-Latinx White in 2010 with a 166% higher gap in 2018 (unadjusted proportions). The gaps in relative risk (RR) between Black, Latinx and Asian patients versus non-Latinx white increased over time, whereas the gap between private versus public/no insurance, and high versus low income decreased (interaction P<0.001). In low-income ZIP codes, patients with Medicaid were less likely to visit low-volume hospitals than patients with private insurance in 2010; however, this gap reversed and increased by 500% in 2018. Patients with low income were more likely to receive PCI at low-volume hospitals relative to patients with high income in all study years.

CONCLUSIONS

The likelihood of receiving PCI at low-volume hospitals has increased across all race/ethnicity, insurance, and income groups over time; however, this increase has not occurred evenly across all sociodemographic groups.

Racial, ethnic, and socioeconomic disparities in out-of-hospital cardiac arrest within the United States: Now is the time for change

This review highlights the current evidence on racial, ethnic, and socioeconomic disparities in cardiac arrest outcomes within the United States. Several studies demonstrate that patients from Black, Hispanic, or lower socioeconomic status backgrounds suffer the most from disparities at multiple levels of the resuscitation pathway, including in the provision of bystander cardiopulmonary resuscitation, defibrillator usage, and postresuscitation therapies. These gaps in care may altogether lead to lower survival rates and worse neurological outcomes for these patients. A multisystem, culturally sensitive approach to improving cardiac arrest outcomes is suggested in this article.

Hispanic Farmers Experience Shorter EMS Response Times but Longer Emergency Department Length of Stay Following Occupational Injuries

BACKGROUND

Agriculture has the highest rate of fatal injuries by sector. Hispanic workers also experience more fatal work injuries than every other minority group combined. Pre-hospital and initial trauma evaluation represent an important marker to understand the impact of a trauma system. We sought to investigate whether Hispanic agricultural workers in the United States (US) experience disparities following traumatic occupational injuries in terms of pre-hospital and emergency department care.

METHODS

We retrospectively analyzed the National Trauma Data Bank from 2012-2016 to understand differences between Hispanic and non-Hispanic farmers in Emergency Medical Services (EMS) response and transport times (minutes), transport mode, transfer rates, presentation to University or Level I trauma hospitals, Injury Severity Scores (ISS), length of stay (LOS) in the emergency department (ED, minutes) or hospital (days), need for the operating room (OR), admittance to the Intensive Care Unit (ICU), and mortality.

RESULTS

A total of 6,161 farmers were included in our analyses (median age 47 years, females 7.0%). Multivariable analyses indicate differences regarding EMS response, EMS transport, and LOS in the ED. Rates of admission to the ICU, surgical operations, days on a ventilator, discharge from the hospital with supportive care, and mortality did not differ between groups.

CONCLUSIONS

Non-Hispanic patients have longer median EMS response and total transport times. Hispanic patients have longer median LOS in the ED. However, the lack of significant differences in management variables other than EMS times and ED LOS indicate an equitable delivery of trauma care once patients were transferred from the ED.

Prehospital Time Interval for Urban and Rural Emergency Medical Services: A Systematic Literature Review

The aim of this study was to discuss the differences in pre-hospital time intervals between rural and urban communities regarding emergency medical services (EMS). A systematic search was conducted through various relevant databases, together with a manual search to find relevant articles that compared rural and urban communities in terms of response time, on-scene time, and transport time. A total of 37 articles were ultimately included in this review. The sample sizes of the included studies was also remarkably variable, ranging between 137 and 239,464,121. Twenty-nine (78.4%) reported a difference in response time between rural and urban areas. Among these studies, the reported response times for patients were remarkably variable. However, most of them (number (n) = 27, 93.1%) indicate that response times are significantly longer in rural areas than in urban areas. Regarding transport time, 14 studies (37.8%) compared this outcome between rural and urban populations. All of these studies indicate the superiority of EMS in urban over rural communities. In another context, 10 studies (27%) reported on-scene time. Most of these studies (n = 8, 80%) reported that the mean on-scene time for their populations is significantly longer in rural areas than in urban areas. On the other hand, two studies (5.4%) reported that on-scene time is similar in urban and rural communities. Finally, only eight studies (21.6%) reported pre-hospital times for rural and urban populations. All studies reported a significantly shorter pre-hospital time in urban communities compared to rural communities. Conclusions: Even with the recently added data, short pre-hospital time intervals are still superior in urban over rural communities.

Influence of Prehospital Emergency Care on Rescue Success Rate and Complication Rate of Senile Patients with Acute Myocardial Infarction

Objective

This research mainly discusses the influence of prehospital emergency care (PHEC) on the rescue success rate and complication rate of senile patients with acute myocardial infarction (AMI).

Methods

We selected 200 senile AMI patients who visited between January 2019 and January 2021, and retrospectively analyzed their clinical data. According to the differences in nursing methods, the patients were assigned to control group (n = 90) and observation group (n = 110), which were treated with routine nursing and PHEC, respectively. Intergroup comparisons were made in terms of rescue success rate, nursing efficacy, clinical parameters and complication rate.

Results

After investigation, the nursing efficacy was higher in the observation group compared with the control group. Additionally, the observation group was observed with statistically shorter time to thrombolysis and hospital stay, as well as evidently lower mortality and complication rates.

Conclusion

The above demonstrates that PHEC can effectively improve the rescue success rate and rescue efficacy, and facilitate the recovery of senile AMI patients, with a low complication rate compared with the routine care, which plays an important role in ensuring patients' life safety and is worth popularizing clinically.

Public Access Defibrillators and Socioeconomic Factors on the Small—Scale Spatial Level in Berlin

BACKGROUND

The use of a public access defibrillator (PAD) increases the probability of surviving an out-of-hospital cardiac arrest (OHCA). No strategies exist, however, for the optimal distribution of PADs in an urban area in order to meet existing needs and ensure equal access for all potential users. It thus seems likely that the accessibility of PADs on the spatial level varies widely as a function of living circumstances.

METHODS

This cross-sectional study is based on registry data concerning PAD (2022, n = 776) and OHCA (2018-2020, n = 4051), along with data on socioeconomic factors on the spatial level in Berlin (12 districts and 137 subdistricts). Associations of socioeconomic factors with the number of PADs per 10 000 inhabitants and the PAD coverage rate of sites of previous OHCAs were investigated.

RESULTS

The median number of PADs per 10 000 inhabitants ranged from 0.46 to 2.67 at the district level, and only five districts had a median PAD coverage rate of sites of previous OHCAs above 0%, after aggregation of the analyses at the subdistrict level. Subdistricts with a more favorable economic status and a greater income disparity had a higher PAD density. Socially disadvantaged subdistricts had no association with PAD density.

CONCLUSION

There are large deficits in the distribution of PADs at the small-scale spatial level in Berlin with respect to the goals of meeting existing needs and ensuring equal access for all potential users. The findings presented here will be of importance for the planning of future PAD programs so that the distributional efficiency and fairness of PAD in urban areas can be improved.

Health inequities in out-of-hospital cardiac arrest

PURPOSE OF REVIEW

Out-of-hospital cardiac arrest (OHCA) is a time-critical emergency in which a rapid response following the chain of survival is crucial to save life. Disparities in care can occur at each link in this pathway and hence produce health inequities. This review summarises the health inequities that exist for OHCA patients and suggests how they may be addressed.

RECENT FINDINGS

There is international evidence that the incidence of OHCA is increased with increasing deprivation and in ethnic minorities. These groups have lower rates of bystander CPR and bystander-initiated defibrillation, which may be due to barriers in accessing cardiopulmonary resuscitation training, provision of public access defibrillators, and language barriers with emergency call handlers. There are also disparities in the ambulance response and in-hospital care following resuscitation. These disadvantaged communities have poorer survival following OHCA.

SUMMARY

OHCA disproportionately affects deprived communities and ethnic minorities. These groups experience disparities in care throughout the chain of survival and this appears to translate into poorer outcomes. Addressing these inequities will require coordinated action that engages with disadvantaged communities.

Novel Prehospital Phenotypes and Outcomes in Adult-Patients with Acute Disease

An early identification of prehospital phenotypes may allow health care workers to speed up and improve patients’ treatment. To determine emergency phenotypes by exclusively using prehospital clinical data, a multicenter, prospective, and observational ambulance-based study was conducted with a cohort of 3,853 adult patients treated consecutively and transferred with high priority from the scene to the hospital emergency department. Cluster analysis determined three clusters with highly different outcome scores and pathological characteristics. The first cluster presented a 30-day mortality after the index event of 45.9%. The second cluster presented a mortality of 26.3%, while mortality of the third cluster was 5.1%. This study supports the detection of three phenotypes with different risk stages and with different clinical, therapeutic, and prognostic considerations. This evidence could allow adapting treatment to each phenotype thereby helping in the decision-making process.

The potential of new prediction models for emergency medical dispatch prioritisation of patients with chest pain: a cohort study

Objectives

To develop emergency medical dispatch (EMD) centre prediction models with high sensitivity and satisfying specificity to identify high-priority patients and patients suitable for non-emergency care respectively, when assessing patients with chest pain.

Methods

Observational cohort study of 2917 unselected patients with chest pain who contacted an EMD centre in Sweden due to chest pain during 2018. Multivariate logistic regression was applied to develop models predicting low-risk or high-risk condition, that is, occurrence of time-sensitive diagnosis on hospital discharge.

Results

Prediction models were developed for the identification of patients suitable for high- and low-priority dispatch, using 11 and 10 variables respectively. The area under the receiver-operating characteristic curve (AUROC) for the high-risk prediction model was 0.79 and for the low-risk model it was 0.74. When applying the high-risk prediction model, 56% of the EMS missions were given highest priority, compared with 65% with the current standard. When applying the low-risk model, 7% were given the lowest priority compared to 1% for the current standard. The new prediction models outperformed today’s dispatch priority accuracy in terms of sensitivity as well as positive and negative predictive value in both high- and low-risk prediction. The low-risk model predicted almost six times as many patients as having low-risk conditions compared with today’s standard. This was done without increasing the number of high-risk patients wrongly assessed as low-risk.

Conclusions

By introducing prediction models, based on logistic regression analyses, using variables obtained by standard EMD-questions on age, sex, medical history and symptomology, EMD prioritisation can be improved compared with using current criteria index-based ones. This will allow a more efficient emergency medical services resource allocation.

Estimation of Health and Economic Benefits of a Small Automatic External Defibrillator for Rapid Treatment of Sudden Cardiac Arrest (SMART): A Cost-Effectiveness Analysis

Background

Sudden cardiac arrest (SCA) occurs in 0.4% of the general population and up to 6% or more of at-risk groups each year. Early CPR and defibrillation improves SCA outcomes but access to automatic external defibrillators (AEDs) remains limited.

Methods

Markov models were used to evaluate the cost-effectiveness of a portable SMART (SMall AED for Rapid Treatment of SCA) approach to early SCA management over a life-time horizon in at-risk and not at-risk populations. Simulated patients (n = 600,000) who had not received an implantable cardioverter defibrillator (ICD) were randomized to a SMART device with CPR prompts or non-SMART approaches. Annual SCA risk was varied from 0.2 to 3.5%. Analysis was performed in a US economy from both societal (SP) and healthcare (HP) perspectives to evaluate the number of SCA fatalities prevented by SMART, and SMART cost-effectiveness at a threshold of $100,000/Quality Adjusted Life Year (QALY).

Results

A SMART approach was cost-effective when annual SCA risk exceeded 1.51% (SP) and 1.62% (HP). The incremental cost-effectiveness ratios (ICER) were $95,251/QALY (SP) and $100,797/QALY (HP) at a 1.60% SCA annual risk. At a 3.5% annual SCA risk, SMART was highly cost-effective from both SP and HP [ICER: $53,925/QALY (SP), $59,672/QALY (HP)]. In microsimulation, SMART prevented 1,762 fatalities across risk strata (1.59% fatality relative risk reduction across groups). From a population perspective, SMART could prevent at least 109,839 SCA deaths in persons 45 years and older in the United States.

Conclusions and Relevance

A SMART approach to SCA prophylaxis prevents fatalities and is cost-effective in patients at elevated SCA risk. The availability of a smart-phone enabled pocket-sized AED with CPR prompts has the potential to greatly improve population health and economic outcomes.

Structural Discrimination in Emergency Care: How a Sick System Affects Us All

Drawing on evidence of socioeconomic disparities in emergency care, we show how structural discrimination is the most pervasive driver of these disparities, largely because of an inequitable distribution of healthcare services and unequal benefits derived from scientific advancement. We analyze how the market-based healthcare system in the U.S. has created a scenario in which the allocation of emergency care resources does not match community demand for emergency care, resulting in disproportionately poor access, treatment, and outcomes among historically underserved populations. Without fundamental reform, there is little hope for decreasing the health outcome gaps between the "haves" and "have-nots" in the United States.

Emergency activations for chest pain and ventricular arrhythmias related to regional COVID-19 across the US

Evidence that patients may avoid healthcare facilities for fear of COVID-19 infection has heightened the concern that true rates of myocardial infarctions have been under-ascertained and left untreated. We analyzed data from the National Emergency Medical Services Information System (NEMSIS) and incident COVID-19 infections across the United States (US) between January 1, 2020 and April 30, 2020. Grouping events by US Census Division, multivariable adjusted negative binomial regression models were utilized to estimate the relationship between COVID-19 and EMS cardiovascular activations. After multivariable adjustment, increasing COVID-19 rates were associated with less activations for chest pain and non-ST-elevation myocardial infarctions. Simultaneously, increasing COVID-19 rates were associated with more activations for cardiac arrests, ventricular fibrillation, and ventricular tachycardia. Although direct effects of COVID-19 infections may explain these discordant observations, these findings may also arise from patients delaying or avoiding care for myocardial infarction, leading to potentially lethal consequences.

Socio-spatial disparities in access to emergency health care-A Scandinavian case study

Having timely access to emergency health care (EHC) depends largely on where you live. In this Scandinavian case study, we investigate how accessibility to EHC varies spatially in order to reveal potential socio-spatial disparities in access. Distinct measures of EHC accessibility were calculated for southern Sweden in a network analysis using a Geographical Information System (GIS) based on data from 2018. An ANOVA test was carried out to investigate how accessibility vary for different measures between urban and rural areas, and negative binominal regression modelling was then carried out to assess potential disparities in accessibility between socioeconomic and demographic groups. Areas with high shares of older adults show poor access to EHC, especially those in the most remote, rural areas. However, rurality alone does not preclude poor access to EHC. Education, income and proximity to ambulance stations were also associated with EHC accessibility, but not always in expected ways. Despite indications of a well-functioning EHC, with most areas served within one hour, socio-spatial disparities in access to EHC were detected both between places and population groups.

Racial and Socioeconomic Disparities in Out-Of-Hospital Cardiac Arrest Outcomes: Artificial Intelligence-Augmented Propensity Score and Geospatial Cohort Analysis of 3,952 Patients

Introduction

Social disparities in out-of-hospital cardiac arrest (OHCA) outcomes are preventable, costly, and unjust. We sought to perform the first large artificial intelligence- (AI-) guided statistical and geographic information system (GIS) analysis of a multiyear and multisite cohort for OHCA outcomes (incidence and poor neurological disposition).

Method

We conducted a retrospective cohort analysis of a prospectively collected multicenter dataset of adult patients who sequentially presented to Houston metro area hospitals from 01/01/07-01/01/16. Then AI-based machine learning (backward propagation neural network) augmented multivariable regression and GIS heat mapping were performed.

Results

Of 3,952 OHCA patients across 38 hospitals, African Americans were the most likely to suffer OHCA despite representing a significantly lower percentage of the population (42.6 versus 22.8%; p < 0.001). Compared to Caucasians, they were significantly more likely to have poor neurological disposition (OR 2.21, 95%CI 1.25–3.92; p=0.006) and be discharged to a facility instead of home (OR 1.39, 95%CI 1.05–1.85; p=0.023). Compared to the safety net hospital system primarily serving poorer African Americans, the university hospital serving primarily higher income commercially and Medicare insured patients had the lowest odds of death (OR 0.45, p < 0.001). Each additional $10,000 above median household income was associated with a decrease in the total number of cardiac arrests per zip code by 2.86 (95%CI -4.26- -1.46; p < 0.001); zip codes with a median income above $54,600 versus the federal poverty level had 14.62 fewer arrests (p < 0.001). GIS maps showed convergence of the greater density of poor neurologic outcome cases and greater density of poorer African American residences.

Conclusion

This large, longitudinal AI-guided analysis statistically and geographically identifies racial and socioeconomic disparities in OHCA outcomes in a way that may allow targeted medical and public health coordinated efforts to improve clinical, cost, and social equity outcomes.

Impact of Using Drones in Emergency Medicine: What Does the Future Hold?

The use of unmanned aerial vehicles or "drones" has expanded in the last decade, as their technology has become more sophisticated, and costs have decreased. They are now used routinely in farming, environmental surveillance, public safety, commercial product delivery, recreation, and other applications. Health-related applications are only recently becoming more widely explored and accepted. The use of drone technology in emergency medicine is especially promising given the need for a rapid response to enhance patient outcomes. The purpose of this paper is to describe some of the main current and expanding applications of drone technology in emergency medicine and to describe challenges and future opportunities. Current applications being studied include delivery of defibrillators in response to out-of-hospital cardiac arrest, blood and blood products in response to trauma, and rescue medications. Drones are also being studied and actively used in emergency response to search and rescue operations as well as disaster and mass casualty events. Current challenges to expanding their use in emergency medicine and emergency medical system (EMS) include regulation, safety, flying conditions, concerns about privacy, consent, and confidentiality, and details surrounding the development, operation, and maintenance of a medical drone network. Future research is needed to better understand end user perceptions and acceptance. Continued technical advances are needed to increase payload capacities, increase flying distances, and integrate drone networks into existing 9-1-1 and EMS systems. Drones are a promising technology for improving patient survival, outcomes, and quality of life, particularly for those in areas that are remote or that lack funds or infrastructure. Their cost savings compared with ground transportation alone, speed, and convenience make them particularly applicable in the field of emergency medicine. Research to date suggests that use of drones in emergency medicine is feasible, will be accepted by the public, is cost-effective, and has broad application.

Operating an eHealth System for Prehospital and Emergency Health Care Support in Light of Covid-19

Introduction: The support of prehospital and emergency call handling and the impact of Covid-19 is discussed throughout this study. The initial purpose was to create an electronic system (eEmergency system) in order to support, improve, and help the procedure of handling emergency calls. This system was expanded to facilitate needed operation changes for Covid-19.

Materials and Methods: An effort to reform the procedures followed for emergency call handling and Ambulance dispatch started on the Island of Cyprus in 2016; along that direction, a central call centre was created. The electronic system presented in this work was designed for this call centre and the new organization of the ambulance services. The main features are the support for ambulance fleet handling, the support for emergency call evaluation and triage procedure, and the improvement of communication between the call centre and the ambulance vehicles. This system started regular operation at the end of 2018. One year later, when Covid-19 period started, we expanded it with the addition of several new features in order to support the handling of patients infected with the new virus.

Results: This system has handled 112,414 cases during the last 25 months out of which 4,254 were Covid-19 cases. These cases include the transfer of patients from their house to the reference hospital, or the transfer of critical patients from the reference hospital to another hospital with an intensive care unit or transfer of patients from one hospital to another one for other reasons, like the number of admissions.

Conclusion: The main purpose of this study was to create an electronic system (eEmergency system) in order to support, improve, and help the procedure of handling emergency calls. The main components and the architecture of this system are outlined in this paper. This system is being successfully used for 25 months and has been a useful tool from the beginning of the pandemic period of Covid-19.

Geographic and Regional Variability in Racial and Ethnic Disparities in Stroke Thrombolysis in the United States

BACKGROUND AND PURPOSE

Intravenous thrombolysis (IVT) after ischemic stroke is underutilized in racially/ethnically minoritized groups. We aimed to determine the regional and geographic variability in racial/ethnic IVT disparities in the United States.

METHODS

Acute ischemic stroke admissions between 2012 and 2018 were identified in the National Inpatient Sample. Multivariable logistic regression was used to test the association between IVT and race/ethnicity, stratified by geographic region and controlling for demographic, clinical, and hospital characteristics.

RESULTS

Of the 545 509 included cases, 47 031 (8.6%) received IVT. Racially/ethnically minoritized groups had significantly lower adjusted odds of IVT compared with White people in the South Atlantic region (odds ratio [OR], 0.86 [95% CI, 0.82-0.91]), the East North Central region (OR, 0.91 [95% CI, 0.85-0.97]) and the Pacific region (OR, 0.90 [95% CI, 0.85-0.96]). In the South Atlantic region, IVT use in racial/ethnic minority groups was below the national average of all racial/ethnic minority patients (P=0.002). Compared with White patients, Black patients had lower odds of IVT in the Middle Atlantic region (OR, 0.84 [95% CI, 0.78-0.91]), the South Atlantic region (OR, 0.78 [95% CI, 0.74-0.82]), and the East North Central region (OR, 0.86 [95% CI, 0.79-0.93]). In the South Atlantic region, this difference was below the national average for Black people (P<0.001). Hispanic patients had significantly lower use of IVT only in the Pacific region (OR, 0.92 [95% CI, 0.85-0.99]), while Asian/Pacific Islander patients had lower odds of IVT in the Mountain (OR, 0.76 [95% CI, 0.59-0.98]) and Pacific region (OR, 0.89 [95% CI, 0.82-0.97]).

CONCLUSIONS

Racial/ethnic disparities in IVT use in the United States vary by region. Geographic hotspots of lower IVT use in racially/ethnically minoritized groups are the South Atlantic region, driven predominantly by lower use of IVT in Black patients, and the East North Central and Pacific regions.

Barriers and facilitators to cardiopulmonary resuscitation within pre-hospital emergency medical services: a qualitative study

Background

Out-of-hospital cardiopulmonary arrest is a common and fatal problem. Rescuing patients with this problem by pre-hospital emergency medical services is associated with various barriers and facilitators. Identifying these barriers as well as the facilitators in a qualitative and an information-rich way will help to improve the quality of performing the maneuver and to increase the patients’ survival. Therefore, the current study was qualitatively conducted with the aim of identifying the factors affecting the cardiopulmonary resuscitation within the pre-hospital emergency medical services.

Methods

This qualitative study was conducted using a content analysis approach in Iran in 2021. The participants were 16 Iranian emergency medical technicians who were selected through a purposive sampling method. For data collection, in-depth and semi-structured interviews were conducted. For data analysis, the Elo and Kyngäs method was applied.

Results

The mean participants’ age was 33.06 ± 7.85 years, and their mean work experience was 10.62 ± 6.63 years. The collected information was categorized into one main category called “complex context of the cardiopulmonary resuscitation” and 5 general categories with 17 subcategories. These categories and subcategories include patient condition (patient’s underlying diseases, age, high weight, number of children, and place of living), dominant atmosphere in companions at home (companions’ feeling of agitation, companions doing harm, and companions helping), policy (educational policy, human resource policy, up-to-date equipment and technology, and do-not-resuscitate policy), performance of the out-of-organizational system (disorganization in the patient handover process, and cooperation of the support organizations), and conditions related to the treatment team (conscience, cultural dominance, and shift burden).

Conclusions

The results showed that the conditions related to the patient and his/her companions, as well as the organizational factors such as the policies and the out-of-organizational factors act as the barriers and the facilitators to the cardiopulmonary resuscitation within pre-hospital emergency medical services. Therefore, the barriers can be modified and the facilitators can be enhanced by taking various measures such as educating, human resource policy-making, upgrading the equipment, and considering appropriate management policies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00514-3.

Factors associated with destination of pediatric EMS transports

OBJECTIVE

Pediatric patients comprise 13% of emergency medical services (EMS) transports, and most are transported to general emergency departments (ED). EMS transport destination policies may guide when to transport patients to a children's hospital, especially for medical complaints. Factors that influence EMS providers 'decisions about where to transport children are unknown. Our objective was to evaluate the factors associated with pediatric EMS transports to children's hospitals for medical complaints.

METHODS

We performed a cross-sectional study of a large, urban EMS system over a 12-month period for all transports of patients 0-17 years old. We electronically queried the EMS database for demographic data, medical presentation and management, comorbidities, and documented reasons for choosing destination. Distances to the destination hospital and nearest children's and community hospital (if not the transport destination) were calculated. Univariate and multiple logistic regression analyses were conducted to determine the association between independent variables and the transport destination.

RESULTS

We identified 10,065 patients, of which 6982 (69%) were for medical complaints. Of these medical complaints, 3518 (50.4%) were transported to a children's hospital ED. Factors associated with transport to a children's hospital include ALS transport, greater transport distance, protocol determination, developmental delay, or altered consciousness. Factors associated with transport to general EDs were older age, unknown insurance status, lower income, greater distance to children's or community hospital, destination determined by closest facility or diversion, abnormal respiratory rate or blood glucose, psychiatric primary impression, or communication barriers present.

CONCLUSIONS

We found that younger patient age, EMS protocol requirements, and paramedic scene response may influence pediatric patient transport to both children's and community hospitals. Socioeconomic factors, ED proximity, diversion status, respiratory rate, chief complaints, and communication barriers may also be contributing factors. Further studies are needed to determine the generalizability of these findings to other EMS systems.

EMS Access Constraints And Response Time Delays For Deprived Critically Ill Patients Near Paris, France

Increased emergency medical services (EMS) response times and areas of low socioeconomic status are both associated with poorer outcomes for several time-sensitive medical conditions attended to by medical personnel before a patient is hospitalized. We evaluated the association between EMS response times, area deprivation level, and on-scene access constraints encountered by EMS in a large urban area in France. We conducted a multicenter prospective cohort study of EMS dispatches occurring in the forty-seven cities in a region southeast of Paris. We fit multilevel mixed-effects linear regression models for multivariate assessment of the predictors of EMS response times and then used multivariate logistic regression on outcomes among a subgroup of patients presenting with out-of-hospital cardiac arrest. We found evidence that access constraints were more frequently encountered by EMS in the most deprived areas compared to less deprived ones, and were associated with increased EMS response times until patient contact and with poorer outcomes from cardiac arrest. Strategies to anticipate and overcome access constraints should be implemented to improve outcomes for emergent conditions attended to by prehospital medical teams.

Socioeconomic disparities in Rapid ambulance response for out-of-hospital cardiac arrest in a public emergency medical service system: A nationwide observational study

OBJECTIVES

This study aimed to examine whether county socioeconomic status (SES) is associated with emergency medical service (EMS) response time and dual dispatch response of out-of-hospital cardiac arrest (OHCA) patients using county property tax per capita in Korea.

METHODS

All EMS-treated adults who suffered OHCAs were enrolled between 2015 and 2017, excluding cases witnessed by EMS providers. The main exposure was property tax per capita in the county where the OHCA occurred. The primary outcome was response time interval, with a secondary outcome of dual dispatch response. Negative binomial regression analysis to calculate incidence rate ratio (IRR) with a 95% confidence interval (CI) was conducted for EMS response time. A multivariable logistic regression analysis for response time interval (<8 min) and dual dispatch response was also conducted.

RESULTS

A total of 71,326 patients in 228 counties were enrolled. Compared to the lowest SES quartile, OHCA patients in the highest SES quartile had shorter median (interquartile range [IQR]) response time intervals (9.5 [5.9] minutes vs. 7.6 [4.2] minutes, IRR [95% CI] 0.95 [0.94-0.96], respectively). The AOR (95% CI) for response time within 8 min was 1.07 (1.01-1.13) for the highest SES quartile compared to the lowest SES quartile. Those in the highest SES quartile also had higher rates of dual dispatch response compared to those in the lowest quantile (50.9% vs 26.6%; AOR [95% CI]: 2.16 [2.03-2.30]).

CONCLUSION

In OHCA patients, those in a lower SES are associated with longer response times and lower dual dispatch response.

Socioeconomic disparities in prehospital cardiac arrest outcomes: An analysis of the NEMSIS database

BACKGROUND

Socioeconomic disparities are engrained in the US healthcare system and may extend to the prehospital cardiac arrest setting where mortality is high.

METHODS

Using the National Emergency Medical Services Information System (NEMSIS) database, 150,003 cases were analyzed comparing socioeconomic status and cardiac arrest outcomes. Cardiac arrest outcomes were measured by the percent of cases that achieved return of spontaneous circulation (ROSC) and the percent of cases in which ROSC occurred in the Emergency Department (ED) as opposed to a prehospital setting which was a proxy for the length of time spent in cardiac arrest. Chi-square tests checked for statistical significance and effect size was measured using Pearson's r values and linear regression coefficients.

RESULTS

Comparing neighborhood poverty level and the percent of cardiac arrest cases that achieved ROSC resulted in a Pearson's r value of 0.9424 (R² = 0.8881, p < 0.005) and a linear regression coefficient of 2.088 (p < 0.05, R² = 0.8881, 95% CI [1.059, 3.117]) meaning for every interval increase in poverty, the chance of an individual in cardiac arrest achieving ROSC decreases 2.09%. Comparing neighborhood poverty level and the percent of ROSC cases that occurred in the ED yielded a Pearson's r value of 0.9005 (R² = 0.8109, p < 0.05) and a linear regression coefficient of 0.7701 (p < 0.05, R² = 0.8109, 95% CI [0.254, 1.286]) meaning for every interval increase in poverty, the chance that ROSC is delayed increases 0.77%.

CONCLUSIONS

Low income individuals in cardiac arrest have a statistically significant lower probability of achieving ROSC and a higher chance of delayed ROSC.

Shortening Ambulance Response Time Increases Survival in Out-of-Hospital Cardiac Arrest

Background The ambulance response time in out-of-hospital cardiac arrest (OHCA) has doubled over the past 30 years in Sweden. At the same time, the chances of surviving an OHCA have increased substantially. A correct understanding of the effect of ambulance response time on the outcome after OHCA is fundamental for further advancement in cardiac arrest care. Methods and Results We used data from the SRCR (Swedish Registry of Cardiopulmonary Resuscitation) to determine the effect of ambulance response time on 30-day survival after OHCA. We included 20 420 cases of OHCA occurring in Sweden between 2008 and 2017. Survival to 30 days was our primary outcome. Stratification and multiple logistic regression were used to control for confounding variables. In a model adjusted for age, sex, calendar year, and place of collapse, survival to 30 days is presented for 4 different groups of emergency medical services (EMS)-crew response time: 0 to 6 minutes, 7 to 9 minutes, 10 to 15 minutes, and >15 minutes. Survival to 30 days after a witnessed OHCA decreased as ambulance response time increased. For EMS response times of >10 minutes, the overall survival among those receiving cardiopulmonary resuscitation before EMS arrival was slightly higher than survival for the sub-group of patients treated with compressions-only cardiopulmonary resuscitation. Conclusions Survival to 30 days after a witnessed OHCA decreases as ambulance response times increase. This correlation was seen independently of initial rhythm and whether cardiopulmonary resuscitation was performed before EMS-crew arrival. Shortening EMS response times is likely to be a fast and effective way of increasing survival in OHCA.

Evaluation of STEMI Regionalization on Access, Treatment, and Outcomes Among Adults Living in Nonminority and Minority Communities

IMPORTANCE

Cardiac care regionalization, specifically for patients with ST-segment elevation myocardial infarction (STEMI), has been touted as a potential mechanism to reduce systematic disparities by protocolizing the treatment of these conditions. However, it is unknown whether such regionalization arrangements have widened or narrowed disparities in access, treatment, and outcomes for minority communities.

OBJECTIVE

To determine the extent to which disparities in access, treatment, and outcomes have changed for patients with STEMI living in zip codes that are in the top tertile of the Black or Hispanic population compared with patients in nonminority zip codes in regionalized vs nonregionalized counties.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used a quasi-experimental approach exploiting the different timing of regionalization across California. Nonpublic inpatient data for all patients with STEMI from January 1, 2006, to October 31, 2015, were analyzed using a difference-in-difference-in-differences estimation approach.

EXPOSURE

Exposure to the intervention was defined as on and after the year a patient's county was exposed to regionalization.

MAIN OUTCOMES AND MEASURES

Access to percutaneous coronary intervention (PCI)-capable hospital, receipt of PCI on the same day and at any time during the hospitalization, and time-specific all-cause mortality.

RESULTS

This study included 139 494 patients with STEMI; 61.9% of patients were non-Hispanic White, 5.6% Black, 17.8% Hispanic, and 9.0% Asian; 32.8% were women. Access to PCI-capable hospitals improved by 6.3 percentage points (95% CI, 5.5 to 7.1 percentage points; P < .001) when patients in nonminority communities were exposed to regionalization. Patients in minority communities experienced a 1.8-percentage point smaller improvement in access (95% CI, -2.8 to -0.8 percentage points; P < .001), or 28.9% smaller, compared with those in nonminority communities when both were exposed to regionalization. Regionalization was associated with an improvement to same-day PCI and in-hospital PCI by 5.1 percentage points (95% CI, 4.2 to 6.1 percentage points; P < .001) and 5.0 percentage points (95% CI, 4.2 to 5.9 percentage points; P < .001), respectively, for patients in nonminority communities. Patients in minority communities experienced only 33.3% and 15.1% of that benefit. Only White patients in nonminority communities experienced mortality improvement from regionalization.

CONCLUSIONS AND RELEVANCE

Although regionalization was associated with improved access to PCI hospitals and receipt of PCI treatment, patients in minority communities derived significantly smaller improvement relative to those in nonminority communities.

Efficacy of a five-minute compression-only cardiopulmonary resuscitation class compared to thirty-minute instruction among college students

Objective

To determine if 5-minute compression-only cardiopulmonary resuscitation (CCO-CPR) instruction is as effective as 30-minute instruction in improving participant knowledge and comfort with performing CCO-CPR as well as teaching CPR quality and responsiveness to an Out of Hospital Cardiac Arrest (OHCA).

Methods

A prospective randomized controlled trial of university undergraduates was performed. Participants were randomized to either a 5-minute (experimental) or 30-minute (control) CCO-CPR instruction class. Pre- and post-testing was performed with a written and simulation test. Measurements collected assessed rate and depth of compressions, time to call 911, and time to start chest compressions. Prior to instruction, subjects’ baseline measurements of CPR performance were evaluated during a standardized sudden death scenario using a Laerdal Skillreporter^TM mannequin. The written test and scenario were repeated after either the five or 30 ​minute CCO-CPR instruction using the same outcome measures. Statistical tests of association for categorical variables were assessed using the chi-square test and the independent samples t-test was utilized for continuous variables. All tests were two-sided and the level of significance was set at α ​= ​0.05.

Results

Among the 59 participants, 28 received 5 ​minutes of instruction and 31 received 30 ​minutes. Fifteen (25.4%) individuals reported prior CPR training. Post intervention, all measurements reached statistically significant improvements in each group but there was no difference between the two groups improvement in depth of compressions (experimental group: 41.8 ​mm, 95% CI 36.6–43.4 vs control group: 46.5 ​mm, 95% CI 40.9–48.3, p ​= ​0.06), compressions per minute (114.3 cpm, 95% CI 105.5–122.0 vs 121.1 cpm, 95% CI 115.1–131.4, p ​= ​0.10), time to starting chest compressions (13.5 vs 12.4 ​sec, p ​= ​0.45), or time to calling 911 (8.34 vs 7.65 ​sec, p ​= ​0.58). Further, there was a statistically significant improvement in participants that said they would probably or definitely perform CCO-CPR in real life after both interventions but no difference between the groups (100% of the experimental group and 93.5% of the control group p ​< ​0.49).

Conclusion

Five-minute instruction is not inferior to 30-minute instruction at teaching undergraduate students how to perform quality bystander CCO-CPR.

The association of scene-access delay and survival with favourable neurological status in patients with out-of-hospital cardiac arrest

BACKGROUND

Rapid emergency medical service (EMS) response after out-of-hospital cardiac arrest (OHCA) is a major determinant of survival, however this is typically measured until EMS vehicle arrival. We sought to investigate whether the interval from EMS vehicle arrival to patient attendance (curb-to-care interval [CTC]) was associated with patient outcomes.

METHODS

We performed a secondary analysis of the "CCC Trial" dataset, which includes EMS-treated adult non-traumatic OHCA. We fit an adjusted logistic regression model to estimate the association between CTC interval (divided into quartiles) and the primary outcome (survival with favourable neurologic status at hospital discharge; mRS ≤ 3). We described the CTC interval distribution among enrolling clusters.

RESULTS

We included 24,685 patients: median age was 68 (IQR 56-81), 23% had initial shockable rhythms, and 7.6% survived with favourable neurological status. Compared to the first quartile (≤62 s), longer CTC quartiles (63-115, 116-180, and ≥181 s) demonstrated the following associations with survival with favourable neurological status: adjusted odds ratios 0.95, 95% CI 0.83-1.09; 0.77, 95% CI 0.66-0.89; 0.66, 95% CI 0.56-0.77, respectively. Of the 49 study clusters, median CTC intervals ranged from 86 (IQR 58-130) to 179 s (IQR 112-256).

CONCLUSION

A lower CTC interval was associated with improved patient outcomes. These results demonstrate a wide range of access metrics within North America, and provide a rationale to create protocols to mitigate access obstacles. A 2-min CTC threshold may represent an appropriate target for quality improvement.

Effects of hourly precipitation and temperature on ambulance response time

BACKGROUND

Longer ambulance response time (ART) delaying treatment would worsen conditions of seriously ill or injured patients, but limited evidence is available on the effects of weather factors on ART. This study aims to assess precipitation- and temperature-ART associations and their potential lagged effects using a novel modeling strategy.

METHODS

Based on 779,156 emergency records during 2010-2016 from the whole population in Shenzhen, China, we creatively combined quantile regression with distributed-lag nonlinear models to examine the non-linear and lagged effects of hourly precipitation and temperature on ART at the 50th and 90th percentiles.

RESULTS

A linear precipitation-ART association with a delay of 9.01 (95%CI, 7.82-10.20) seconds at median ART for a 1 mm increase in hourly precipitation, and the effects lasted for 5 h with the greatest effect at the current hour. A two linear thresholds temperature-ART association revealed 1 °C decrease below 19 °C caused 1.68 (95%CI, 0.92-2.44) seconds delay in total ART over lag 0-7 h, and 1 °C increase above 24 °C caused 2.44 (95%CI, 1.55-3.33) seconds delay. The hourly call volumes exceeding 54 calls caused 8.79 (95%CI, 8.71-8.86) seconds delay in total ART for 1 more call, but not affected the effects of weather factors. The internal ART suffered more from the hourly call volumes, while the external ART suffered more from precipitation and temperature. The effects were apparently greater on ART at the 90th percentile than median.

CONCLUSIONS

Precipitation and temperature are independent risk factors for ambulance services performance, and their lagged effects are notable. The external ART and patients with long ART are vulnerable. More attention should be paid to weather and ART, and these findings may have implications for effective policies to reduce ART to protect public health.