Delays in Emergency Care and Mortality during Major U.S. Marathons

Survival of out-of-hospital cardiac arrest patients admitted to the hospital during the Tokyo Summer Olympic and Paralympic Games in Japan

Background

The influence of the Tokyo Summer Olympic/Paralympic Games on normal emergency medical system operations in Japan had not yet been fully elucidated. In this study, we examined whether out-of-hospital cardiac arrest (OHCA) patients treated during the Tokyo Olympic/Paralympic Games had differences in outcomes.

Methods

Using the nationwide JAAM-OHCA Registry, we evaluated the outcomes of OHCA patients admitted to the hospital during the Tokyo Olympic/Paralympic Games (July 23 to Aug. 8 and Aug. 24 to Sept. 5) in 2021, compared to those during same the dates in 2020 (Term 1: July 23 to Aug. 8 and Aug. 24 to Sept. 5), those during the pre-Olympic/Paralympic term during the same weekdays in the weeks before the event (Term 2: June. 18 to July. 4 and July. 6 to July. 18), and those during the post-Olympic/Paralympic term during the same weekdays in the weeks after the event (Term 3: Sept. 10 to Sept. 26 and Sept. 28 to Oct. 10). The primary outcome was 30-day survival, and multivariable logistic analysis was performed, adjusted for age and sex.

Results

A total of 3,111 OHCA patients were included in the study period (786 in the Olympic/Paralympic group, 774 in Term 1, 747 in Term 2, and 804 in Term 3). Crude 30-day survivals were 7.4% (58/786), 9.3% (72/774), 6.8% (51/747), and 8.2% (66/804), respectively. Using the Olympic/Paralympic group as a reference, multivariable logistic analysis revealed that 30-day survivals in Term 1 (OR 1.27 95% CI 0.88-1.83p = 0.20), Term 2 (OR 0.92 95% CI 0.62-1.36p = 0.67), and Term 3 (OR 1.10 95% CI 0.76-1.59p = 0.63) did not differ significantly.

Conclusions

No significant differences in 30-day survival for OHCA patients admitted during the Tokyo Summer Olympic/Paralympic Games were identified.

Mass Gathering Events at an Event Hall in Osaka Are a Non-direct Risk of Admission to a Neighboring Emergency Hospital

BACKGROUND

The influence of planned mass gathering events on surrounding residents is not understood sufficiently.

OBJECTIVES

The purpose of this study was to investigate how events at an event hall affect a neighboring emergency hospital throughout the year.

METHODS

This was a single-center, retrospective, observational study conducted on all patients who presented to the emergency department from January 1 to December 31, 2019. The event hall is located 200 meters from the hospital, and various events such as music concerts and professional baseball games are held at the hall throughout the year. We collected patient information from the electronic medical records. The factors associated with hospitalization were assessed using a multivariable logistic regression analysis.

RESULTS

This study comprised 18,907 patients who visited our emergency department. The number of patients on event days was 9,981 and that on no-event days was 8,922. The mean (SD) number of patients visiting on event days was 56.4 (14.9), and that on no-event days was 47.5 (14.1) (p<0.05). The multivariable logistics regression analysis showed age (adjusted odds ratio (AOR): 1.03; 95% confidence interval (CI): 1.03-1.04), male gender (AOR: 1.21; 95% CI: 1.13-1.31), transportation by emergency medical services (AOR: 2.56; 95% CI: 2.37-2.75), rain days (AOR: 1.14; 95% CI: 1.04-1.23), and event day (AOR: 1.11; 95% CI: 1.02-1.20) to be independent risk factors of hospitalization.

CONCLUSIONS

In this study, we found that event day was one of the independent risk factors of admission to the hospital from the emergency department.

Impact of Severe Winter Weather on Operations of a Radiation Oncology Department

Purpose

During winter 2022, western New York faced 2 major storms with blizzard conditions and record-breaking snowfall. The severe weather resulted in power outages and travel bans. This study investigates the impact of these conditions on patient adherence to radiation therapy. Combining data from a large academic center and its satellite clinic, this single-center study sheds light on the challenges faced by cancer care facilities during severe weather and proposes suggestions to prevent and mitigate harm done by severe weather.

Methods and Materials

In this study, data were collected using the MOSAIQ Record and Verify system (v. 2.81) to generate deidentified reports of scheduled and treated patients. The treatment adherence rate was calculated by dividing the number of patients treated by the total number of patients scheduled. Data were specifically collected for patients undergoing treatment on linear accelerators at a primary academic center and a satellite facility. The study focused on working days from November 1, 2022, to March 31, 2023, excluding weekends and holidays (as treatments are not routinely scheduled). Severe weather days were identified using advisories from the National Weather Service and the local institution, including specific periods in November, December, and January.

Results

In the study, 15,010 scheduled treatment visits were recorded across the academic center and the satellite clinic. The mean daily treatment adherence rate was 91.7%. Severe weather conditions led to a significant reduction in adherence, with rates dropping to 77.8%. Adherence rates during nonsevere weather days were notably higher at 93.9%. Statistical analysis confirmed the substantial influence of severe weather on adherence (P < .001). Severe weather had a more pronounced impact on the satellite clinic during periods of severe weather, with absolute reduction in adherence rates of 21.9% versus 15% in the primary hospital. Moreover, adherence at the satellite clinic was lower than at the primary hospital site even under standard operating conditions (92.2% vs 94.0%, P < .001).

Conclusion

As a part of operational planning, it is important to be aware how severe weather can impact treatment adherence. Study findings underscore the importance of proactive measures to ensure patient access to health care services during adverse weather events and highlight the broader significance of incorporating consideration of social determinants of health into contingency planning for maintaining treatment continuity.

Social mass gathering events influence emergency medical services call volume

Background

Prior literature suggests that mass gathering events pose challenges to an emergency medical services (EMS) system. We aimed to investigate whether events influence EMS call rates.

Materials and methods

This study is a retrospective review of all primary response ambulance calls in Rhode Island (US) between January 1st, 2018 and August 31st, 2022. The number of EMS calls per day was taken from the state's EMS registry. Event data was collected using a Google (Google LLC, Mountain View, CA) search. We used separate Poisson regression models with the number of ambulance calls as the dependent and the social event categories sports, agricultural, music events, and public exhibitions as independent variables. All models controlled for the population at risk and the period of the COVID-19 pandemic. Results are presented as increases or decreases in calls per 100,000 inhabitants from the mean over the study period.

Results

The mean number of daily EMS calls was 38 ± 4 per 100,000 inhabitants. EMS encountered significantly more missions on days with music events (+3, 95% CI [2; 3]) and public exhibitions (+2, 95% CI [1; 2]). In contrast, days with agricultural events were associated with fewer calls (-1, 95% CI [-1; 0]). We did not find any effect of sports events on call rates.

Conclusion

Increased ambulance call volumes are observed on days with music events and public exhibitions. Days with agricultural events are associated with fewer EMS calls.

How important are delays in treatment for health outcomes? The case of ambulance response time and cardiovascular events

The cost effectiveness of medical treatments is not precisely known due to the compounding effect of multiple determining factors. Ambulance response time (RT) to emergency calls is exploited to learn more about the effect of the timing of treatment on health outcomes. This causal relation is identified by exploiting rainfall at the time of the ambulance run as a shock to RT. The analysis focuses on patients who have undergone a cardiac event and shows that a one-minute increase in average RT leads to 105 more deaths each year in one Italian region. Finally, the economic value of the lives that would be saved by reducing RT is quantified to facilitate policymaking.

Ransomware Cyberattack Associated With Cardiac Arrest Incidence and Outcomes at Untargeted, Adjacent Hospitals

OBJECTIVES

Healthcare ransomware cyberattacks have been associated with major regional hospital disruptions, but data reporting patient-oriented outcomes in critical conditions such as cardiac arrest (CA) are limited. This study examined the CA incidence and outcomes of untargeted hospitals adjacent to a ransomware-infected healthcare delivery organization (HDO).

DESIGN SETTING AND PATIENTS

This cohort study compared the CA incidence and outcomes of two untargeted academic hospitals adjacent to an HDO under a ransomware cyberattack during the pre-attack (April 3-30, 2021), attack (May 1-28, 2021), and post-attack (May 29, 2021-June 25, 2021) phases.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Emergency department and hospital mean daily census, number of CAs, mean daily CA incidence per 1,000 admissions, return of spontaneous circulation, survival to discharge, and survival with favorable neurologic outcome were measured. The study evaluated 78 total CAs: 44 out-of-hospital CAs (OHCAs) and 34 in-hospital CAs. The number of total CAs increased from the pre-attack to attack phase (21 vs. 38; p = 0.03), followed by a decrease in the post-attack phase (38 vs. 19; p = 0.01). The number of total CAs exceeded the cyberattack month forecast (May 2021: 41 observed vs. 27 forecasted cases; 95% CI, 17.0-37.4). OHCA cases also exceeded the forecast (May 2021: 24 observed vs. 12 forecasted cases; 95% CI, 6.0-18.8). Survival with favorable neurologic outcome rates for all CAs decreased, driven by increases in OHCA mortality: survival with favorable neurologic rates for OHCAs decreased from the pre-attack phase to attack phase (40.0% vs. 4.5%; p = 0.02) followed by an increase in the post-attack phase (4.5% vs. 41.2%; p = 0.01).

CONCLUSIONS

Untargeted hospitals adjacent to ransomware-infected HDOs may see worse outcomes for patients suffering from OHCA. These findings highlight the critical need for cybersecurity disaster planning and resiliency.

The Lancet Commission to reduce the global burden of sudden cardiac death: a call for multidisciplinary action

Despite major advancements in cardiovascular medicine, sudden cardiac death (SCD) continues to be an enormous medical and societal challenge, claiming millions of lives every year. Efforts to prevent SCD are hampered by imperfect risk prediction and inadequate solutions to specifically address arrhythmogenesis. Although resuscitation strategies have witnessed substantial evolution, there is a need to strengthen the organisation of community interventions and emergency medical systems across varied locations and health-care structures. With all the technological and medical advances of the 21st century, the fact that survival from sudden cardiac arrest (SCA) remains lower than 10% in most parts of the world is unacceptable. Recognising this urgent need, the Lancet Commission on SCD was constituted, bringing together 30 international experts in varied disciplines. Consistent progress in tackling SCD will require a completely revamped approach to SCD prevention, with wide-sweeping policy changes that will empower the development of both governmental and community-based programmes to maximise survival from SCA, and to comprehensively attend to survivors and decedents' families after the event. International collaborative efforts that maximally leverage and connect the expertise of various research organisations will need to be prioritised to properly address identified gaps. The Commission places substantial emphasis on the need to develop a multidisciplinary strategy that encompasses all aspects of SCD prevention and treatment. The Commission provides a critical assessment of the current scientific efforts in the field, and puts forth key recommendations to challenge, activate, and intensify efforts by both the scientific and global community with new directions, research, and innovation to reduce the burden of SCD worldwide.

Ransomware Attack Associated With Disruptions at Adjacent Emergency Departments in the US

Importance

Cyberattacks on health care delivery organizations are increasing in frequency and sophistication. Ransomware infections have been associated with significant operational disruption, but data describing regional associations of these cyberattacks with neighboring hospitals have not been previously reported, to our knowledge.

Objective

To examine an institution's emergency department (ED) patient volume and stroke care metrics during a month-long ransomware attack on a geographically proximal but separate health care delivery organization.

Design, Setting, and Participants

This before and after cohort study compares adult and pediatric patient volume and stroke care metrics of 2 US urban academic EDs in the 4 weeks prior to the ransomware attack on May 1, 2021 (April 3-30, 2021), as well as during the attack and recovery (May 1-28, 2021) and 4 weeks after the attack and recovery (May 29 to June 25, 2021). The 2 EDs had a combined mean annual census of more than 70 000 care encounters and 11% of San Diego County's total acute inpatient discharges. The health care delivery organization targeted by the ransomware constitutes approximately 25% of the regional inpatient discharges.

Exposure

A month-long ransomware cyberattack on 4 adjacent hospitals.

Main Outcomes and Measures

Emergency department encounter volumes (census), temporal throughput, regional diversion of emergency medical services (EMS), and stroke care metrics.

Results

This study evaluated 19 857 ED visits at the unaffected ED: 6114 (mean [SD] age, 49.6 [19.3] years; 2931 [47.9%] female patients; 1663 [27.2%] Hispanic, 677 [11.1%] non-Hispanic Black, and 2678 [43.8%] non-Hispanic White patients) in the preattack phase, 7039 (mean [SD] age, 49.8 [19.5] years; 3377 [48.0%] female patients; 1840 [26.1%] Hispanic, 778 [11.1%] non-Hispanic Black, and 3168 [45.0%] non-Hispanic White patients) in the attack and recovery phase, and 6704 (mean [SD] age, 48.8 [19.6] years; 3326 [49.5%] female patients; 1753 [26.1%] Hispanic, 725 [10.8%] non-Hispanic Black, and 3012 [44.9%] non-Hispanic White patients) in the postattack phase. Compared with the preattack phase, during the attack phase, there were significant associated increases in the daily mean (SD) ED census (218.4 [18.9] vs 251.4 [35.2]; P < .001), EMS arrivals (1741 [28.8] vs 2354 [33.7]; P < .001), admissions (1614 [26.4] vs 1722 [24.5]; P = .01), patients leaving without being seen (158 [2.6] vs 360 [5.1]; P < .001), and patients leaving against medical advice (107 [1.8] vs 161 [2.3]; P = .03). There were also significant associated increases during the attack phase compared with the preattack phase in median waiting room times (21 minutes [IQR, 7-62 minutes] vs 31 minutes [IQR, 9-89 minutes]; P < .001) and total ED length of stay for admitted patients (614 minutes [IQR, 424-1093 minutes] vs 822 minutes [IQR, 497-1524 minutes]; P < .001). There was also a significant increase in stroke code activations during the attack phase compared with the preattack phase (59 vs 102; P = .01) as well as confirmed strokes (22 vs 47; P = .02).

Conclusions and Relevance

This study found that hospitals adjacent to health care delivery organizations affected by ransomware attacks may see increases in patient census and may experience resource constraints affecting time-sensitive care for conditions such as acute stroke. These findings suggest that targeted hospital cyberattacks may be associated with disruptions of health care delivery at nontargeted hospitals within a community and should be considered a regional disaster.

Characterization of prehospital time delay in primary percutaneous coronary intervention for acute myocardial infarction: analysis of geographical infrastructure-dependent and -independent components

BACKGROUND

Prehospital delay in reaching a percutaneous coronary intervention (PCI) facility is a major problem preventing early coronary reperfusion in patients with ST-elevation myocardial infarction (STEMI). The aim of this study was to identify modifiable factors that contribute to the interval from symptom onset to arrival at a PCI-capable center with a focus on geographical infrastructure-dependent and -independent factors.

METHODS

We analyzed data from 603 STEMI patients who received primary PCI within 12 h of symptom onset in the Hokkaido Acute Coronary Care Survey. We defined onset-to-door time (ODT) as the interval from the onset of symptoms to arrival at the PCI facility and we defined door-to-balloon time (DBT) as the interval from arrival at the PCI facility to PCI. We analyzed the characteristics and factors of each time interval by type of transportation to PCI facilities. In addition, we used geographical information system software to calculate the minimum prehospital system time (min-PST), which represents the time required to reach a PCI facility based on geographical factors. We then subtracted min-PST from ODT to find the estimated delay-in-arrival-to-door (eDAD), which represents the time required to reach a PCI facility independent of geographical factors. We investigated the factors related to the prolongation of eDAD.

RESULTS

DBT (median [IQR]: 63 [44, 90] min) was shorter than ODT (median [IQR]: 104 [56, 204] min) regardless of the type of transportation. However, ODT was more than 120 min in 44% of the patients. The min-PST (median [IQR]: 3.7 [2.2, 12.0] min) varied widely among patients, with a maximum of 156 min. Prolongation of eDAD (median [IQR]: 89.1 [49, 180] min) was associated with older age, absence of a witness, onset at night, no emergency medical services (EMS) call, and transfer via a non-PCI facility. If eDAD was zero, ODT was projected to be less than 120 min in more than 90% of the patients.

CONCLUSIONS

The contribution of geographical infrastructure-dependent time in prehospital delay was substantially smaller than that of geographical infrastructure-independent time. Intervention to shorten eDAD by focusing on factors such as older age, absence of a witness, onset at night, no EMS call, and transfer via a non-PCI facility appears to be an important strategy for reducing ODT in STEMI patients. Additionally, eDAD may be useful for evaluating the quality of STEMI patient transport in areas with different geographical conditions.

Kidney health for all: preparedness for the unexpected in supporting the vulnerable

As the rate of natural disasters and other devastating events caused by human activities increases, the burden on the health and well-being of those affected by kidney disease has been immeasurable. Health system preparedness, which involves creating a resilient system that is able to deal with the health needs of the entire community during times of unexpected disruptions to usual care, has become globally important. In the wake of the COVID-19 pandemic, there is a heightened awareness of the amplification of negative effects on the renal community. Paradoxically, the complex medical needs of those who have kidney diseases are not met by systems handling crises, often compounded by an acute increase in burden via new patients as a result of the crisis itself. Disruptions in kidney care as a result of unexpected events are becoming more prevalent and likely to increase in the years to come. It is therefore only appropriate that the theme for this year's World Kidney Day will focus on Kidney Health for All: preparedness for the unexpected in supporting the vulnerable.

Unmanned Aerial Vehicle Mediated Drug Delivery for First Aid

Timely administration of key medications toward patients with sudden diseases is critical to saving lives. However, slow transport of first-aid therapeutics and the potential absence of trained people for drug usage can lead to severe injuries or even death. Herein, an unmanned aerial vehicle (UAV)-mediated first-aid system for targeted delivery (uFAST) is developed. It allows unattended administration of emergency therapeutics-loaded transdermal microneedle (MN) patches toward patients to relieve symptoms by a contact-triggered microneedle applicator (CTMA). The implementability and safety of the uFAST for first aid is demonstrated in a severe hypoglycemic pig model by automatically delivering a glucagon patch with immediate and bioresponsive dual release modes. This platform technique may facilitate the development of UAV-mediated first-aid treatments for other sudden diseases.

Are hospitals with both medical/surgical and psychiatric services associated with decreased difficulty in ambulance transfer for patients with self-harm behaviour? A nationwide retrospective observational study using ambulance transfer data in Japan

OBJECTIVES

Ambulance diversion and prolonged prehospital transfer time have a significant impact on patient care outcomes. Self-harm behaviour in particular is associated with difficulty in hospital acceptance and longer prehospital transfer time. This study aimed to determine if hospitals with both medical/surgical and psychiatric inpatient beds and high-level emergency care centres are associated with a decreased rate of difficulty in hospital acceptance and shorter prehospital transfer time for patients seeking medical care after self-harm behaviour.

DESIGN AND SETTING

A retrospective observational study using the database of Japanese ambulance dispatch data in 2015.

PARTICIPANTS

Patients who were transferred by ambulances after self-harm behaviour.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Multivariable logistic regression analysis and multivariable linear regression analysis were performed to assess whether the presence of hospitals with both medical/surgical and psychiatric inpatient beds and high-level emergency care centres in the city were associated with a decreased rate of difficulty in hospital acceptance and shorter prehospital transfer time.

RESULTS

The number of transfers due to self-harm behaviour in 2015 was 32 849. There was an association between decreased difficulty in hospital acceptance and the presence of high-level emergency care centres (OR 0.63, 95% CI 0.55 to 0.71, p<0.01) and hospitals with both medical/surgical and psychiatric inpatient beds (OR 0.50, 95% CI 0.38 to 0.66, p<0.01). There was a significant reduction in prehospital transfer time in the city with high-level emergency care centres (4.21 min, 95% CI 3.53 to 4.89, p<0.01) and hospitals with medical/surgical and psychiatric inpatient beds (3.46 min, 95% CI 2.15 to 4.77, p<0.01).

CONCLUSION

Hospitals with both medical/surgical and psychiatric inpatient beds and high-level emergency care centres were associated with significant decrease in difficulty in hospital acceptance and shorter prehospital transfer time.

Organ Donation and Transplants During Major US Motorcycle Rallies

Importance

Large-scale motorcycle rallies attract thousands of attendees and are associated with increased trauma-related morbidity and mortality.

Objective

To examine the association of major US motorcycle rallies with the incidence of organ donation and transplants.

Design, Setting, and Participants

This population-based, retrospective cross-sectional study used data from the Scientific Registry of Transplant Recipients for deceased organ donors aged 16 years or older involved in a motor vehicle crash and recipients of organs from these donors from March 2005 to September 2021.

Exposure

Dates of 7 large US motorcycle rallies and regions near these events.

Main Outcomes and Measures

The main outcomes were incidence of motor vehicle crash-related organ donation and number of patients receiving a solid organ transplant from these donors. An event study design was used to estimate adjusted rates of organ donation during the dates of 7 major US motorcycle rallies compared with the 4 weeks before and after the rallies in rally-affected and rally-unaffected (control) regions. Donor and recipient characteristics and metrics of organ quality were compared between rally and nonrally dates.

Results

The study included 10 798 organ donors (70.9% male; mean [SD] age, 32.5 [13.7] years) and 35 329 recipients of these organs (64.0% male; 49.3 [15.5] years). During the rally dates, there were 406 organ donors and 1400 transplant recipients. During the 4 weeks before and after the rallies, there were 2332 organ donors and 7714 transplant recipients. Donors and recipients during rally and nonrally dates were similar in demographic and clinical characteristics, measures of organ quality, measures of recipient disease severity, and recipient waiting time. During rallies, there were 21% more organ donors per day (incidence rate ratio [IRR], 1.21; 95% CI, 1.09-1.35; P = .001) and 26% more transplant recipients per day (IRR, 1.26; 95% CI, 1.12-1.42; P < .001) compared with the 4 weeks before and after the rallies in the regions where they were held.

Conclusions and Relevance

In this cross-sectional study, major motorcycle rallies in the US were associated with increased incidence of organ donation and transplants. While safety measures to minimize morbidity and mortality during motorcycle rallies should be prioritized, this study showed the downstream association of these events with organ donation and transplants.

Understanding the impact of lockdowns on short-term excess mortality in Australia

During 2020 and 2021, Australia implemented relatively stringent government restrictions yet had few COVID-19 deaths. This provides an opportunity to understand the effects of lockdowns and quarantining restrictions on short-term mortality and to help provide evidence in understanding how such public health policies can impact on health. Our analysis is based on preliminary mortality data collected by the Australian Bureau of Statistics. Rates were estimated by disease and over time and compared with mortality statistics in the period 2015-2019. Comparing deaths in 2020-2021 with 2015-2019 show the annual mortality rate (per 100 000 people) fell by 5.9% from 528.4 in 2015-2019 to 497.0 in 2020-2021. Declines in mortality are across many disease categories including respiratory diseases (down 9.4 deaths per 100 000), cancer (down 7.5 deaths per 100 000) and heart disease (down 8.4 deaths per 100 000). During 2020 and 2021, Australian age-standardised mortality rates fell by 6%. This drop was similar for men and women, and was driven by a reduction in both communicable and non-communicable causes of death. Such evidence can help inform public health policies designed to both control COVID-19 and other infectious diseases.

Ambulance diversion and ED destination by race/ethnicity: evaluation of Massachusetts' ambulance diversion ban

Background

The impact of ambulance diversion on potentially diverted patients, particularly racial/ethnic minority patients, is largely unknown. Treating Massachusetts’ 2009 ambulance diversion ban as a natural experiment, we examined if the ban was associated with increased concordance in Emergency Medical Services (EMS) patients of different race/ethnicity being transported to the same emergency department (ED).

Methods

We obtained Medicare Fee for Service claims records (2007–2012) for enrollees aged 66 and older. We stratified the country into patient zip codes and identified zip codes with sizable (non-Hispanic) White, (non-Hispanic) Black and Hispanic enrollees. For a stratified random sample of enrollees from all diverse zip codes in Massachusetts and 18 selected comparison states, we identified EMS transports to an ED. In each zip code, we identified the most frequent ED destination of White EMS-transported patients (“reference ED”). Our main outcome was a dichotomous indicator of patient EMS transport to the reference ED, and secondary outcome was transport to an ED serving lower-income patients (“safety-net ED”). Using a difference-in-differences regression specification, we contrasted the pre- to post-ban changes in each outcome in Massachusetts with the corresponding change in the comparison states.

Results

Our study cohort of 744,791 enrollees from 3331 zip codes experienced 361,006 EMS transports. At baseline, the proportion transported to the reference ED was higher among White patients in Massachusetts and comparison states (67.2 and 60.9%) than among Black (43.6 and 46.2%) and Hispanic (62.5 and 52.7%) patients. Massachusetts ambulance diversion ban was associated with a decreased proportion transported to the reference ED among White (− 2.7 percentage point; 95% CI, − 4.5 to − 1.0) and Black (− 4.1 percentage point; 95% CI, − 6.2 to − 1.9) patients and no change among Hispanic patients. The ban was associated with an increase in likelihood of transport to a safety-net ED among Hispanic patients (3.0 percentage points, 95% CI, 0.3 to 5.7) and a decreased likelihood among White patients (1.2 percentage points, 95% CI, − 2.3 to − 0.2).

Conclusion

Massachusetts ambulance diversion ban was associated with a reduction in the proportion of White and Black EMS patients being transported to the most frequent ED destination for White patients, highlighting the role of non-proximity factors in EMS transport destination.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08358-8.

The Impact of Delayed Symptomatic Treatment Implementation in the Intensive Care Unit

We estimated the harm related to medication delivery delays across 12,474 medication administration instances in an intensive care unit using retrospective data in a large urban academic medical center between 2012 and 2015. We leveraged an instrumental variables (IV) approach that addresses unobserved confounds in this setting. We focused on nurse shift changes as disruptors of timely medication (vasodilators, antipyretics, and bronchodilators) delivery to estimate the impact of delay. The average delay around a nurse shift change was 60.8 min (p < 0.001) for antipyretics, 39.5 min (p < 0.001) for bronchodilators, and 57.1 min (p < 0.001) for vasodilators. This delay can increase the odds of developing a fever by 32.94%, tachypnea by 79.5%, and hypertension by 134%, respectively. Compared to estimates generated by a naïve regression approach, our IV estimates tend to be higher, suggesting the existence of a bias from providers prioritizing more critical patients.

[Medical emergencies during running events]

Hintergrund

Die Anzahl an kurz- und langstreckigen Laufveranstaltungen in Deutschland nimmt zu. Laufen als Breitensport wird von einer Vielzahl an Personen unterschiedlicher Altersklassen, Risikogruppen und Professionalisierungsgrade betrieben, woraus ein breites Spektrum medizinischer Notfälle resultiert.

Ziel der Arbeit

Der vorliegende Beitrag erläutert die Inzidenz, Pathophysiologie und Therapie relevanter Notfallbilder bei Laufveranstaltungen. Ziel ist die Optimierung der Arbeitsabläufe des Rettungsdienstpersonals.

Material und Methoden

Es erfolgte eine Literaturrecherche in PubMed.

Ergebnisse

Anstrengungsassoziierte Muskelkrämpfe, gastrointestinale Symptome, Kollaps, Kompartmentsyndrom und Tendinopathien sind häufige Erscheinungsbilder und resultieren meist aus akuter oder chronischer Überanstrengung. Der Kreislaufstillstand bzw. plötzliche Herztod ist ein seltenes Ereignis bei Laufveranstaltungen. Bewusstseinsstörungen und generalisierte Krampfanfälle sind schwerwiegende Komplikationen. Disseminierte intravasale Koagulopathie, belastungsinduzierte Hyponatriämie, Hitzschlag, Rhabdomyolyse und thromboembolische Ereignisse sind mit hoher Morbidität und Mortalität verbunden. Substanzen zur Erhöhung der Schmerzschwelle und leistungssteigernde Substanzen sind unter Läufern stark verbreitet und gehen mit einer hohen Rate an Nebenwirkungen einher.

Diskussion

Unspezifische Symptome wie Erbrechen, Fieber, Kollaps, Muskelschmerzen, Übelkeit, und Schwäche sind die führenden Symptome bei Laufveranstaltungen. Eine sorgfältige Anamnese ist wegweisend für eine zielgerichtete klinische Therapie. Präklinisch steht eine Symptomkontrolle im Mittelpunkt. Das Flüssigkeitsmanagement stellt eine besondere Herausforderung dar.

Burden of Injury and Illness in the Road Race Medical Tent: A Narrative Review

OBJECTIVE

To summarize the literature relating to prehospital care at 5 km through marathon distance road races and present the epidemiology of common medical encounters, significant medical complications, and medical outcomes.

DATA SOURCES

We searched PubMed and Google Scholar for the published literature pertaining to road race medical tent encounters at 5 km through marathon distance road races from 2000 to 2018. We included English-language, original articles reporting on injury and illness incidence.

MAIN RESULTS

Standard medical encounter definitions have recently been formulated in response to the previous lack of uniform definitions. The incidence of medical complications at road races may be influenced by environmental conditions and race distance. Minor and moderate medical encounters, such as dermatologic injuries, musculoskeletal injuries, and exercise-associated collapse, are common. Serious and life-threatening medical complications, including exertional heat stroke, exercise-associated hyponatremia, and cardiac arrest, are less frequent. Fatalities are also rare, with rates of 0.3 to 5 per 100 000 participants reported at marathons. The ratio of hospital transports to medical encounters is low.

CONCLUSIONS

On-site medical services play a key role in the safety of both runners and the community. Future research and care initiatives in this field should focus on optimizing treatment protocols, promoting injury prevention efforts and reducing host community costs.

The impact of certificate of need laws on heart attack mortality: Evidence from county borders

Certificate of need (CON) regulations requires that health care providers obtain state approval before offering a new service or expanding existing facilities. The purported goal of CON regulations is to reduce health care costs by generating regional economies of scale and reducing redundant investments resulting from excessive competition. Critics of CON regulations note that the regulatory environment increases the costs of expansion and may incentivize health care providers to forgo capital investment, which can have a negative effect on health outcomes. To estimate the net effect of CON regulations, I use a border discontinuity design to measure within-regional heart attack mortality spanning 1968 to 1982. I estimate that CON regulations led to an increase in heart attack deaths, by 6%-10%, three years after the policy was enacted.

G20 Summit and emergency medical services in Osaka, Japan

Aim

To assess the impact of the Summit on Financial Markets and the World Economy held in Osaka City, Japan (G20 Osaka Summit) on the emergency medical services (EMS) system.

Methods

This study used the ORION database with its population‐based registry of emergency patients comprising both ambulance and in‐hospital records in Osaka Prefecture, Japan. The G20 Osaka Summit was held in Osaka City from 28 to 29 June, 2019. Changes in the EMS system and traffic regulations in Osaka were made during the period from 27 to 30 June, but we focused on the two summit days as the G20 period. The control periods comprised the same calendar days 1 week before and 1 week after the G20 period. We evaluated differences in the number of emergency transports, difficulties in obtaining hospital acceptance of patients, deaths among hospitalized emergency patients, and ambulance transport times between the two periods.

Results

In total, 2,590 cases in the G20 period and 5,152 cases in the control periods were registered. The relative risk of cases during the G20 versus control periods was 1.01 (0.96–1.05). Significant decreases were observed in the number of traffic accidents as ambulance calls (relative risk = 0.77; 95% confidence interval, 0.64–0.91). There were no significant differences in difficulties in obtaining hospital acceptance or deaths among hospitalized emergency patients between the G20 and control periods. In addition, ambulance transport times during the G20 period were not significantly longer than those in the control periods.

Conclusion

The G20 Osaka Summit did not adversely impact the provision of emergency medical care in the Osaka area.

Racial/ethnic disparities in emergency department wait times in the United States, 2013-2017

BACKGROUND

Previous research shows that Black and Hispanic patients have longer ED wait times than White patients, but these data do not reflect recent changes such as the Affordable Care Act. In addition, previous research does not account for the non-normal distribution of wait times, wherein a sizable subgroup of patients seen promptly and those not seen promptly experience long wait times.

METHODS

We utilized National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets (2013-2017) to examine mean ED wait time comparing visits by Black, Hispanic, and Asian patients to White patients. Using a two-part regression model, we adjusted for patient, hospital, and health system factors, and estimated differences, for each of five triage levels, in (a) likelihood of waiting at least 5 min and (b) difference in wait time among those not seen promptly.

RESULTS

Our cohort included 38,800 White, 14,838 Black, 10,619 Hispanic, and 1257 Asian patient visits. Black (triage level 3) and Hispanic (triage levels 3 and 4) patients had longer mean wait times than White patients. Adjusted likelihood of not being seen promptly was lower among Blacks (triage levels 3, 4 and 5), Hispanics (triage level 5) and Asians (triage level 5) compared to Whites. Among those waiting at least 5 min, adjusted wait time was longer among Blacks in triage level 3 (5.2 min, 95% CI, 1.3 to 9.0) and level 4 (2.5 min, 95% CI, 0.2 to 4.9), Hispanics in triage level 4 (4.7 min, 95% CI, 1.7 to 7.7) and Asians in triage level 5 (16.3 min, 95% CI, 0.6 to 31.9) compared to Whites.

CONCLUSIONS

Minority patients were less likely to wait to be seen, but waited longer if not seen promptly. These data exhibit that ED wait time disparities persist for African American and Hispanic patients and extend this observation to Asian patients.

Assessment of Care Handoffs Among Hospitalist Physicians and 30-Day Mortality in Hospitalized Medicare Beneficiaries

IMPORTANCE

Inpatients treated by hospitalist physicians, who often work contiguous days, experience handoffs at the end of a scheduled shift block. Evidence suggests that transitions of patient care, or handoffs, among physician trainees are associated with adverse patient outcomes. However, little is known about the association between handoffs and patient outcomes among attending physicians, even though similar concerns apply.

OBJECTIVE

To examine the association between inpatient handoffs of hospitalist physicians and patient mortality among hospitalized Medicare beneficiaries.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed a random sample of Medicare beneficiaries who were hospitalized with a general medical condition between January 1, 2011, and December 31, 2016, and treated by a hospitalist. The study compared outcomes of patients with low vs high probability of physician handoff based on date of patient admission relative to the admitting hospitalist's last working day in a scheduled block, hypothesizing that otherwise similar patients admitted toward the end of a physician's shift block would be more likely to be handed off to another physician compared with patients admitted earlier in the shift block. Data analysis was performed from July 1, 2018, to January 12, 2021.

EXPOSURE

High vs low probability of physician handoff.

MAIN OUTCOMES AND MEASURES

The main outcome was patient 30-day mortality rate.

RESULTS

A total of 1 074 000 patients (mean [SD] age, 75.9 [13.7] years; 57.4% female; 82.1% White) were studied. Multivariable regression models adjusted for beneficiary clinical and demographic characteristics and hospital fixed effects (a within-hospital analysis, effectively comparing patients treated at the same hospital). Among 597 288 hospitalizations, no overall difference in 30-day mortality was observed between patients admitted in the 2 days prior (days -1 and -2) to the treating hospitalist's last working day (a high handoff probability) compared with days -6 and -7 (a low handoff probability) (adjusted rate, 10.6%; 95% CI, 10.5%-10.7% vs 10.6%; 95% CI, 10.5%-10.7%; adjusted difference, 0.0%; 95% CI, -0.2% to 0.1%). However, in an exploratory analysis, among patients with high illness severity, defined as those in the top quartile of estimated mortality, 30-day mortality was higher for those with high vs low likelihood of physician handoff (adjusted mortality, 27.8%; 95% CI, 27.6%-27.9% vs 26.8%; 95% CI, 26.6%-27.1%; absolute adjusted difference, 1.0%; 95% CI, 0.5%-1.4%).

CONCLUSIONS AND RELEVANCE

In this national analysis of Medicare beneficiaries hospitalized with a general medical condition and treated by a hospitalist physician, physician handoff was not associated with increased mortality overall.

Medicine at mass gatherings: current progress of preparedness of emergency medical services and disaster medical response during 2020 Tokyo Olympic and Paralympic Games from the perspective of the Academic Consortium (AC2020)

Mass gatherings are events characterized by “the concentration of people at a specific location for a specific purpose over a set period of time that have the potential to strain the planning and response resources of the host country or community.” Previous reports showed that, as a result of the concentration of people in the limited area, injury and illness occurred due to several factors. The response plan should aim to provide timely medical care to the patients and to reduce the burden on emergency hospitals, and to maintain a daily emergency medical services system for residents of the local area. Although a mass gathering event will place a significant burden on the local health‐care system, it can provide the opportunity for long‐term benefits of public health‐care and improvement of daily medical service systems after the end of the event. The next Olympic and Paralympic Games will be held in Tokyo, during which mass gatherings will occur on a daily basis in the context of the coronavirus disease (COVID‐19) epidemic. The Academic Consortium on Emergency Medical Services and Disaster Medical Response Plan during the Tokyo Olympic and Paralympic Games in 2020 (AC2020) was launched 2016, consisting of 28 academic societies in Japan, it has released statements based on assessments of medical risk and publishing guidelines and manuals on its website. This paper outlines the issues and countermeasures for emergency and disaster medical care related to the holding of this big event, focusing on the activities of the academic consortium.

Delayed emergencies: The composition and magnitude of non-respiratory emergency department visits during the COVID-19 pandemic

IMPORTANCE

COVID-19 has been associated with excess mortality among patients not diagnosed with COVID-19, suggesting disruption of acute health care provision may play a role.

OBJECTIVE

To determine the degree of declines in emergency department (ED) visits attributable to COVID-19 and determine whether these declines were concentrated among patients with fewer comorbidities and lower severity visits.

DESIGN

We conducted a differences-in-differences analysis of all commercial health insurance claims for ED visits in the first 20 weeks of 2018, 2019, and 2020. The intervention period began March 9 (week 11) of 2020, following state stay-at-home orders.

SETTING

We analyzed claims from Blue Cross Blue Shield of Louisiana (BCBSLA), located in a state with an early US COVID-19 outbreak. Visit and patient risk was assessed through comorbidities previously described as increasing the risk of COVID-19 decompensation, the hospital location's COVID-19 outbreak status, and the Ambulatory Care Sensitive Condition algorithm.

PARTICIPANTS

The study population comprised all ED visits from all BCBSLA members, whether admitted or discharged. There were 332,917 ED visits over the study period. The study population spanned member demographics including sex, age, and geography. Uninsured adults were not included due to data limitations.

EXPOSURES

The COVID-19 outbreak beginning March 9, 2020 in Louisiana.

MAIN OUTCOMES AND MEASURES

The main outcome of interest for this analysis is the difference (percent change) in all ED visits, categorized as either respiratory or non-respiratory, from week 1-20 in 2019 and week 1-10 in 2020, compared to week 11-20 in 2020.

RESULTS

In this differences-in-differences study using data from a commercial health insurer, we found that non-respiratory ED visits declined by 39%, whereas respiratory visits did not experience a significant decline. Visits that were potentially deferrable or from lower risk patient populations showed greater declines, but even high-risk patients and non-avoidable visits experienced large declines in non-respiratory ED visits. Non-respiratory ED visits declined by only 18% in areas experiencing COVID outbreak.

CONCLUSIONS AND RELEVANCE

COVID-19 has resulted in significant avoidance of ED care, comprising a mix of deferrable and high severity care. Hospital and public health pronouncements should emphasize appropriate care seeking.

Association of Affordable Care Act Implementation With Ambulance Utilization for Asthma Emergencies in New York City, 2008-2018

IMPORTANCE

Emergency medical services (EMS) are an essential component of the health care system, but the effect of insurance expansion on EMS call volume remains unclear.

OBJECTIVE

This study investigated the association between health insurance expansion and EMS dispatches for asthma, an ambulatory care-sensitive condition. We hypothesized that insurance expansion under the Patient Protection and Affordable Care Act (ACA) would be associated with decreased EMS dispatches for asthma emergencies.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study examined 14 865 267 ambulance calls dispatched within New York City from 2008 to 2018, including 217 303 calls for asthma-related emergencies, and used interrupted time series analysis to study the change in the annual incidence of EMS dispatches for asthma emergencies after implementation of the ACA. Multivariable linear regression examined the association between the uninsured rate and the incidence of asthma-related dispatches, controlling for population demographic characteristics and air quality index.

EXPOSURES

Implementation of ACA on January 1, 2014.

MAIN OUTCOMES AND MEASURES

Incidence of EMS dispatches for asthma emergencies per 100 000 population per year (ie, asthma EMS dispatch rate) as classified by the 911 call-taker.

RESULTS

In this study of 217 303 EMS dispatches for asthma-related emergencies, there was a decrease in the asthma EMS dispatch rate after implementation of the ACA, from a mean (SD) of 261 (24) dispatches per 100 000 population per year preintervention to 211 (47) postintervention (P = .047). This decrease in asthma EMS dispatch rate after ACA implementation was significant on interrupted time series analysis. Prior to 2014, the annual asthma EMS dispatch rate was increasing by 11.8 calls per 100 000 population per year (95% CI, 6.1 to 17.4). After ACA implementation, the asthma EMS dispatch rate decreased annually by 28.5 calls per 100 000 population per year (95% CI, -37.6 to -19.3), a significant change in slope from the preintervention period (P < .001). Multivariable linear regression, controlling for percentage of individuals younger than age 18 years, degree of racial/ethnic diversity, median household income, and air quality index, found that a 1% decrease in the citywide uninsured rate was associated with a decrease of 98.9 asthma dispatches per 100 000 population per year (95% CI, 5.72-192.10; P = .04).

CONCLUSIONS AND RELEVANCE

Insurance expansion within New York City under the ACA was associated with a significant reduction in the asthma EMS dispatch rate. Insurance expansion may be a viable method to reduce EMS utilization for ambulatory care-sensitive conditions such as asthma.

Longitudinal description and evaluation of an emergency department avoidance strategy for a youth mass gathering (Schoolies) in Australia

OBJECTIVE

ED avoidance strategies including In-Event Health Service (IEHS) processes during mass gathering events (MGEs), such as 'Schoolies week', may be important for EDs, ambulance services, the local population, and attendees. The aim of the present study was to provide a longitudinal description of emergency care requirements for young adults (16-18 years old); focussing on the impact of the Schoolies MGEs.

METHODS

This retrospective observational study included youth (16-18 years) presentations made (i) to local public EDs during Schoolies week in 2008-2014 and (ii) to local EDs over a 3-week period (pre, during, post-Schoolies week) and the IEHS in 2015 and 2016. Descriptive and inferential statistics were undertaken.

RESULTS

Youth presentations (n = 4256) were included. Presentation rates/1000 fluctuated over time (range 6.2-21.2). The IEHS provided care for 167 and 288 youth during 2015 and 2016 Schoolies week, respectively. Demographic factors (gender, age, region domiciled) and episode of care factors (time of presentation, mode of arrival, urgency, time to triage, time to be seen by a clinician and length of stay) between 2008 and 2016 varied by year. Toxicology (alcohol and other drugs), trauma, and mental health concerns were the most common diagnoses.

CONCLUSIONS

The IEHS, operational during Schoolies, appeared to reduce pressures on local EDs by offering rapid, targeted care for potentially vulnerable youth; decrease requirements for hospital transport and minimise impacts on care provision for the local community. Given increases in ED crowding and pressures on ambulance services, such care models may be worth considering for other types of MGEs and in other locations.

Medical Tent Utilization at 10-km Road Races: Injury, Illness, and Influencing Factors

PURPOSE

To increase awareness of the need for coordinated medical care at 10-km races and to help direct future medical planning for these events.

METHODS

We related medical encounter data from nineteen 10-km road races to runner, race, and environmental characteristics. We quantified the most commonly used resources and described the disposition of runners in these encounters.

RESULTS

Across the 19 races and 90,265 finishers, there were 562 medical events for a cumulative incidence of 6.2 events per 1000 finishers (95% confidence interval, 5.7-6.8). Race size was associated with an increased incidence of medical events. Overall, the most common diagnosis was heat-related illness (1.6 per 1000 finishers), followed by musculoskeletal complaints (1.3 per 1000 finishers) and fluid-electrolyte imbalances (1.2 per 1000 finishers). For all diagnoses, runners with finishing times in the first performance quintile and in the fifth performance quintile had greater representation in the medical tent than mid-pack runners. Most runners were treated with supportive care, basic first aid, and oral rehydration. Ninety-four runners (1.0 per 1000 finishers) required ice water immersion for exertional heat stroke. There were low rates of hospital transport (0.2 per 1000 finishers), and no fatalities.

CONCLUSIONS

In 10-km road races, injury rates are low compared with longer races in similar weather conditions. Common medical issues can be managed with basic resources in the on-site medical tent. Green flag start race conditions may not predict race safety with regard to exertional heat stroke risk. There were no deaths in nearly 100,000 finishers.

Collateral damage - Impact of a pandemic on stroke emergency services

Background

The COVID-19 pandemic's impact on stroke care is two-fold — direct impact of the infection and indirect impact on non-COVID-19 diseases. Anecdotal evidence and clinical observation suggest that there is a decrease in the number of patients presenting with stroke during the pandemic. We aim to understand the impact of the COVID-19 pandemic on the utilization of stroke emergency services on a single comprehensive stroke center (CSC).

Methods

We performed a retrospective analysis of a prospectively maintained database and compared all emergency department (ED) encounters, acute stroke admissions (including TIA), and thrombectomy cases admitted in March 2017-2019 to patients admitted in March 2020 at a comprehensive stroke center.

Results

Number of total ED encounters (22%, p=0.005), acute ischemic strokes (40%, p=0.001), and TIAs (60%, p=0.163) decreased between March of 2017–2019 compared to March of 2020. The number of patients undergoing EVT in March 2020 was comparable to March 2017–2019 (p=0.430).

Conclusion

A pandemic-related stay-at-home policy reduces the utilization of stroke emergency services at a CSC. This effect appears to be more prominent for ED encounters, all stroke admissions and TIAs, and less impactful for severe strokes. Given the relatively low prevalence of COVID-19 cases in our region, this decrement is likely related to healthcare seeking behavior rather than capacity saturation.

Impact of traffic, poverty and facility ownership on travel time to emergency care in Nairobi, Kenya

BACKGROUND

In many low and middle-income countries (LMICs), timely access to emergency healthcare services is limited. In urban settings, traffic can have a significant impact on travel time, leading to life-threatening delays for time-sensitive injuries and medical emergencies. In this study, we examined travel times to hospitals in Nairobi, Kenya, one of the largest and most congested cities in the developing world.

METHODS

We used a network approach to estimate average minimum travel times to different types of hospitals (e.g. ownership and level of care) in Nairobi under both congested and uncongested traffic conditions. We also examined the correlation between travel time and socioeconomic status.

RESULTS

We estimate the average minimum travel time during uncongested traffic conditions to any level 4 health facility (primary hospitals) or above in Nairobi to be 4.5 min (IQR 2.5-6.1). Traffic added an average of 9.0 min (a 200% increase). In uncongested conditions, we estimate an average travel time of 7.9 min (IQR 5.1-10.4) to level 5 facilities (secondary hospitals) and 11.6 min (IQR 8.5-14.2) to Kenyatta National Hospital, the only level 6 facility (tertiary hospital) in the country. Traffic congestion added an average of 13.1 and 16.0 min (166% and 138% increase) to travel times to level 5 and level 6 facilities, respectively. For individuals living below the poverty line, we estimate that preferential use of public or faith-based facilities could increase travel time by as much as 65%.

CONCLUSION

Average travel times to health facilities capable of providing emergency care in Nairobi are quite low, but traffic congestion double or triple estimated travel times. Furthermore, we estimate significant disparities in timely access to care for those individuals living under the poverty line who preferentially seek care in public or faith-based facilities.

An Overview of Chicago (Illinois USA) Marathon Prehospital Care Demographics, Patient Care Operations, and Injury Patterns

INTRODUCTION

Large-scale mass-sporting events are increasingly requiring greater prehospital event planning and preparation to address inherent event-associated medical conditions in addition to incidents that may be unexpected. The Bank of America Chicago Marathon (Chicago, Illinois USA) is one of the largest marathons in the world, and with the improvement of technology, the use of historical patient and event data, in conjunction with environmental conditions, can provide organizers and public safety officials a way to plan based on injury patterns and patient demands for care by predicting the placement and timing of needed medical support and resources.

PROBLEM

During large-scale events, disaster planning and preparedness between event organizers, Emergency Medical Services (EMS), and local, state, and federal agencies is critical to ensure participant and public safety.

METHODS

This study looked at the Bank of America Chicago Marathon, a significant endurance event, and took a unique approach of reviewing digital runner data retrospectively over a five-year period to establish patterns of medical demand geographically, temporally, and by the presenting diagnoses. Most medical complaints were musculoskeletal in nature; however, there were life-threatening conditions such as hyperthermia and cardiac incidents that highlight the need for detailed planning, coordination, and communication to ensure a safe and secure event.

CONCLUSIONS

The Chicago Marathon is one of the largest marathons in the world, and this study identified an equal number of participants requiring care on-course and at the finish line. Most medical complaints were musculoskeletal in nature; however, there were life-threatening conditions such as hyperthermia and cardiac incidents that highlight the need for detailed planning, multi-disciplined coordination, and communication to ensure a safe and secure event. As technology has evolved, the use, analysis, and implementation of historical digital data with various environmental conditions can provide organizers and public safety officials a map to plan injury patterns and patient demands by predicting the placement and timing of needed medical support, personnel, and resources.

The Effect of All-Terrain Vehicle Crash Location on Emergency Medical Services Time Intervals

Over 100,000 all-terrain vehicle (ATV)-related injuries are evaluated in U.S. emergency departments each year. In this study, we analyzed the time intervals for emergency medical services (EMS) providers responding to ATV crashes in different location types. Data from the Iowa State Trauma Registry and a statewide ATV crash/injury database was matched with Iowa EMS Registry records from 2004–2014. Ground ambulance responses to 270 ATV crashes were identified, and response characteristics and time intervals were analyzed. Off-road crashes had a longer median patient access interval (p < 0.001) and total on scene interval (p = 0.002) than roadway crashes. Crashes in remote locations had a longer median patient access interval (p < 0.001) and total on scene interval (p < 0.001), but also a longer median on scene with patient interval (p = 0.004) than crashes in accessible locations. Fifteen percent of remote patient access times were >6 min as compared to 3% of accessible crashes (p = 0.0004). There were no differences in en route to scene or en route to hospital time. Comparisons by location type showed no differences in injury severity score or number of total procedures performed. We concluded that responding EMS providers had an increased length of time to get to the patient after arriving on scene for off-road and remote ATV crashes relative to roadway and accessible location crashes, respectively.

The affordable care act and ambulance response times

This study contributes to the literature on the capacity challenges faced by health care providers after insurance expansions by examining the Affordable Care Act (ACA) and ambulance response times. Exploiting temporal and geographic variation in the implementation of the ACA as well as pre-treatment differences in uninsured rates, we estimate that the expansions of private and Medicaid coverage under the ACA combined to slow ambulance response times by an average of 24%. We conclude that, through extending coverage to individuals who, in its absence, would not have availed themselves of emergency medical services, the ACA added strain to emergency response systems.

Hacking 9-1-1: Infrastructure Vulnerabilities and Attack Vectors

9-1-1 call centers are a critical component of prehospital care: they accept emergency calls, dispatch field responders such as emergency medical services, and provide callers with emergency medical instructions before their arrival. The aim of this study was to describe the technical structure of the 9-1-1 call-taking system and to describe its vulnerabilities that could lead to compromised patient care. 9-1-1 calls answered from mobile phones and landlines use a variety of technologies to provide information about caller location and other information. These interconnected technologies create potential cyber vulnerabilities. A variety of attacks could be carried out on 9-1-1 infrastructure to various ends. Attackers could target individuals, groups, or entire municipalities. These attacks could result in anything from a nuisance to increased loss of life in a physical attack to worse overall outcomes owing to delays in care for time-sensitive conditions. Evolving 9-1-1 systems are increasingly connected and dependent on network technology. As implications of cybersecurity vulnerabilities loom large, future research should examine methods of hardening the 9-1-1 system against attack.

Association of Ambulance Use in New York City With the Implementation of the Patient Protection and Affordable Care Act

Importance

Expanding insurance coverage may be associated with overuse of medical care because newly insured patients are insulated from having to pay the full cost.

Objective

To examine the use of ambulance transport before and after the rollout of the Patient Protection and Affordable Care Act (ACA) in New York City (NYC), New York.

Design, Setting, and Participants

In this case-control study, the volume of ambulance dispatches in NYC for minor injuries before and after the rollout of the ACA was examined. Data were drawn from a census of all ambulance dispatches in NYC between January 1, 2013, and July 31, 2016. Ambulance dispatches for more severe injuries, which are more difficult to characterize as unnecessary, were used as the control group. Analyses were conducted from August 17, 2017, to May, 10, 2019.

Main Outcome and Measures

The main outcome was the number of ambulance dispatches for minor injuries, defined per month per dispatch zone. The implementation of the ACA was measured using an indicator variable of 1 for dispatches starting January 1, 2014, and 0 for dispatches before January 1, 2014. The number of ambulance dispatches for injuries and major injuries was used to account for secular trends. Injury severity was classified by the dispatchers based on information from the 911 callers with a severity score on a scale of 1 to 8, where 1 is the most severe; minor injuries had a score of 7; injuries, 5; and major injuries, 3.

Results

There were 4 787 180 ambulance dispatches in NYC during the study. After the 2014 expansion of insurance coverage under the ACA, there was an increase in ambulance dispatches for minor injuries compared with dispatches for more severe injuries. Compared with the preimplementation mean (SD) of 20.75 (14.24) minor injury dispatches per dispatch zone per month, there were 7.71 (95% CI, 1.23-14.19) additional minor injury dispatches per dispatch zone per month compared with dispatches for other types of injuries, an increase of 37.2%. Given that NYC has 31 dispatch zones, this increase is equivalent to approximately 239 additional dispatches per month or 2868 additional dispatches per year for minor injuries.

Conclusions and Relevance

There was a significant increase in use of ambulance transport for minor injuries in NYC after the ACA insurance expansion, suggesting that the change in health insurance structure was associated with increased use of emergency medical services in nonemergent situations. Future reforms to the US health insurance system should take into account the potential for increased use of emergency medical services in nonemergent situations, which the literature suggests may lead to congestion and slower response times.

Health Care Provision During a Sporting Mass Gathering: A Structure and Process Description of On-Site Care Delivery

INTRODUCTION

Mass gatherings such as marathons are increasingly frequent. During mass gatherings, the provision of timely access to health care services is required for the mass-gathering population, as well as for the local community. However, the nature and impact of health care provision during sporting mass gatherings is not well-understood.

PURPOSE

The aim of this study was to describe the structures and processes developed for an emergency health team to operate an in-event, acute health care facility during one of the largest mass-sporting participation events in the southern hemisphere, the Gold Coast Marathon (Queensland, Australia).

METHODS

A pragmatic, qualitative methodology was used to describe the structures and processes required to operate an in-event, acute health care facility providing services for marathon runners and spectators. Content analysis from 12 semi-structured interviews with emergency department (ED) clinical staff working during the two-day event was undertaken in 2016.

FINDINGS

Important structural elements of the in-event health care facility included: physical spaces, such as the clinical zones in the marathon health tent and surrounding area, and access and egress points; and resources such as bilingual staff, senior medical staff, and equipment such as electrocardiograms (ECGs) and intravenous fluids. Process elements of the in-event health care facility included clear communication pathways, as well as inter-professional care coordination and engagement involving shared knowledge of and access to resources, and distinct but overlapping clinical scope between nurses and doctors. This was seen to be critical for timely care provision and appropriate case management. Staff reported many perceived benefits and opportunities of in-event health care delivery, including ED avoidance and disaster training.

CONCLUSIONS

This in-event model of emergency care delivery, established in an out-of-hospital location, enabled the delivery of acute health care that could be clearly described and defined. Staff reported satisfaction with their ability to provide a meaningful contribution to hospital avoidance and to the local community. With the number of sporting mass gatherings increasing, this temporary, in-event model of health care provision is one option for event and health care planners to consider.JohnstonANB, WadhamJ, Polong-BrownJ, AitkenM, RanseJ, HuttonA, RichardsB, CrillyJ.Health care provision during a sporting mass gathering: a structure and process description of on-site care delivery. Prehosp Disaster Med. 2019;34(1):62-71.

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

IMPORTANCE

Emergency medical services (EMS) provide critical prehospital care, and disparities in response times to time-sensitive conditions, such as cardiac arrest, may contribute to disparities in patient outcomes.

OBJECTIVES

To investigate whether ambulance 9-1-1 times were longer in low-income vs high-income areas and to compare response times with national benchmarks of 4, 8, or 15 minutes across income quartiles.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cross-sectional study was performed of the 2014 National Emergency Medical Services Information System data in June 2017 using negative binomial and logistic regressions to examine the association between zip code-level income and EMS response times. The study used ambulance 9-1-1 response data for out-of-hospital cardiac arrest from 46 of 50 state repositories (92.0%) in the United States. The sample included 63 600 cardiac arrest encounters of patients who did not die on scene and were transported to the hospital.

MAIN OUTCOMES AND MEASURES

Four time measures were examined, including response time, on-scene time, transport time, and total EMS time. The study compared response times with EMS response time benchmarks for responding to cardiac arrest calls within 4, 8, and 15 minutes.

RESULTS

The study sample included 63 600 cardiac arrest encounters of patients (mean [SD] age, 60.6 [19.0] years; 57.9% male), with 37 550 patients (59.0%) from high-income areas and 8192 patients (12.9%) from low-income areas. High-income areas had greater proportions of white patients (70.1% vs 62.2%), male patients (58.8% vs 54.1%), privately insured patients (29.4% vs 15.9%), and uninsured patients (15.3% vs 7.9%), while low-income areas had a greater proportion of Medicaid-insured patients (38.3% vs 15.8%). The mean (SD) total EMS time was 37.5 (13.6) minutes in the highest zip code income quartile and 43.0 (18.8) minutes in the lowest. After controlling for urban zip code, weekday, and time of day in regression analyses, total EMS time remained 10% longer (95% CI, 9%-11%; P < .001), translating to 3.8 minutes longer in the poorest zip codes. The EMS response time to patients in high-income zip codes was more likely to meet 8-minute and 15-minute cutoffs compared with low-income zip codes.

CONCLUSIONS AND RELEVANCE

Patients with cardiac arrest from the poorest neighborhoods had longer EMS times compared with those from the wealthiest, and response times were less likely to meet national benchmarks in low-income areas, which may lead to increased disparities in prehospital delivery of care over time.

Out-of-Hospital Cardiac Arrests During the Japanese Professional Baseball Championship Series

Because the Japan Professional Baseball Championship Series (Japan Series) is a stressful sports event, it is possible that watching Japan Series matches may increase the risk of cardiovascular events. Therefore, we investigated the potential association between the Japan Series and the incidence of out-of-hospital cardiac arrest (OHCA) events. National registry data for all cases of OHCA between 2005 and 2014 from 47 prefectures of Japan were obtained. We used a time-stratified case-crossover design with a conditional Poisson regression model to compare OHCA events during the Japan Series with those events that occurred during the periods except for dates of the Japan Series. The estimated associations for each prefecture were pooled at the nationwide level using a random-effects meta-analysis. In total, 666,020 OHCAs of presumed cardiac origin were reported during the study period. On days of Japan Series matches, the pooled relative risk of OHCA was 1.033 (95% confidence interval 1.012 to 1.055; p = 0.002; I² = 3.5%, P for heterogeneity = 0.405). Stratified analyses by gender revealed that the substantial increase in OHCA during the events was observed for men, whereas we found no significant increase for women. We also found a considerable rise in OHCA among patients aged ≥65 years; however, there was no significant evidence of increased risk in those aged 18 to 64 years. In conclusion, stressful baseball match is associated with an increased risk of OHCA. Prevention measures for severe emotional stress-related OHCA should be implemented, particularly for elderly men.

The Gillette Stadium Experience: A Retrospective Review of Mass Gathering Events From 2010 to 2015

Objective

Mass gathering events can substantially impact public safety. Analyzing patient presentation and transport rates at various mass gathering events can help inform staffing models and improve preparedness.

Methods

A retrospective review of all patients seeking medical attention across a variety of event types at a single venue with a capacity of 68,756 from January 2010 through September 2015.

Results

We examined 232 events with a total of 8,260,349 attendees generating 8157 medical contacts. Rates were 10 presentations and 1.6 transports per 10,000 attendees with a non-significant trend towards increased rates in postseason National Football League games. Concerts had significantly higher rates of presentation and transport than all other event types. Presenting concern varied significantly by event type and gender, and transport rate increased predictably with age. For cold weather events, transport rates increased at colder temperatures. Overall, on-site physicians did not impact rates.

Conclusions

At a single venue hosting a variety of events across a 6-year period, we demonstrated significant variations in presentation and transport rates. Weather, gender, event type, and age all play important roles. Our analysis, while representative only of our specific venue, may be useful in developing response plans and staffing models for similar mass gathering venues. (Disaster Med Public Health Preparedness. 2018;12:752-758).