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Funk Corcoran T, Crowe R, Martin-Gill C, Ramgopal S. Mapping prehospital clinician impression to hospital-based diagnoses in children transported to the hospital by emergency medical services. PREHOSP EMERG CARE 2024:1-11. [PMID: 38913542 DOI: 10.1080/10903127.2024.2370511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/10/2024] [Indexed: 06/26/2024]
Abstract
Objectives: Emergency medical services (EMS) serves a critical role in the delivery of services to children with out-of-hospital emergencies. The EMS clinicians' initial field diagnoses, termed "impressions", facilitate focused patient assessments, guide the application of prehospital treatment protocols, and help determine transport destination. We sought to evaluate the concordance of the EMS clinician impression to a child's hospital-based diagnosis.Methods: We retrospectively studied de-identified pediatric (<18 years old) scene runs transported to the hospital and with available linked hospital data from the 2021 ESO Data Collaborative, a multi-agency prehospital electronic health record dataset. EMS impressions and primary emergency department or admission-based diagnoses were categorized into one of twenty-one major groups in the Diagnosis Grouping System. We identified the most common hospital-based discharge diagnoses and evaluated for the agreement between EMS impression and hospital-based diagnosis using Cohen's Kappa statistic.Results: We included 35,833 pediatric transports from the scene with linked prehospital and in-hospital data (median age 11 years, interquartile range, 3-15 years; 50.9% male). The most common categories for both EMS impressions and hospital-based diagnoses were as follows respectively: trauma (26.1%; 24.6%), neurologic diseases (18.9%; 16.4%), psychiatric and behavioral diseases and substance use disorder (11.8%; 11.6%), and respiratory diseases (11.1% and 9.5%). A total of 23,224 out of 35,833 patients, or 64.8%, had concordant EMS impressions and hospital-based diagnoses. There was high agreement between common EMS impression and in-hospital diagnoses (trauma 77.3%; neurologic diseases 70.3%; respiratory diseases 64.5%; and psychiatric, behavioral disease and substance use disorder 73.9%). Hospital-based diagnoses demonstrated moderate concordance with prehospital data (Cohen's κ = 0.59).Conclusions: We found moderate concordance between EMS primary impression and hospital diagnoses. The EMS encounter is brief and without capabilities of advanced testing, but initial impressions may influence the basis of the triage assignment and interventions during the hospital-based encounter. By evaluating EMS impressions and ultimate hospital diagnoses, pediatric protocols may be streamlined, and specific training emphasized in pursuit of improving patient outcomes. Future work is needed to examine instances of discordance and evaluate the impact on patient care and outcomes.
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Affiliation(s)
- Tara Funk Corcoran
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Farcas AM, Crowe RP, Kennel J, Little N, Haamid A, Camacho MA, Pleasant T, Owusu-Ansah S, Joiner AP, Tripp R, Kimbrell J, Grover JM, Ashford S, Burton B, Uribe J, Innes JC, Page DI, Taigman M, Dorsett M. Achieving Equity in EMS Care and Patient Outcomes Through Quality Management Systems: A Position Statement. PREHOSP EMERG CARE 2024:1-11. [PMID: 38727731 DOI: 10.1080/10903127.2024.2352582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024]
Abstract
Improving health and safety in our communities requires deliberate focus and commitment to equity. Inequities are differences in access, treatment, and outcomes between individuals and across populations that are systemic, avoidable, and unjust. Within health care in general, and Emergency Medical Services (EMS) in particular, there are demonstrated inequities in the quality of care provided to patients based on a number of characteristics linked to discrimination, exclusion, or bias. Given the critical role that EMS plays within the health care system, it is imperative that EMS systems reduce inequities by delivering evidence-based, high-quality care for the communities and patients we serve. To achieve equity in EMS care delivery and patient outcomes, the National Association of EMS Physicians recommends that EMS systems and agencies: make health equity a strategic priority and commit to improving equity at all levels.assess and monitor clinical and safety quality measures through the lens of inequities as an integrated part of the quality management process.ensure that data elements are structured to enable equity analysis at every level and routinely evaluate data for limitations hindering equity analysis and improvement.involve patients and community stakeholders in determining data ownership and stewardship to ensure its ongoing evolution and fitness for use for measuring care inequities.address biases as they translate into the quality of care and standards of respect for patients.pursue equity through a framework rooted in the principles of improvement science.
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Affiliation(s)
- Andra M Farcas
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | | | - Jamie Kennel
- Oregon Health & Science University and Oregon Institute of Technology, Portland, Oregon
| | | | - Ameera Haamid
- Section of Emergency Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Mario Andres Camacho
- Department of Emergency Medicine, Denver Health Medical Center, School of Medicine, University of Colorado, Denver, Colorado
| | | | - Sylvia Owusu-Ansah
- Division of Pediatric Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anjni P Joiner
- Department of Emergency Medicine, School of Medicine, Duke University, Durham, North Carolina
| | - Rickquel Tripp
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joshua Kimbrell
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center, Jamaica, New York
| | - Joseph M Grover
- UNC Department of Emergency Medicine, Chapel Hill, North Carolina
| | | | - Brooke Burton
- Unified Fire Authority in Salt Lake County, Salt Lake City, Utah
| | - Jeffrey Uribe
- Department of Emergency Medicine, Medstar Health, Columbia, Maryland
| | - Johanna C Innes
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - David I Page
- Center for Prehospital Care, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | | | - Maia Dorsett
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York
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MacAllister SA, Fernandez AR, Smith MJ, Myers JB, Crowe RP. Prehospital Sepsis Recognition and Outcomes for Patients with Sepsis by Race and Ethnicity. PREHOSP EMERG CARE 2023:1-7. [PMID: 38095600 DOI: 10.1080/10903127.2023.2294269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND First medical contact for patients with sepsis often initiates in the prehospital setting, yet limited studies have explored the EMS sepsis recognition-mortality relationship. Racial and ethnic minority patients often have worse sepsis outcomes, yet the role of prehospital recognition in this inequity has not been explored. Our objective was to describe prehospital sepsis recognition and hospital mortality, with analysis by patient race and ethnicity. METHODS Using linked EMS and hospital records from the 2021 ESO Data Collaborative, we retrospectively analyzed 9-1-1 EMS transports for adult patients with emergency department ICD-10 sepsis diagnosis codes. EMS sepsis recognition was defined as a primary or secondary sepsis impression, use of an electronic health record specialty sepsis form, or a prehospital sepsis alert. We used multivariable logistic regression to assess the association between EMS sepsis recognition and hospital mortality, adjusting for age, sex, race and ethnicity, scene socioeconomic status, and documented clinical characteristics: altered mental status, hypotension, tachypnea, tachycardia, fever. We conducted a secondary analysis of patients who were positive for the quick sequential organ failure assessment (qSOFA) using first prehospital vital signs. RESULTS We analyzed 20,172 records for EMS-transported patients with diagnosed sepsis. Overall, 8% of patients were Black, 8% were Hispanic, and 72% were White. Prehospital sepsis recognition was 18%. Prehospital sepsis recognition was similar across racial and ethnic groups (Black: 17.2%, Hispanic: 17.4%, White: 18.1%) and adjusted odds of sepsis recognition did not differ between racial and ethnic groups. Overall mortality was 11% (2,186). Prehospital sepsis recognition was associated with a 18% reduction in adjusted odds of mortality (OR: 0.82, 95% CI: 0.70-0.94). Of patients who were qSOFA positive in the field (n = 2,168), EMS sepsis recognition was 32% and was similar across race and ethnicities. Adjusted odds of mortality were 0.68 (95% CI: 0.53-0.88) when sepsis was recognized in the prehospital setting. CONCLUSION EMS identified sepsis in fewer than one in three patients even after limiting to those positive for qSOFA, without differences by race and ethnicity. EMS sepsis recognition was associated with reduced odds of mortality; however, Black patients remained at greater odds of death suggesting additional factors that warrant investigation.
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Febres-Cordero S, Shasanmi-Ellis RO, Sherman ADF. Labeled as "drug-seeking": nurses use harm reduction philosophy to reflect on mending mutual distrust between healthcare workers and people who use drugs. Front Public Health 2023; 11:1277562. [PMID: 37908688 PMCID: PMC10614634 DOI: 10.3389/fpubh.2023.1277562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/25/2023] [Indexed: 11/02/2023] Open
Abstract
Introduction Over 50 years of approaching drug use from the "War on Drugs" has led to ignoring the systemic structural and social determinants of health, enforced drug use stigma, and damaging stereotypes of people who use drugs or are labeled as "drug-seeking," and sorely failed to support those needing assistance. On philosophy of harm reduction and power People who use drugs are often disenfranchised and pathologized by being labeled as "a drug addict," which then serves as a rationalization for mistreatment by healthcare providers. This is in opposition to a harm-reduction approach. Harm reduction philosophy is an epistemic valuation necessary for drug use stigma and our moral obligation to reduce harm from interlocking systems of power that perpetuate harm. On drug-seeking mistrust and human rights We have encountered many clients who use drugs that report harmful interactions with healthcare providers. Harm reduction is an issue of health equity, social justice, and fundamental human rights. This paper presents three vignettes, the author's experiences of being labeled as-and advocating for family members labeled as "drug-seeking." Discussion To better serve as healthcare providers, workers must be equipped to work with people who use drugs and reinforce the social justice commitment against medical stigma, neglect, racism, and inadequate pain coverage and withdrawal treatment. Nurses and our epistemic lens can meet the challenge of complex intersectional issues affecting our use of power to develop more just and equitable health systems and advance our rebuilding of a trusting relationship with the people we serve.
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Brunson DC, Miller KA, Matheson LW, Carrillo E. Race and Ethnicity and Prehospital Use of Opioid or Ketamine Analgesia in Acute Traumatic Injury. JAMA Netw Open 2023; 6:e2338070. [PMID: 37847499 PMCID: PMC10582796 DOI: 10.1001/jamanetworkopen.2023.38070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/05/2023] [Indexed: 10/18/2023] Open
Abstract
Importance Racial and ethnic disparities in pain management have been characterized in many hospital-based settings. Painful traumatic injuries are a common reason for 911 activations of the EMS (emergency medical services) system. Objective To evaluate whether, among patients treated by EMS with traumatic injuries, race and ethnicity are associated with either disparate recording of pain scores or disparate administration of analgesia when a high pain score is recorded. Design, Settings, and Participants This cohort study included interactions from 2019 to 2021 for US patients ages 14 to 99 years who had experienced painful acute traumatic injuries and were treated and transported by an advanced life support unit following the activation of the 911 EMS system. The data were analyzed in January 2023. Exposures Acute painful traumatic injuries including burns. Main Outcomes and Measures Outcomes were the recording of a pain score and the administration of a nonoral opioid or ketamine. Results The study cohort included 4 781 396 EMS activations for acute traumatic injury, with a median (IQR) patient age of 59 (35-78) years (2 497 053 female [52.2%]; 31 266 American Indian or Alaskan Native [0.7%]; 59 713 Asian [1.2%]; 742 931 Black [15.5%], 411 934 Hispanic or Latino [8.6%], 10 747 Native Hawaiian or other Pacific Islander [0.2%]; 2 764 499 White [57.8%]; 16 161 multiple races [0.3%]). The analysis showed that race and ethnicity was associated with the likelihood of having a pain score recorded. Compared with White patients, American Indian and Alaskan Native patients had the lowest adjusted odds ratio (AOR) of having a pain score recorded (AOR, 0.74; 95% CI, 0.71-0.76). Among patients for whom a high pain score was recorded (between 7 and 10 out of 10), Black patients were about half as likely to receive opioid or ketamine analgesia as White patients (AOR, 0.53; 95% CI, 0.52-0.54) despite having a pain score recorded almost as frequently as White patients. Conclusions and Relevance In this nationwide study of patients treated by EMS for acute traumatic injuries, patients from racial or ethnic minority groups were less likely to have a pain score recorded, with Native American and Alaskan Natives the least likely to have a pain score recorded. Among patients with a high pain score, patients from racial and ethnic minority groups were also significantly less likely to receive opioid or ketamine analgesia treatment, with Black patients having the lowest adjusted odds of receiving these treatments.
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Affiliation(s)
- Dalton C. Brunson
- School of Medicine, Stanford University School of Medicine, Stanford, California
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
| | - Kate A. Miller
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Loretta W. Matheson
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
| | - Eli Carrillo
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
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Riney L, Palmer S, Finlay E, Bertrand A, Burcham S, Hendry P, Shah M, Kothari K, Ashby DW, Ostermayer D, Semenova O, Abo BN, Abes B, Shimko N, Myers E, Frank M, Turner T, Kemp M, Landry K, Roland G, Fishe JN. Examination of disparities in prehospital encounters for pediatric asthma exacerbations. J Am Coll Emerg Physicians Open 2023; 4:e13042. [PMID: 37811360 PMCID: PMC10560007 DOI: 10.1002/emp2.13042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/15/2023] [Accepted: 08/31/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction There are disparities in multiple aspects of pediatric asthma care; however, prehospital care disparities are largely undescribed. This study's objective was to examine racial and geographic disparities in emergency medical services (EMS) medication administration to pediatric patients with asthma. Methods This is a substudy of the Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial, which includes data from pediatric asthma patients ages 2-18 years. We examined rates of EMS administration of systemic corticosteroids and inhaled bronchodilators by patient race. We geocoded EMS scene addresses, characterized the locations' neighborhood-based conditions and resources relevant to children using the Child Opportunity Index (COI) 2.0, and analyzed associations between EMS scene address COI with medications administered by EMS. Results A total of 765 patients had available racial data and 825 had scene addresses that were geocoded to a COI. EMS administered at least 1 bronchodilator to 84.7% (n = 492) of non-White patients and 83.2% of White patients (n = 153), P = 0.6. EMS administered a systemic corticosteroid to 19.4% (n = 113) of non-White patients and 20.1% (n = 37) of White patients, P = 0.8. There was a significant difference in bronchodilator administration between COI categories of low/very low versus moderate/high/very high (85.0%, n = 485 vs. 75.9%, n = 192, respectively, P = 0.003). Conclusions There were no racial differences in EMS administration of medications to pediatric asthma patients. However, there were significantly higher rates of EMS bronchodilator administration for encounters in low/very low COIs. That latter finding may reflect inequities in asthma exacerbation severity for patients living in disadvantaged areas.
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Affiliation(s)
- Lauren Riney
- Cincinnati Children's Hospital Medical CenterUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Sam Palmer
- College of Design, Construction, and PlanningUniversity of Florida GeoPlan CenterGainesvilleFloridaUSA
| | - Erik Finlay
- College of Design, Construction, and PlanningUniversity of Florida GeoPlan CenterGainesvilleFloridaUSA
| | - Andrew Bertrand
- Department of Emergency MedicineUniversity of Florida College of MedicineJacksonvilleFloridaUSA
| | - Shannon Burcham
- Department of PediatricsUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Phyllis Hendry
- Department of Emergency MedicineUniversity of Florida College of MedicineJacksonvilleFloridaUSA
| | - Manish Shah
- Baylor College of MedicineTexas Children's HospitalHoustonTexasUSA
| | - Kathryn Kothari
- Baylor College of MedicineTexas Children's HospitalHoustonTexasUSA
| | - David W. Ashby
- Baylor College of MedicineTexas Children's HospitalHoustonTexasUSA
| | | | - Olga Semenova
- Cincinnati Children's Hospital Medical CenterUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Benjamin N. Abo
- Lee County Emergency Medical ServicesFort MyersFloridaUSA
- Department of Emergency MedicineFlorida State University College of MedicineTallahasseeFloridaUSA
- Sarasota County Fire DepartmentSarasotaFloridaUSA
| | - Benjamin Abes
- Lee County Emergency Medical ServicesFort MyersFloridaUSA
| | - Nichole Shimko
- Golisano Children's Hospital of Southwest FloridaFort MyersFloridaUSA
| | - Emily Myers
- Sarasota County Fire DepartmentSarasotaFloridaUSA
| | - Marshall Frank
- Department of Emergency MedicineFlorida State University College of MedicineTallahasseeFloridaUSA
- Sarasota County Fire DepartmentSarasotaFloridaUSA
| | - Tim Turner
- Walton County Fire Rescue DepartmentDefuniak SpringsFloridaUSA
| | - Mac Kemp
- Leon County EMSTallahasseeFloridaUSA
| | | | - Greg Roland
- Nassau County Fire DepartmentYuleeFloridaUSA
| | - Jennifer N. Fishe
- Department of Emergency MedicineUniversity of Florida College of MedicineJacksonvilleFloridaUSA
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Supples MW, Vaizer J, Liao M, Arkins T, Lardaro TA, Faris G, O'Donnell DP, Glober NK. Patient Demographics Are Associated with Differences in Prehospital Pain Management among Trauma Patients. PREHOSP EMERG CARE 2022; 27:1048-1053. [PMID: 36191334 DOI: 10.1080/10903127.2022.2132565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/01/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Disparities have been observed in the treatment of pain in emergency department patients. However, few studies have evaluated such disparities in emergency medical services (EMS). We describe pain medication administration for trauma indications in an urban EMS system and how it varies with patient demographics. METHODS We performed a retrospective review of the electronic medical records of adult patients transported for isolated trauma (without accompanying medical complaint) from 1/1/18 to 6/30/2020 by a third service EMS agency in a major United States metropolitan area. We performed descriptive statistics on epidemiology, type of pain medications administered, and pain scores. Kruskall-Wallis and chi-square or Fisher's exact tests were used to compare continuous and categorical variables, respectively. We constructed a logistic regression model to estimate the odds of nontreatment of pain by age, race, sex, transport interval, pain score, and Glasgow Coma Scale (GCS) score for patients with pain scores of at least four on a one to ten scale, the threshold for pain treatment per the EMS protocol. RESULTS Of 32,463 EMS patients with traumatic injuries included in the analysis, 40% (12,881/32,463) were African American, 50% (16,284/32,463) were female, the median age was 27 years (IQR 45-64), and the median initial pain score was 5 (IQR 2-8). Fifteen percent (4,989/32,463) received any analgesic. Initial pain scores were significantly higher for African American and female patients. African American patients were less likely to receive analgesia compared to White and Hispanic patients (19% versus 25% and 23%, respectively, p < 0.0001). Adjusting for age, pain score, transport interval, and GCS, African American compared to White, and female compared to male patients were less likely to be treated for pain, OR 1.59 (95% CI 1.47-1.72) and OR 1.20 (95% CI 1.11-1.28), respectively. CONCLUSION Among patients with isolated traumatic injuries treated in a single, urban EMS system, African American and female patients were less likely to receive analgesia than White or male patients. Analgesics were given to a small percentage of patients who were eligible for treatment by protocol, and intravenous opioids were used in the vast majority patients who received treatment.
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Affiliation(s)
| | - Julia Vaizer
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Mark Liao
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | - Gregory Faris
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Nancy K Glober
- Indiana University School of Medicine, Indianapolis, Indiana
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