Description of the 2012 NEMSIS Public-Release Research Dataset

AI-based approach for transcribing and classifying unstructured emergency call data: A methodological proposal

Emergency care-sensitive conditions (ECSCs) require rapid identification and treatment and are responsible for over half of all deaths worldwide. Prehospital emergency care (PEC) can provide rapid treatment and access to definitive care for many ECSCs and can reduce mortality in several different settings. The objective of this study is to propose a method for using artificial intelligence (AI) and machine learning (ML) to transcribe audio, extract, and classify unstructured emergency call data in the Serviço de Atendimento Móvel de Urgência (SAMU) system in southern Brazil. The study used all "1-9-2" calls received in 2019 by the SAMU Novo Norte Emergency Regulation Center (ERC) call center in Maringá, in the Brazilian state of Paraná. The calls were processed through a pipeline using machine learning algorithms, including Automatic Speech Recognition (ASR) models for transcription of audio calls in Portuguese, and a Natural Language Understanding (NLU) classification model. The pipeline was trained and validated using a dataset of labeled calls, which were manually classified by medical students using LabelStudio. The results showed that the AI model was able to accurately transcribe the audio with a Word Error Rate of 42.12% using Wav2Vec 2.0 for ASR transcription of audio calls in Portuguese. Additionally, the NLU classification model had an accuracy of 73.9% in classifying the calls into different categories in a validation subset. The study found that using AI to categorize emergency calls in low- and middle-income countries is largely unexplored, and the applicability of conventional open-source ML models trained on English language datasets is unclear for non-English speaking countries. The study concludes that AI can be used to transcribe audio and extract and classify unstructured emergency call data in an emergency system in southern Brazil as an initial step towards developing a decision-making support tool.

Database quality assessment in research in paramedicine: a scoping review

BACKGROUND

Research in paramedicine faces challenges in developing research capacity, including access to high-quality data. A variety of unique factors in the paramedic work environment influence data quality. In other fields of healthcare, data quality assessment (DQA) frameworks provide common methods of quality assessment as well as standards of transparent reporting. No similar DQA frameworks exist for paramedicine, and practices related to DQA are sporadically reported. This scoping review aims to describe the range, extent, and nature of DQA practices within research in paramedicine.

METHODS

This review followed a registered and published protocol. In consultation with a professional librarian, a search strategy was developed and applied to MEDLINE (National Library of Medicine), EMBASE (Elsevier), Scopus (Elsevier), and CINAHL (EBSCO) to identify studies published from 2011 through 2021 that assess paramedic data quality as a stated goal. Studies that reported quantitative results of DQA using data that relate primarily to the paramedic practice environment were included. Protocols, commentaries, and similar study types were excluded. Title/abstract screening was conducted by two reviewers; full-text screening was conducted by two, with a third participating to resolve disagreements. Data were extracted using a piloted data-charting form.

RESULTS

Searching yielded 10,105 unique articles. After title and abstract screening, 199 remained for full-text review; 97 were included in the analysis. Included studies varied widely in many characteristics. Majorities were conducted in the United States (51%), assessed data containing between 100 and 9,999 records (61%), or assessed one of three topic areas: data, trauma, or out-of-hospital cardiac arrest (61%). All data-quality domains assessed could be grouped under 5 summary domains: completeness, linkage, accuracy, reliability, and representativeness.

CONCLUSIONS

There are few common standards in terms of variables, domains, methods, or quality thresholds for DQA in paramedic research. Terminology used to describe quality domains varied among included studies and frequently overlapped. The included studies showed no evidence of assessing some domains and emerging topics seen in other areas of healthcare. Research in paramedicine would benefit from a standardized framework for DQA that allows for local variation while establishing common methods, terminology, and reporting standards.

Secular Trends in Airway Management of Out-of-Hospital Cardiac Arrest in the National Emergency Medical Services Information System (NEMSIS) Dataset

INTRODUCTION

Prehospital airway management is essential in resuscitation from out-of-hospital cardiac arrest (OHCA). No longitudinal national studies have described longitudinal trends in airway device choice. We sought to evaluate secular trends of OHCA endotracheal intubation (ETI) and supraglottic airway (SGA) in the United States (US).

METHODS

We evaluated ETI and SGA use for 2013-2022 in adult OHCA in the US using the National EMS Information System (NEMSIS) database. We identified OHCA events (CPR performed or defibrillation) and evaluated the proportions of ETI and SGA used during OHCA. We repeated the results stratified by urbanicity. We used descriptive statistics to describe the prevalence of airway device use by urbanicity.

RESULTS

During the study period, we observed 320,154,097 adult 9-1-1 events. Of 3,118,703 OHCA, there were 699,568 and 337,458 cases with reported ETI and SGA attempts. The dominant airway choice was ETI, though the trend of ETI choice decreased as SGA increased over time. From 2013 to 2022, SGA use increased in urban settings, while rural and suburban remained stable.

CONCLUSION

Over ten years, rates of advanced airway use have increased, with ETI remaining the predominant airway for adults in OHCA. Interestingly, ETI choice decreased as SGA increased over the study period. SGA use distinctly differed in urban settings, increasing concerns for disparities in care provision among communities. With the increased use of SGA over time, further evaluation of patient outcomes is required in datasets with robust linkage to Utstein variables.

Race and Ethnicity and Prehospital Use of Opioid or Ketamine Analgesia in Acute Traumatic Injury

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.

Prehospital Cardiac Arrest Should be Considered When Evaluating Coronavirus Disease 2019 Mortality in the United States

BACKGROUND

Public health emergencies leave little time to develop novel surveillance efforts. Understanding which preexisting clinical datasets are fit for surveillance use is of high value. Coronavirus disease 2019 (COVID-19) offers a natural applied informatics experiment to understand the fitness of clinical datasets for use in disease surveillance.

OBJECTIVES

This study evaluates the agreement between legacy surveillance time series data and discovers their relative fitness for use in understanding the severity of the COVID-19 emergency. Here fitness for use means the statistical agreement between events across series.

METHODS

Thirteen weekly clinical event series from before and during the COVID-19 era for the United States were collected and integrated into a (multi) time series event data model. The Centers for Disease Control and Prevention (CDC) COVID-19 attributable mortality, CDC's excess mortality model, national Emergency Medical Services (EMS) calls, and Medicare encounter level claims were the data sources considered in this study. Cases were indexed by week from January 2015 through June of 2021 and fit to Distributed Random Forest models. Models returned the variable importance when predicting the series of interest from the remaining time series.

RESULTS

Model r2 statistics ranged from 0.78 to 0.99 for the share of the volumes predicted correctly. Prehospital data were of high value, and cardiac arrest (CA) prior to EMS arrival was on average the best predictor (tied with study week). COVID-19 Medicare claims volumes can predict COVID-19 death certificates (agreement), while viral respiratory Medicare claim volumes cannot predict Medicare COVID-19 claims (disagreement).

CONCLUSION

Prehospital EMS data should be considered when evaluating the severity of COVID-19 because prehospital CA known to EMS was the strongest predictor on average across indices.

Documented Use of Emergency Medical Dispatch Protocols is Associated with Improved Survival in Out of Hospital Cardiac Arrest

OBJECTIVE

There are over 300,000 out-of-hospital cardiac arrests (OHCA) annually in the United States (US) and despite many scientific advances in the field, the survival rate remains low. We seek to determine if return of spontaneous circulation (ROSC) is higher when use of emergency medical dispatch (EMD) protocols is documented for OHCA calls compared to when no EMD protocol use is documented. We also seek identify care-related processes that differ in calls that use EMD protocols.

METHODS

This is a retrospective cohort study of U.S. adults with OHCA prior to emergency medical services (EMS) arrival using 2019 National EMS Information System data. The primary exposure was EMD usage during EMS call. The primary outcome was prehospital ROSC, and secondary outcomes included automated external defibrillator (AED) use before EMS arrival, bystander CPR, and end-of-event EMS survival (survival to the end of the EMS care at transport destination). Multivariable logistic regression adjusted for age, sex, race/ethnicity, primary insurance, rurality, initial rhythm, arrest etiology, and witnessed arrest.

RESULTS

Of the 96,269 OHCA cases included, EMD use was documented in 73%. Overall, 26% of subjects achieved ROSC in EMS care. EMD subjects were more likely to achieve ROSC (27.2% vs. 23.5%, uOR 1.22, 95%CI 1.18 - 1.26) even after adjusting for subject and arrest characteristics (aOR 1.13, 95%CI 1.08 - 1.17). EMD subjects also had higher end-of-event survival (19.1% vs. 16.4%, aOR 1.20, 95%CI 1.15 - 1.25). AED use before EMS arrival was more common in the EMD group (28.3% vs. 26.3% %diff 2.0, 95%CI 1.4 to 2.6), as was CPR before EMS arrival (63.8% vs. 55.1%, difference 8.6%, 95%CI 7.9 to 9.3%).

CONCLUSIONS

In this retrospective analysis, the rate of ROSC was higher in adult OHCA patients when EMD protocol use was reported compared to when it was not reported. The group with documented EMD use also experienced higher rates of bystander AED use, bystander CPR, and end-of-event survival.

A comparison between sudden cardiac arrest on military bases and non-military settings

INTRODUCTION

Out-of-hospital cardiac arrests contribute to significant morbidity and mortality in both non-military/civilian and military populations. Early CPR and AED use have been linked with improved outcomes. There is public health interest in identifying communities with high rates of both with the hopes of creating generalizable tactics for improving cardiac arrest survival.

METHODS

We examined a national registry of EMS activations in the United States (NEMSIS). Inclusion criteria were witnessed cardiac arrests from January 2020 to September 2022 where EMS providers documented the location of the arrest, whether CPR was provided prior to their arrival (yes/no), and whether an AED was applied prior to their arrival (yes/no). Cardiac arrests were then classified as occurring on a military base or in a non-military setting.

RESULTS

A total of 60 witnessed cardiac arrests on military bases and 202,605 witnessed cardiac arrests in non-military settings met inclusion criteria. Importantly, the prevalence of CPR and AED use prior to EMS arrival was significantly higher on military bases compared to non-military settings.

CONCLUSIONS

Reasons for the trends we observed may be a greater availability of CPR-trained individuals and AEDs on military bases, as well as a widespread willingness to provide aid to victims of cardiac arrest. Further research should examine cardiac arrests on military bases.

Differences in Out-of-Hospital Cardiac Arrest Management and Outcomes across Urban, Suburban, and Rural Settings

BACKGROUND

Rural prehospital care settings are underrepresented in the out-of-hospital cardiac arrest (OHCA) literature. This study aimed to describe treatment patterns and the odds of a favorable patient outcome (e.g., return of spontaneous circulation (ROSC) or being presumptively alive at the end of the incident) among rural OHCA patients in the U.S.

METHODS

Using the 2018 National Emergency Medical Services Informational System (NEMSIS) dataset, we analyzed OHCA incidents where an emergency medical services (EMS) unit provided cardiopulmonary resuscitation (CPR) and either terminated the resuscitation or completed transport. We excluded traumatic injuries, pediatric patients, and incidents with response time >60 minutes. The primary outcome was ROSC at any time during the EMS incident. The secondary outcome was a binary end-of-event indicator previously described for use in NEMSIS to estimate longer-term outcomes. Multivariable logistic regression was performed for each outcome measure comparing rural, suburban, and urban settings while controlling for key factors.

RESULTS

A total of 64,489 OHCA incidents were included, with 5,601 (8.9%) in rural settings. Among the full sample of OHCA incidents, ROSC was achieved in 20,578 (33.6%) cases, including 29.2% in rural settings and 34.1% in urban or suburban settings (p < 0.001). Advanced life support units responded to 95.3% of all calls, and a greater proportion of rural OHCA incidents were managed by basic life support units (7.4% vs. 4.2%, p < 0.001). Rural OHCA incidents had longer response times (7.5 vs. 5.9 minutes, p < 0.001), and rural patients were less likely to receive epinephrine (69.3% vs. 73.3%, p < 0.001). Further, EMS clinicians in rural areas were more likely to use mechanical CPR (29.5% vs. 27.6%, p < 0.01) and were less likely to perform advanced airway management (48.5% vs. 54.2%, p < 0.001). Rural patients had lower odds of achieving ROSC than urban patients after controlling for other factors (OR 0.81, 95% CI: 0.75-0.87). Rural patients also had lower odds of having a positive end-of-event outcome (i.e., presumptively alive) after controlling for other factors (OR 0.86, 95% CI: 0.79-0.93).

CONCLUSION

In this national sample of EMS-treated OHCAs, rural patients had lower odds of a favorable outcome (e.g., ROSC or presumptively alive) compared to those in urban settings.

Time to Antiarrhythmic and Association with Return of Spontaneous Circulation in the United States

INTRODUCTION

Recent clinical trials have failed to identify a benefit of antiarrhythmic administration during cardiac arrest. However, little is known regarding the time to administration of antiarrhythmic drugs in clinical practice or its impact on return of spontaneous circulation (ROSC). We utilized a national EMS registry to evaluate the time of drug administration and association with ROSC.

METHODS

We utilized the 2018 and 2019 NEMSIS datasets, including all non-traumatic, adult 9-1-1 EMS activations for cardiac arrests with initial shockable rhythm and that received an antiarrhythmic. We calculated the time from 9-1-1 call to administration of antiarrhythmic. We excluded cases with erroneous time stamps. Stratified by initial antiarrhythmic (amiodarone and lidocaine), we created a mixed-effect logistic regression model evaluating the association between every 5-minute increase in time to antiarrhythmic and ROSC. We modeled EMS agency as a random intercept and adjusted for confounders.

RESULTS

There were 449,630 adults, non-traumatic cardiac arrests identified with 11,939 meeting inclusion criteria. 9,236 received amiodarone and 1,327 received lidocaine initially. The median time in minutes to initial dose for amiodarone was 19.9 minutes (IQR 15.8-25.6) and for lidocaine was 19.5 minutes (IQR 15.2-25.4). Increasing time to initial antiarrhythmic was associated with decreased odds of ROSC for both amiodarone (aOR 0.9; 95% CI 0.9-0.94) and lidocaine (aOR 0.9; 95% CI 0.8-0.97).

CONCLUSION

Time to administration of anti-arrhythmic medication varied, but most patients received the first dose of anti-arrhythmic drug more than 19 minutes after the initial 9-1-1 call. Longer time to administration of an antiarrhythmic in patients with an initial shockable rhythm was associated with decreased ROSC rates.

Considering non-hospital data in clinical informatics use cases, a review of the National Emergency Medical Services Information System (NEMSIS)

Background

The National Emergency Medical Services (EMS) Information System (NEMSIS) Technical Assistance Center (TAC) collects and curates EMS activation level records for the United States. Originated as an outcomes assessment and service comparison tool, NEMSIS may have other high value clinical and public health uses.

Methods

This study acquired a 100% activation level public dataset for 2019 from NEMSIS TAC and assessed item response quantities. Subsumption of NEMSIS terms within other controlled clinical vocabularies was also considered.

Results

None of the assessed terminologies (LOINC, ICD10-CM, SNOMED-CT) could describe meaningful volumes of NEMSIS item response codes. The 2019 activation year dataset included 36,525 non-date/time or calculated distinct item responses for 43 activation descriptive items. Said item responses yielded 2,101,844,053 activation distinct non-blank responses. Several NEMSIS item responses had high clinical and public health value.

Conclusions

NEMSIS can support multiple public health use cases in addition to EMS outcomes assessment. A comprehensive custom value set is appropriate to integrate NEMSIS item response codes into controlled terminologies, FHIR or hospital Electronic Health Record applications.

Emergency Medical Services Clinicians' Perspectives on Pediatric Non-Transport

OBJECTIVES

Emergency medical services clinicians do not transport one-third of all children assessed, even without official pediatric non-transport protocols. Little is known about how EMS clinicians and caregivers decide not to transport a child. Our objectives were to describe how EMS clinicians currently decide whether or not to transport a child and identify barriers to and enablers of successfully implementing an EMS clinician-initiated pediatric non-transport protocol.

METHODS

We conducted six virtual focus groups with EMS clinicians from the mid-Atlantic. A PhD trained facilitator moderated all groups using a semi-structured moderator guide. Multiple investigators independently coded a deidentified sample transcript. One team member then completed axial coding of the remaining transcripts. Thematic saturation was achieved. Clusters of similar codes were grouped into themes by consensus.

RESULTS

We recruited 50 participants, of whom 70% were paramedics and 28% emergency medical technicians. There was agreement that caregivers often use 9-1-1 for low acuity complaints. Participants stated that non-transport usually occurs after shared decision-making between EMS clinicians and caregivers; EMS clinicians advise whether transport is necessary, but caregivers are responsible for making the final decision and signing refusal documentation. Subthemes for how non-transport decisions were made included the presence of agency protocols, caregiver preferences, absence of a guardian on the scene, EMS clinician variability, and distance to the nearest ED. Participants identified the following features that would enable successful implementation of an EMS clinician-initiated non-transport process: a user-friendly interface, clear protocol endpoints, the inclusion of vital sign parameters, resources to leave with caregivers, and optional direct medical oversight.

CONCLUSIONS

EMS clinicians in our study agreed that non-transport is currently a caregiver decision, but noted a collaborative process of shared decision-making where EMS clinicians advise caregivers whether transport is indicated. Further research is needed to understand the safety of this practice. This study suggests there may be a need for EMS-initiated alternative disposition/non-transport protocols.

Prehospital care for traumatic cardiac arrest in the US: A cross-sectional analysis and call for a national guideline

AIM

We describe emergency medical services (EMS) protocols and prehospital practice patterns related to traumatic cardiac arrest (TCA) management in the U.S.

METHODS

We examined EMS management of TCA by 1) assessing variability in recommended treatments in state EMS protocols for TCA and 2) analyzing EMS care using a nationwide sample of EMS activations. We included EMS activations involving TCA in adult (≥18 years) patients where resuscitation was attempted by EMS. Descriptive statistics for recommended and actual treatments were calculated and compared between blunt and penetrating trauma using χ² and independent 2-group Mann-Whitney U tests.

RESULTS

There were 35 state EMS protocols publicly available for review, of which 16 (45.7%) had a specific TCA protocol and 17 (48.5%) had a specific termination of resuscitation protocol for TCA. Recommended treatments varied. We then analyzed 9,565 EMS activations involving TCA (79.1% blunt, 20.9% penetrating). Most activations (93%) were managed by advanced life support. Return of spontaneous circulation was achieved in 25.5% of activations, and resuscitation was terminated by EMS in 26.4% of activations. Median prehospital scene time was 16.4 minutes; scene time was shorter for penetrating mechanisms than blunt (12.0 vs 17.0 min, p < 0.001). Endotracheal intubation was performed in 32.0% of activations, vascular access obtained in 66.6%, crystalloid fluids administered in 28.8%, and adrenaline administered in 60.1%.

CONCLUSION

Actual and recommended approaches to EMS treatment of TCA vary nationally. These variations in protocols and treatments highlight the need for a standardized approach to prehospital management of TCA in the U.S.

Disparities in Prehospital Non-Traumatic Pain Management

INTRODUCTION

While prior research has identified racial disparities in prehospital analgesia for traumatic pain, little is known about non-traumatic pain. Using a national prehospital dataset, we sought to evaluate for racial and ethnic disparities in analgesia given by EMS for non-traumatic pain.

METHODS

We analyzed the 2018 and 2019 data from the ESO Data Collaborative, a collection of de-identified prehospital electronic health records from nearly 1,300 participating EMS agencies in the US. We included all transported, adult, non-traumatic encounters with a primary or secondary impression of a pain complaint, and we stratified encounters based on race and ethnicity as recorded by the EMS clinicians. We performed a mixed model analysis, modeling EMS agency as a random intercept and adjusting for age, sex, pain location, level of service, location of incident, and highest pain score. With non-Hispanic White patients as the reference group, we then evaluated the association between race/ethnicity and receiving any pain medication (acetaminophen, non-steroidal anti-inflammatories, or opioids), receiving opioid pain medication, and receiving pain medication within 20 minutes of EMS arrival.

RESULTS

We included 1,035,486 patients; 67.5% non-Hispanic White, 26.8% Black, 4.9% Hispanic, 0.5% Asian, 0.1% Native Hawaiian or Other Pacific Islander, and 0.2% American Indian or Alaska Native patients. 4.7% of patients received pain medications. Compared to White patients (5.1%), Black patients were less likely to receive pain medication (3.3%, aOR 0.7; 95% CI 0.7-0.7) and Hispanics were more likely to receive pain medication (7.6%, aOR 1.5; 95% CI 1.4-1.6). Black patients were also less likely to receive opioids (1.8% for Black v 3.0% for White, aOR 0.7; 95% CI 0.6-0.7), while Hispanic patients were more likely to receive opioids (4.9%, aOR 1.4; 95% CI 1.3-1.5). The odds of receiving pain medication within 20 minutes was lower for Black patients (aOR 0.9; 95% CI 0.8-0.95) but no different for Hispanic patients (aOR 1.0; 95% CI 0.9-1.1), when compared to White patients.

CONCLUSION

Pain medication administration is uncommon for non-traumatic pain complaints. While Black patients were less likely than White patients to receive pain medications and receive pain medication within 20 minutes, Hispanics were more likely to receive pain medications.

Epidemiology of Emergency Medical Services Activations for Sport-Related Injuries in the United States

Background

Literature examining emergency medical services (EMS) activations for sport-related injuries is limited to the pediatric, high school, and collegiate student-athlete populations, excluding older individuals and recreational athletes. The purpose of this study was to examine EMS activations for sport-related injuries using the National EMS Information System Database from 2017-2018.

Methods

Data were obtained using the National EMS Information System Database from 2017-2018. EMS activations were limited to 9-1-1 responses for individuals aged 3-99 who sustained a sports-related injury. Independent variables included patient age group: pediatric (<18 years old) vs. adult (≥18 years old). Dependent variables were patient age, gender, and chief complaint anatomic location. Frequencies and proportions were calculated for each variable. Injury proportion ratios (IPRs) with 95% confidence intervals were calculated to compare chief complaint anatomic location by age group.

Results

There were 71,322 sport-related injuries. Patients were 36.6±22.9 years and most (58.1%, n=41,132) were male. Adults had higher proportions of injuries affecting the abdomen (IPR: 2.05, 95%CI: 1.83, 2.31), chest (IPR: 1.90, 95%CI: 1.75, 2.05), general/global (IPR: 1.54, 95%CI: 1.50, 1.58), and genitalia (IPR: 2.40, 95%CI: 1.39, 4.15), and lower proportions of injuries affecting the back (IPR: 0.55, 95%CI: 0.50, 0.60), lower extremity (IPR: 0.63, 95%CI: 0.60, 0.65), upper extremity (IPR: 0.50, 95%CI: 0.47, 0.53), head (IPR: 0.73, 95%CI: 0.70, 0.77), and neck (IPR: 0.18, 95%CI: 0.16, 0.20) compared to pediatric patients.

Conclusion

Injuries sustained differed between adult and pediatric patients, indicating sport-related emergencies may change across the lifespan. General/global chief complaints likely indicate sport-related injuries affecting multiple anatomic locations and organ systems. Stakeholders planning large or high-risk athletic events should consider arranging standby or dedicated advanced life support units for their events.

Description of the 2020 NEMSIS Public-Release Research Dataset

Background: The National Emergency Medical Services Information System (NEMSIS) is a federally funded program designed to standardize Emergency Medical Services (EMS) patient care reporting and facilitate state and national data repositories for the assessment and improvement of EMS systems of care. This manuscript characterizes the 2020 submissions to the National EMS Database, detailing the strengths and limitations associated with use of these data for public health surveillance, improving prehospital patient care, critical resource allocation, clinician safety, system quality assurance and research purposes.Methodology: Using the 2020 NEMSIS Public-Release Research Dataset (NEMSIS dataset), we evaluated the dataset completeness (i.e., presence of missing/null values), dataset content and assessed data generalizability. The analysis focused on 911 EMS activations resulting in the treatment and transport of a patient, except for out-of-hospital cardiac arrests for which all patients were included regardless of transport status.Results: In 2020, 43,488,767 EMS activations were reported to the National EMS Database by 12,319 agencies serving 50 states and territories. Of the 19,533,036 911 EMS activations reportedly treating and transporting a patient, the majority were attended by "non-volunteer" clinicians (77%) working in a fire-based EMS agency (35%) certified to offer Advanced Life Support (ALS) Paramedic service (80%) and located in an urban area (82%). 911 call centers most often dispatched EMS for "sick person" (20%), while EMS clinicians most likely reported asthenia (7%) as the patient's primary symptom as well as the clinician's primary impression (6%), and documented "fall on same level, slip, or trip" as the most common cause of injury (37%). The NEMSIS dataset demonstrates some "missingness" and element inconsistencies, but methods may be employed to mitigate these data limitations.Conclusions: The National EMS Database is a free and publicly available resource for evaluating EMS system utilization, response, and prehospital patient care. Understanding the characteristics of the underlying dataset and known data limitations will help ensure proper analysis and reporting of research and quality metrics based on nationally standardized NEMSIS data.

An assessment of the non-fatal crash risks associated with substance use during rush and non-rush hour periods in the United States

BACKGROUND

Understanding how substance use is associated with severe crash injuries may inform emergency care preparedness.

OBJECTIVES

This study aims to assess the association of substance use and crash injury severity at all times of the day and during rush (6-9 AM; 3-7 PM) and non-rush-hours. Further, this study assesses the probabilities of occurrence of low acuity, emergent, and critical injuries associated with substance use.

METHODS

Crash data were extracted from the 2019 National Emergency Medical Services Information System. The outcome variable was non-fatal crash injury, assessed on an ordinal scale: critical, emergent, low acuity. The predictor variable was the presence of substance use (alcohol or illicit drugs). Age, gender, injured part, revised trauma score, the location of the crash, the road user type, and the geographical region were included as potential confounders. Partially proportional ordinal logistic regression was used to assess the unadjusted and adjusted odds of critical and emergent injuries compared to low acuity injury.

RESULTS

Substance use was associated with approximately two-fold adjusted odds of critical and emergent injuries compared to low acuity injury at all times of the day and during the rush and non-rush hours. Although the proportion of substance use was higher during the non-rush hour period, the interaction effect of rush hour and substance use resulted in higher odds of critical and emergent injuries compared to low acuity injury.

CONCLUSION

Substance use is associated with increased odds of critical and emergent injury severity. Reducing substance use-related crash injuries may reduce adverse crash injuries.

Real-world study of multiple naloxone administrations for opioid overdose reversal among emergency medical service providers

Background: The increasing rates of highly potent, illicit synthetic opioids (i.e., fentanyl) in the US is exacerbating the ongoing opioid epidemic. Multiple naloxone administrations (MNA) may be required to successfully reverse opioid overdoses. We conducted a real-world study to assess the rate of MNA for opioid overdose and identify factors associated with MNA. Methods: Data from the 2015-2020 National Emergency Medical Services Information System was examined to determine trends in events requiring MNA. Logistic regression analysis was performed to determine factors associated with MNA. Results: The percentage of individuals receiving MNA increased from 18.4% in 2015 to 28.4% in 2020. The odds of an event requiring MNA significantly increased by 11% annually. The adjusted odds ratio (aOR) for MNA were greatest among males, when advanced life support (ALS) was provided, and when the dispatch complaint indicated there was a drug poisoning event. Conclusions: The 54% increase in MNA since 2015 parallels the rise in overdose deaths attributable to synthetic opioids. This growth is visible in all regions of the country, including the West, where the prevalence of illicitly manufactured synthetic opioids is intensifying. Given this phenomenon, higher naloxone formulations may fulfill an unmet need in addressing the opioid overdose crisis.

The association of crash response times and deaths at the crash scene: A cross-sectional analysis using the 2019 National Emergency Medical Service Information System

BACKGROUND

Deaths at the crash scene (DAS) are crash deaths that occur within minutes after a crash. Rapid crash responses may reduce the occurrence of DAS.

OBJECTIVES

This study aims to assess the association of crash response time and DAS during the rush and nonrush hour periods by rurality/urbanicity.

METHOD

This single-year cross-sectional study used the 2019 National Emergency Medical Services (EMS) Information System. The outcome variable was DAS. The predictor variables were crash response measures: EMS Chute Initiation Time (ECIT) and EMS Travel Time (ETT). Age, gender, substance use, region of the body injured, and the revised trauma score were used as potential confounders. Logistic regression was used to assess the unadjusted and adjusted odds of DAS.

RESULTS

A total of 654,675 persons were involved in EMS-activated road crash events, with 49.6% of the population exposed to crash events during the rush hour period. A total of 2,051 persons died at the crash scene. Compared to the baseline of less than 1 minute, ECIT ranging from 1 to 5 minutes was significantly associated with 58% (95% CI: 1.45-1.73) increased odds of DAS. Also, when compared to the baseline of less than 9 minutes, ETT ranging between 9 and 18 minutes was associated with 34% (95% CI: 1.22-1.47) increased odds of DAS. These patterns were consistent during the rush and nonrush hour periods and across rural and urban regions.

CONCLUSION

Reducing crash response times may reduce the occurrence of DAS.

Association between dispatch complaint and critical prehospital time intervals in suspected stroke 911 activations in the National Emergency Medical Services Information System, 2012-2016

OBJECTIVE

Emergency Medical Services can help improve stroke outcomes by recognizing stroke symptoms, establishing response priority for 911 calls, and minimizing prehospital delays. This study examines 911 stroke events and evaluates associations between events dispatched as stroke and critical EMS time intervals.

MATERIALS AND METHODS

Data from the National Emergency Medical Services Information System, 2012 to 2016, were analyzed. Activations from 911 calls with a primary or secondary provider impression of stroke were included for adult patients transported to a hospital destination. Three prehospital time intervals were evaluated: (1) response time (RT) ≤8 min, (2) on-scene time (OST) ≤15 min, and (3) transport time (TT) ≤12 min. Associations between stroke dispatch complaint and prehospital time intervals were assessed using multivariate regression to estimate adjusted risk ratios (ARR) and 95% confidence intervals (CIs).

RESULTS

Approximately 37% of stroke dispatch complaints were identified by EMS as a suspected stroke. Compared to stroke events without a stroke dispatch complaint, median OST was shorter for events with a stroke dispatch (16 min vs. 14 min, respectively). In adjusted analyses, events dispatched as stroke were more likely to meet the EMS time benchmark for OST ≤15 min (OST, 1.20 [1.20-1.21]), but not RT or TT (RT, [1.00-1.01]; TT, 0.95 [0.94-0.95]).

CONCLUSIONS

Our results indicate that dispatcher recognition of stroke symptoms reduces the time spent on-scene by EMS personnel. These findings can inform future EMS stroke education and quality improvement efforts to emphasize dispatcher recognition of stroke signs and symptoms, as EMS dispatchers play a crucial role in optimizing the prehospital response.

The timing of administering aspirin and nitroglycerin in patients with STEMI ECG changes alter patient outcome

BACKGROUND

Both chewed aspirin and sublingual nitroglycerin are fast acting medications and reach therapeutic levels within a few minutes. Current guidelines for managing acute coronary syndrome (ACS) do not recognize the importance of the order or timing of administering aspirin and nitroglycerin. This retrospective study aimed to examine if there was any benefit to the timing of giving aspirin before or after nitroglycerin in cases of ACS.

METHODS

From the large National Emergency Medical Services Information System (NEMSIS) 2017 Version database, 2594 patients with acute coronary syndrome were identified (based on chest pain and their ECG finding) that received aspirin plus nitroglycerin in prehospital settings. Based on which medication was given first, the patients were separated in 2 groups: an aspirin-first and a nitroglycerin-first group. The 2246 patients who received aspirin first were further stratified based on the time between administration of aspirin and the first dose of nitroglycerin. The other 348 patients who received nitroglycerin first were similarly stratified.

RESULTS

In patients with STEMI ischemia, giving nitroglycerin 10 min after aspirin dosing (compared to giving them simultaneously) leads to a greater than 20% reduction in need for additional nitroglycerin, a greater than 7% decrease in subjective pain experienced by the patient and reduced need for additional opioids. The aspirin-first group in total, had a 39.6% decrease in subjective pain experience after giving additional nitroglycerin compared to nitroglycerin-first group.

CONCLUSION

In patients with ACS, this study found that giving nitroglycerin 10 min after aspirin was associated with a reduction in subjective pain scores, as well as a reduced need for additional nitroglycerin or opioids. Future prospective trials examining the timing of aspirin vs. nitroglycerin are needed to confirm these findings.

National Characteristics of Non-Transported Children by Emergency Medical Services in the United States

Study Objective: Most 911 calls result in ambulance transport to an emergency department. In some cases, transport is refused or deemed unnecessary. The frequency of pediatric non-transport is unknown. Our primary objective was to describe the proportion of pediatric EMS activations resulting in non-transport. Our secondary objective was to identify patient, community, and EMS agency factors associated with pediatric non-transport.Methods: We conducted a cross-sectional study using 2019 data from the National EMS Information System registry. We compared non-transport rates for children (<18 y/o), adults (18 - 60 y/o) and elderly (>60 y/o) patients. We then used generalized estimating equations to identify factors associated with pediatric non-transport while accounting for geographical clustering.Results: There were 21,931,490 EMS activations, including 1,403,454 pediatric 911 responses. 30% of pediatric 911 responses resulted in non-transport. Non-transport was less likely for adults (19%, OR 0.54 [0.54, 0.55]) and elderly patients (13%, OR 0.35 [0.35, 0.36]). The most common pediatric non-transport dispositions were: refused evaluation/care, and treated/released. Non-transport was associated with: pulmonary (aOR 3.84 [3.30, 4.48]) and musculoskeletal chief complaints (aOR 3.75 [3.22, 4.36]). Non-transport was more likely for: rural EMS calls (aOR 1.28 [1.24, 1.32]); calls classified by EMS as Lower Acuity (aOR 7.88 [5.98, 10.38]); and Tribal EMS agencies (aOR 3.49 [3.09, 3.94]).Conclusion: Almost one-third of pediatric 911 activations result in non-transport. Although very few children have been included in pilots of alternate transport processes to date, non-transport is actually more common in children than adults. More work is needed to understand better the patient safety and economic implications of this practice.

Public Health Surveillance of Behavioral Health Emergencies through Emergency Medical Services Data

Objective: To identify the demographic, clinical and EMS characteristics of events documented as behavioral health emergencies (BHE) by EMS. Methods: This was a cross-sectional study using the 2018 National Emergency Medical Services Information System (NEMSIS) Version 3 dataset. All events that had patient care provided with a documented impression (field diagnosis) of ICD-10 codes F01-F99 (i.e., mental, behavioral, and neurodevelopmental disorders) were labeled a BHE and included. Descriptive statistics were calculated. Results: A total of 1,594,821 (7.3%) EMS calls had a BHE impression. The most common was mental and behavioral disorders due to psychoactive substance use (42.3%). More males than females had BHEs (54.6% vs. 45.4%), and most patients were ages 18-34 (31.5%). Most BHE occurred in urban settings (89.6%). Almost half (47.9%) were dispatched with a complaint unrelated to behavioral health. Conclusion: BHEs were noted in 7.3% of NEMSIS events, and the majority were associated with substance use disorders. EMS professionals need comprehensive training on best practices for BHE. Stakeholders should have information on prevalence of BHEs to ensure proper educational standards, training practices, and resource allocation.

Out-of-Hospital Ketamine: Indications for Use, Patient Outcomes, and Associated Mortality

STUDY OBJECTIVE

To describe out-of-hospital ketamine use, patient outcomes, and the potential contribution of ketamine to patient death.

METHODS

We retrospectively evaluated consecutive occurrences of out-of-hospital ketamine administration from January 1, 2019 to December 31, 2019 reported to the national ESO Data Collaborative (Austin, TX), a consortium of 1,322 emergency medical service agencies distributed throughout the United States. We descriptively assessed indications for ketamine administration, dosing, route, transport disposition, hypoxia, hypercapnia, and mortality. We reviewed cases involving patient death to determine whether ketamine could be excluded as a potential contributing factor.

RESULTS

Indications for out-of-hospital ketamine administrations in our 11,291 patients were trauma/pain (49%; n=5,575), altered mental status/behavioral indications (34%; n=3,795), cardiovascular/pulmonary indications (13%; n=1,454), seizure (2%; n=248), and other (2%; n=219). The highest median dose was for altered mental status/behavioral indications at 3.7 mg/kg (interquartile range, 2.2 to 4.4 mg/kg). Over 99% of patients (n=11,274) were transported to a hospital. Following ketamine administration, hypoxia and hypercapnia were documented in 8.4% (n=897) and 17.2% (n=1,311) of patients, respectively. Eight on-scene and 120 in-hospital deaths were reviewed. Ketamine could not be excluded as a contributing factor in 2 on-scene deaths, representing 0.02% (95% confidence interval 0.00% to 0.07%) of those who received out-of-hospital ketamine. Among those with in-hospital data, ketamine could not be excluded as a contributing factor in 6 deaths (0.3%; 95% confidence interval 0.1% to 0.7%).

CONCLUSION

In this large sample, out-of-hospital ketamine was administered for a variety of indications. Patient mortality was rare. Ketamine could not be ruled out as a contributing factor in 8 deaths, representing 0.07% of those who received ketamine.

Data missingness in the Michigan NEMSIS (MI-EMSIS) dataset: a mixed-methods study

OBJECTIVE

The study was done to evaluate levels of missing and invalid values in the Michigan (MI) National Emergency Medical Services Information System (NEMSIS) (MI-EMSIS) and explore possible causes to inform improvement in data reporting and prehospital care quality.

METHODS

We used a mixed-methods approach to study trends in data reporting. The proportion of missing or invalid values for 18 key reported variables in the MI-EMSIS (2010-2015) dataset was assessed overall, then stratified by EMS agency, software platform, and Medical Control Authorities (MCA)-regional EMS oversight entities in MI. We also conducted 4 focus groups and 10 key-informant interviews with EMS participants to understand the root causes of data missingness in MI-EMSIS.

RESULTS

Only five variables of the 18 studied exhibited less than 10% missingness, and there was apparent variation in the rate of missingness across all stratifying variables under study. No consistent trends over time regarding the levels of missing or invalid values from 2010 to 2015 were identified. Qualitative findings indicated possible causes for this missingness including data-mapping issues, unclear variable definitions, and lack of infrastructure or training for data collection.

CONCLUSIONS

The adoption of electronic data collection in the prehospital setting can only support quality improvement if its entry is complete. The data suggest that there are many EMS agencies and MCAs with very high levels of missingness, and they do not appear to be improving over time, demonstrating a need for investment in efforts in improving data collection and reporting.

Retrospective cross sectional analysis of demographic disparities in outcomes of CPR performed by EMS providers in the United States

Objective

To investigate demographic disparities in prehospital cardiopulmonary resuscitation (CPR) initiation and successful outcomes of patients with out-of-hospital cardiac arrest (OHCA) treated by emergency medical services (EMS) providers.

Methods

We analyzed the National Emergency Medical Service Information Systems (NEMSIS) 2017 database, analyzing patient gender, age and race against CPR initiation and Return of Spontaneous Circulation (ROSC). The analysis was performed for a subset of patients who received bystander interventions (n = 3,362), then repeated for the whole cohort of patients (n = 5,833).

Results

Within the subgroup of patients that received CPR or AED application prior to the arrival of the paramedics, a logistic regression for CPR initiation rates as a function of race, gender and age reported the following adjusted odds ratios: African American (AA) to White 0.570 (95%CI [0.419, 0.775]), Hispanic to White 0.735 (95%CI [0.470, 1.150]); female to male 0.768 (95%CI [0.598, 0.986]); senior to adult 0.708 (95%CI [0.545, 0.920). Similarly, a logistic regression of ROSC as a function of race, gender and age reported the following adjusted odds ratios: AA to White 0.652 (95%CI [0.533, 0.797]) Hispanic to White 1.018 (95%CI [0.783, 1.323]); female to male 0.887 (95%CI [0.767, 1.025]); senior to adult 0.817 (95%CI [0.709, 0.940]). Similar trends existed in the entire cohort of patients.

Conclusions

These results suggest that there are discrepancies in patient care during cardiopulmonary arrest performed by EMS for OHCA, inviting further exploration of healthcare differences in the prehospital EMS approach to OHCA.

Methods and Implementation of the 2019 EMS Practice Analysis

Background: The EMS Practice Analysis provides a vision of current prehospital care by defining the work performed by EMS professionals. In this manuscript, we present the National Advanced Life Support (ALS) EMS Practice Analysis for the advanced EMT (AEMT) and paramedic levels of certification. The goal of the 2019 EMS Practice Analysis is to define the work performed by EMS professionals and present a new template for future practice analyses. Methods: The project was executed in three phases. Phase 1 defined the types/frequency of EMS clinical presentations using the 2016 National Emergency Medical Services Information System (NEMSIS) dataset. Phase 2 defined the criticality or potential for harm of these clinical presentations through a survey of a random sample of nationally certified EMS professionals and medical directors. Phase 3 defined the tasks and the associated knowledge, skills, and abilities (KSA) that encompass EMS care through focus groups of subject matter experts. Results: In Phase 1, the most common EMS adult impressions were traumatic injury, abdominal pain/problems, respiratory distress/arrest, behavioral/psychiatric disorder, and syncope/fainting. The most common pediatric impressions were traumatic injury, behavioral/psychiatric disorder, respiratory distress/arrest, seizure, and abdominal pain/problems. Criticality was defined in Phase 2 with the highest risk of harm for adults being airway obstruction, respiratory distress/arrest, cardiac arrest, hypovolemia/shock, allergic reaction, or stroke/CVA. In comparison, pediatric patients presenting with airway obstruction, respiratory distress/arrest, cardiac arrest, hypovolemia/shock, allergic reaction, stroke/CVA, and inhalation injury had the highest potential for harm. Finally, in Phase 3, task statements were generated for both paramedic and AEMT certification levels. A total of 425 tasks and 1,734 KSAs were defined for the paramedic level and 405 tasks and 1,636 KSAs were defined for the AEMT level. Conclusion: The 2019 ALS Practice Analysis describes prehospital practice at the AEMT and paramedic levels. This approach allows for a detailed and robust evaluation of EMS care while focusing on each task conducted at each level of certification in EMS. The data can be leveraged to inform the scope of practice, educational standards, and assist in validating the ALS levels of the certification examination.

Low titer group O whole blood resuscitation: Military experience from the point of injury

INTRODUCTION

In the far forward combat environment, the use of whole blood is recommended for the treatment of hemorrhagic shock after injury. In 2016, US military special operations teams began receiving low titer group O whole blood (LTOWB) for use at the point of injury (POI). This is a case series of the initial 15 patients who received LTOWB on the battlefield.

METHODS

Patients were identified in the Department of Defense Trauma Registry, and charts were abstracted for age, sex, nationality, mechanism of injury, injuries and physiologic criteria that triggered the transfusion, treatments at the POI, blood products received at the POI and the damage-control procedures done by the first surgical team, next level of care, initial interventions by the second surgical team, Injury Severity Score, and 30-day survival. Descriptive statistics were used to characterize the clinical data when appropriate.

RESULTS

Of the 15 casualties, the mean age was 28, 50% were US military, and 63% were gunshot wounds. Thirteen patients survived to discharge, one died of wounds after arrival at the initial resuscitative surgical care, and two died prehospital. The mean Injury Severity Score was 21.31 (SD, 18.93). Eleven (68%) of the causalities received additional blood products during evacuation/role 2 and/or role 3. Vital signs were available for 10 patients from the prehospital setting and 9 patients upon arrival at the first surgical capable facility. The mean systolic blood pressure was 80.5 prehospital and 117 mm Hg (p = 0.0002) at the first surgical facility. The mean heart rate was 105 beats per minute prehospital and 87.4 beats per minute (p = 0.075) at the first surgical facility. The mean hospital stay was 24 days.

CONCLUSION

The use of cold-stored LTOWB at POI is feasible during combat operations. Further data are needed to validate and inform best practice for POI transfusion.

LEVEL OF EVIDENCE

Therapeutic study, level V.

Trends and Characteristics of Emergency Medical Services in Italy: A 5-Years Population-Based Registry Analysis

Background: Emergency Medical Services (EMS) plays a fundamental role in providing good quality healthcare services to citizens, as they are the first responders in distressing situations. Few studies have used available EMS data to investigate EMS call characteristics and subsequent responses. Methods: Data were extracted from the emergency registry for the period 2013–2017. This included call and rescue vehicle dispatch information. All relationships in analyses and differences in events proportion between 2013 and 2017 were tested against the Pearson’s Chi-Square with a 99% level of confidence. Results: Among the 2,120,838 emergency calls, operators dispatched at least one rescue vehicle for 1,494,855. There was an estimated overall incidence of 96 emergency calls and 75 rescue vehicles dispatched per 1000 inhabitants per year. Most calls were made by private citizens, during the daytime, and were made from home (63.8%); 31% of rescue vehicle dispatches were advanced emergency medical vehicles. The highest number of rescue vehicle dispatches ended at the emergency department (74.7%). Conclusions: Our data showed that, with some exception due to environmental differences, the highest proportion of incoming emergency calls is not acute or urgent and could be more effectively managed in other settings than in an Emergency Departments (ED). Better management of dispatch can reduce crowding and save hospital emergency departments time, personnel, and health system costs.

Emergency medical services targeting opioid user disorder: An exploration of current out-of-hospital post-overdose interventions

OBJECTIVE

The opioid epidemic continues to escalate, and out-of-hospital emergency medical services (EMS) play a vital role in acute overdose reversal, but could serve a broader role post-incident for follow-up, outreach, and referrals. Our objective is to identify the scope and prevalence of community-based, post-opioid overdose EMS programs across the United States.

METHODS

We used a narrative review of prior studies in PubMed and Scopus for the last 20 years (1999-2020) to identify relevant medical literature and a web search to identify gray literature of EMS interventions involving opioids.

RESULTS

Out of nearly 22,000 EMS agencies across the United States, we found evidence of only 27 programs published in medical or gray literature involving post-overdose interventions. They were most commonly found in the north and eastern region of the country. Although most of these programs incorporate harm reduction and education, other more innovative aspects such as linkage to outpatient addiction treatment or peer support services, are much less common. The most comprehensive programs involved combinations of innovative outreach, specialized referrals, integration with police and criminal justice, peer support, and even treatment initiation.

CONCLUSIONS

Out-of-hospital emergency care has the potential to provide more comprehensive care after drug overdose, but many programs either do not currently have such an intervention in place, or are not disseminating their practices for other agencies to assimilate. EMS protocols and policies that encourage greater adoption of active community paramedicine practices for opioids should be encouraged.

Heat-Related Illnesses Transported by United States Emergency Medical Services

Background and objectives: Heat-related illness (HRI) can have significant morbidity and mortality consequences. Research has predominately focused on HRI in the emergency department, yet health care leading up to hospital arrival can impact patient outcomes. Therefore, the purpose of this study was to describe HRI in the prehospital setting. Materials and Methods: A descriptive epidemiological design was utilized using data from the National Emergency Medical Services (EMS) Information System for the 2017-2018 calendar years. Variables of interest in this study were: patient demographics (age, gender, race), US census division, urbanicity, dispatch timestamp, incident disposition, primary provider impression, and regional temperatures. Results: There were 34,814 HRIs reported. The majority of patients were white (n = 10,878, 55.6%), males (n = 21,818, 62.7%), and in the 25 to 64 age group (n = 18,489, 53.1%). Most HRIs occurred in the South Atlantic US census division (n = 11,732, 33.7%), during the summer (n = 23,873, 68.6%), and in urban areas (n = 27,541, 83.5%). The hottest regions were East South Central, West South Central, and South Atlantic, with peak summer temperatures in excess of 30.0 °C. In the spring and summer, most regions had near normal temperatures within 0.5 °C of the long-term mean. EMS dispatch was called for an HRI predominately between the hours of 11:00 a.m.-6:59 p.m. (n = 26,344, 75.7%), with the majority (27,601, 79.3%) of HRIs considered heat exhaustion and requiring the patient to be treated and transported (n = 24,531, 70.5%). Conclusions: All age groups experienced HRI but particularly those 25 to 64 years old. Targeted education to increase public awareness of HRI in this age group may be needed. Region temperature most likely explains why certain divisions of the US have higher HRI frequency. Afternoons in the summer are when EMS agencies should be prepared for HRI activations. EMS units in high HRI frequency US divisions may need to carry additional treatment interventions for all HRI types.

Effect of the Coronavirus Disease 2019 (COVID-19) Pandemic on the U.S. Emergency Medical Services System: A Preliminary Report

Background

Our objective was to quantify trends in emergency medical services (EMS) incidents as the effects of the COVID‐19 pandemic spread across the United States and to determine if there was an increase in EMS‐attended deaths.

Methods

We conducted a 3‐year comparative retrospective cohort analysis of data from the National EMS Information System. Data were included if care was provided between the 40th and 21st weeks of the next year and compared over 3 years. We included incidents identified through 9‐1‐1 where patient contact was made. The total number of EMS incidents per week was used as the denominator to calculate the rate of patient deaths and possible injury. We assessed for temporal and seasonal trends.

Results

Starting in the 10th week of 2020 there was a decrease in the number of EMS activations in the United States compared to the prior weeks and the same time period in previous years. The number of activations between week 10 and week 16 decreased by 140,292 or 26.1%. The portion of EMS activations reporting a patient disposition of death nearly doubled between the 11th and 15th weeks of 2020 (1.49%–2.77% of all activations). The number of EMS activations documenting a possible injury decreased from 18.43% to 15.27% between weeks 10 and 13.

Conclusion

We found that early in the COVID‐19 outbreak there was a significant decrease in the number of EMS responses across the United States. Simultaneously the rate of EMS‐attended death doubled, while the rate of injuries decreased.

Out-of-hospital assessment and treatment of adults with atraumatic headache

OBJECTIVE

Little is known about the presentation or management of patients with headache in the out-of-hospital setting. Our primary objective is to describe the out-of-hospital assessment and treatment of adults with benign headache. We also describe meaningful pain reduction stratified by commonly administered medications.

METHODS

This retrospective evaluation was conducted using data from a large national cohort. We included all 911 responses by paramedics for patients 18 and older with headache. We excluded patients with trauma, fever, suspected alcohol/drug use, or who received medications suggestive of an alternate condition. We presented our findings with descriptive statistics.

RESULTS

Of the 5,977,612 emergency responses, 1.1% (66,235) had a provider-documented primary impression of headache or migraine and 52.5% (34,763) met inclusion criteria. An initial pain score was recorded for 73.5% (25,544) of patients, and 58.5% (14,948) of these patients had multiple pain scores documented. Of the patients with multiple pain scores documented, 53.8% (8037) of patients had an initial pain score >5. Of these, 7.1% (573) were administered any medication. Among patients receiving a single medication, Fentanyl was the most commonly administered (32.1%, 126). As a group, opioids were the most commonly administered class of drugs (38.9%, 153) and were associated with the largest proportion of clinically significant pain reduction (69.3%, 106). Dopamine antagonists were given least frequently (9.9%, 39) but had the second largest proportion of pain reduction (43.6%, 17).

CONCLUSION

Out-of-hospital pain scores were documented infrequently and less than one in five patients with initial pain scores >5 received medication. Additionally, adherence to evidence-based guidelines was infrequent.

The effect of rural hospital closures on emergency medical service response and transport times

OBJECTIVE

To examine the effect of rural hospital closures on EMS response time (minutes between dispatch notifying unit and arriving at scene); transport time (minutes between unit leaving the scene and arriving at destination); and total activation time (minutes between 9-1-1 call to responding unit returning to service), as longer EMS times are associated with worse patient outcomes.

DATA SOURCES/STUDY SETTING

We use secondary data from the National EMS Information System, Area Health Resource, and Center for Medicare & Medicaid Provider of Service files (2010-2016).

STUDY DESIGN

We examined the effects of rural hospital closures on EMS transport times for emergent 9-1-1 calls in rural areas using a pre-post, retrospective cohort study with the matched comparison group using difference-in-difference and quantile regression models.

PRINCIPAL FINDINGS

Closures increased mean EMS transport times by 2.6 minutes (P = .09) and total activation time by 7.2 minutes (P = .02), but had no effect on mean response times. We also found closures had heterogeneous effects across the distribution of EMS times, with shorter response times, longer transport times, and median total activation times experiencing larger effects.

CONCLUSIONS

Rural hospital closures increased mean transport and total activation times with varying effects across the distribution of EMS response, transport, and total times. These findings illuminate potential barriers to accessing timely emergency services due to closures.

Who receives naloxone from emergency medical services? Characteristics of calls and recent trends

Background: With the rapid rise in opioid overdose-related deaths, state policy makers have expanded policies to increase the use of naloxone by emergency medical services (EMS). However, little is known about changes in EMS naloxone administration in the context of continued worsening of the opioid crisis and efforts to increase use of naloxone. This study examines trends in patient demographics and EMS response characteristics over time and by county urbanicity. Methods: We used data from the 2013-2016 National EMS Information System to examine trends in patient demographics and EMS response characteristics for 911-initiated incidents that resulted in EMS naloxone administration. We also assessed temporal, regional, and urban-rural variation in per capita rates of EMS naloxone administrations compared with per capita rates of opioid-related overdose deaths. Results: From 2013 to 2016, naloxone administrations increasingly involved young adults and occurred in public settings. Particularly in urban counties, there were modest but significant increases in the percentage of individuals who refused subsequent treatment, were treated and released, and received multiple administrations of naloxone before and after arrival of EMS personnel. Over the 4-year period, EMS naloxone administrations per capita increased at a faster rate than opioid-related overdose deaths across urban, suburban, and rural counties. Although national rates of naloxone administration were consistently higher in suburban counties, these trends varied across U.S. Census Regions, with the highest rates of suburban administration occurring in the South. Conclusions: Naloxone administration rates increased more quickly than opioid deaths across all levels of county urbanicity, but increases in the percentage of individuals requiring multiple doses and refusing subsequent care require further attention.

"Make the Call, Don't Miss a Beat" Campaign: Effect on Emergency Medical Services Use in Women with Heart Attack Signs

BACKGROUND

Our objective was to evaluate the relationship between the "Make The Call, Don't Miss a Beat" national mass media campaign and emergency medical services (EMS) use among women with possible heart attack symptoms.

METHODS

We linked campaign TV public service advertisement data with national EMS activation data for 2010 to 2014. We identified EMS activations (i.e., responses) for possible heart attack symptoms and for unintentional injuries for both women and men. We estimated the impact of the campaign on the fraction of the 1.7 to 15.9 million activations of women with possible heart attack symptoms compared with 1.9 million female activations for unintentional injuries within each EMS agency and month using quasi-binomial logistic regression controlling for time and state.

RESULTS

Of the 3,175 U S. counties, 90% were exposed to the campaign. However, less than 2% of U.S. counties reached moderate TV exposure (≥300 gross rating points) during the entire campaign period. We did not observe an increase in the fraction of female activations for possible heart attack during periods or in counties with higher campaign exposure.

CONCLUSIONS

This mass media campaign that relied heavily on TV public service advertisements was not associated with increased EMS use by women with possible heart attack symptoms, even among counties that were more highly exposed to the campaign advertisements.

Association Between Emergency Medical Service Response Time and Motor Vehicle Crash Mortality in the United States

Importance

Motor vehicle crashes (MVCs) are a leading public health concern. Emergency medical service (EMS) response time is a modifiable, system-level factor with the potential to influence trauma patient survival. The relationship between EMS response time and MVC mortality is unknown.

Objectives

To measure the association between EMS response times and MVC mortality at the population level across US counties.

Design, Setting, and Study Population

This population-based study included MVC-related deaths in 2268 US counties, representing an estimated population of 239 464 121 people, from January 1, 2013, through December 31, 2015. Data were analyzed from October 1, 2017, through April 30, 2018.

Exposure

The median EMS response time to MVCs within each county (county response time), derived from data collected by the National Emergency Medical Service Information System.

Main Outcomes and Measures

The county rate of MVC-related death, calculated using crash fatality data recorded in the Fatality Analysis Reporting System of the National Highway Traffic Safety Administration.

Results

During the study period, 2 214 480 ambulance responses to MVCs were identified (median, 229 responses per county [interquartile range (IQR), 73-697 responses per county]) in 2268 US counties. The median county response time was 9 minutes (IQR, 7-11) minutes. Longer response times were significantly associated with higher rates of MVC mortality (≥12 vs <7 minutes; mortality rate ratio, 1.46; 95% CI, 1.32-1.61) after adjusting for measures of rurality, on-scene and transport times, access to trauma resources, and traffic safety laws. This finding was consistent in both rural/wilderness and urban/suburban settings, where a significant proportion of MVC fatalities (population attributable fraction: rural/wilderness, 9.9%; urban/suburban, 14.1%) were associated with prolonged response times (defined by the median value, ≥10 minutes and ≥7 minutes, respectively).

Conclusions and Relevance

Among 2268 US counties, longer EMS response times were associated with higher rates of MVC mortality. A significant proportion of MVC-related deaths were associated with prolonged response times in both rural/wilderness and urban/suburban settings. These findings suggest that trauma system-level efforts to address regional disparities in MVC mortality should evaluate EMS response times as a potential contributor.

Impact of prehospital mechanical ventilation: A retrospective matched cohort study of 911 calls in the United States

Prehospital use of ventilators by emergency medical services (EMS) during 911 calls is increasing. This study described the impact of prehospital mechanical ventilation on prehospital time intervals and on mortality.This retrospective matched-cohort study used 4 consecutive public releases of the US National Emergency Medical Services Information System dataset (2011-2014). EMS activations with recorded ventilator use were randomly matched with activations without ventilator use (1 to 1) on age (range ± 2 years), gender, provider's primary impression, urbanicity, and level of service.A total of 5740 EMS activations were included (2870 patients per group). Patients in the ventilator group had a mean age of 69.1 (±17.3) years with 49.4% males, similar to the non-ventilator group. Activations were mostly in urban settings (83.8%) with an advanced life support level of care (94.5%). Respiratory distress (77.8%) and cardiac arrest (6.8%) were the most common provider's primary impressions. Continuous positive airway pressure was the most common mode of ventilation used (79.2%).Mortality was higher at hospital discharge (29.0% vs 21.1%, P = .01) but not at emergency department (ED) discharge (8.4% vs 7.4%, P = .19) with prehospital ventilator use. Both total on-scene time and total prehospital time intervals increased with reported ventilator use (4.10 minutes (95% confidence interval [CI]: 2.71-5.49) and 3.59 minutes (95% CI: 3.04-4.14), respectively).Ventilator use by EMS agencies in 911 calls in the US is associated with higher prehospital time intervals without observed impact on survival to ED discharge. More EMS outcome research is needed to provide evidence-based prehospital care guidelines and targeted resource utilization.

Emergency Medical Services Experience With Barb Removal After Taser Use By Law Enforcement: A Descriptive National Study

Background

Conducted electrical weapons (CEWs), including Thomas A. Swift Electric Rifles (TASERs), are increasingly used by law enforcement officers (LEOs) in the US and world-wide. Little is known about the experience of Emergency Medical Service (EMS) providers with these incidents.

Objectives

This study describes EMS encounters with documented TASER use and barb removal, characteristics of resulting injuries, and treatment provided.

Methods

This retrospective study used five combined, consecutive National Emergency Medical Services Information System (NEMSIS; Salt Lake City, Utah USA) public-release datasets (2011-2015). All EMS activations with documented TASER barb removal were included. Descriptive analyses were carried out.

Results

The study included 648 EMS activations with documented TASER barb removal, yielding a prevalence rate of 4.55 per 1,000,000 EMS activations. Patients had a mean age of 35.9 years (SD=18.2). The majority were males (80.2%) and mainly white (71.3%). Included EMS activations were mostly in urban or suburban areas (78.3%). Over one-half received Advanced Life Support (ALS)-level of service (58.2%). The most common chief complaint reported by dispatch were burns (29.9%), followed by traumatic injury (16.1%). Patients had pain (45.6%) or wound (17.2%) as a primary symptom, with most having possible injury (77.8%). Reported causes of injury were mainly fire and flames (29.8%) or excessive heat (16.7%). The provider’s primary impressions were traumatic injury (66.3%) and behavioral/psychiatric disorder (16.8%). Only one cardiac arrest (0.2%) was reported. Over one-half of activations resulted in patient transports (56.3%), mainly to a hospital (91.2%). These encounters required routine EMS care (procedures and medications). An increase in the prevalence of EMS activations with documented TASER barb removal over the study period was not significant (P=.27).

Conclusion

At present, EMS activations with documented TASER barb removal are rare. Routine care by EMS is expected, and life-threatening emergencies are not common. All EMS providers should be familiar with local policies and procedures related to TASER use and barb removal.

El SayedM, El TawilC, TamimH, MailhacA, MannNC. Emergency Medical Services experience with barb removal after TASER use by law enforcement: a descriptive national study. Prehosp Disaster Med. 2019;34(1):38–45.

Hypoglycemia Emergencies: Factors Associated with Prehospital Care, Transportation Status, Emergency Department Disposition, and Cost

Objectives: The objectives of this study were to evaluate demographic/clinical characteristics and treatment/transportation decisions by emergency medical services (EMS) for patients with hypoglycemia and link EMS activations to patient disposition, outcomes, and costs to the emergency medical system. This evaluation was to identify potential areas where improvements in prehospital healthcare could be made. Methods: This was a retrospective analysis of the National Emergency Medical Services Information System (NEMSIS) registry and three national surveys: Nationwide Emergency Department Sample (NEDS), National Hospital Ambulatory Medical Care Survey (NHAMCS), and Medical Expenditure Panel Survey (MEPS) from 2013, to examine care of hypoglycemia from the prehospital and the emergency department (ED) perspectives. Results: The study estimated 270,945 hypoglycemia EMS incidents from the NEMSIS registry. Treatments were consistent with national guidelines (i.e., oral glucose, intravenous [IV] dextrose, or glucagon), and patients were more likely to be transported to the ED if the incident was in a rural setting or they had other chief concerns related to the pulmonary or cardiovascular system. Use of IV dextrose decreased the likelihood of transportation. Approximately 43% of patients were not transported from the scene. Data from the NEDS survey estimated 258,831 ED admissions for hypoglycemia, and 41% arrived by ambulance. The median ambulance expenditure was $664 ± 98. From the ED, 74% were released. The average ED charge that did not lead to hospital admission was $3106 ± 86. Increased odds of overnight admission included infection and acute renal failure. Conclusions: EMS activations for hypoglycemia are sizeable and yet a considerable proportion of patients are not transported to or are discharged from the ED. Seemingly, these events resolved and were not medically complex. It is possible that implementation and appropriate use of EMS treat-and-release protocols along with utilizing programs to educate patients on hypoglycemia risk factors and emergency preparedness could partially reduce the burden of hypoglycemia to the healthcare system.

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.

Assessment of Key Health and Wellness Indicators Among North Carolina Emergency Medical Service Providers

OBJECTIVE

The objective of this study was to characterize key health indicators in Emergency Medical Services (EMS) personnel and identify areas for intervention in order to ensure a strong and capable emergency health workforce.

METHODS

Participants were EMS personnel delivering patients to 4 regional tertiary care emergency departments within North Carolina (NC). After transferring patient care and agreeing to participate, height, weight, and blood pressure (BP) measurements were recorded and each participant completed a questionnaire regarding demographics, activity levels, alcohol consumption, smoking, and medical history. Data were analyzed descriptively.

RESULTS

A sample of 452 EMS personnel from across NC was enrolled. The cohort was predominantly male (74.1%) and employed full-time (85.5%). The prevalence of overweight and obesity (80.3%) among EMS personnel was higher than the NC population (65.6%) and the general United States (US) population (70.8%). A previous diagnosis of high BP was reported by only 18.3% of participants, but 65.1% had elevated BP at the time of measurement. Alcohol consumption in the past 30 days among participants (55.4%) was slightly higher than state estimates (48.0%) and similar to national estimates (57.1%). However, heavy drinking (22.2%) and binge drinking (28.8%) were reported at much higher rates than state (5.6% and 15.2%, respectively) and national (6.6% and 18.3%, respectively) estimates. The prevalence of current smoking (21.5%) and quit attempts (48.8%) in the cohort was similar to state (21.8% and 55.0%, respectively) and national (21.2% and 55.7%, respectively) estimates. Likewise, the proportion of EMS providers meeting the Center for Disease Control's activity guidelines (49.6%) was similar to that found in the NC (46.8%) and the general US (48.0%) populations.

CONCLUSIONS

These findings suggest a high prevalence of overweight and obesity, heavy drinking, binge drinking, and high BP among NC EMS personnel. Similar to fire service personnel, these rates are higher than the general US population. As such, they suggest areas where intervention would have the greatest positive impact on the health and performance of the EMS workforce.

Naloxone Administration Frequency During Emergency Medical Service Events - United States, 2012-2016

As the opioid epidemic in the United States has continued since the early 2000s (1,2), most descriptions have focused on misuse and deaths. Increased cooperation with state and local partners has enabled more rapid and comprehensive surveillance of nonfatal opioid overdoses (3).* Naloxone administrations obtained from emergency medical services (EMS) patient care records have served as a useful proxy for overdose surveillance in individual communities and might be a previously unused data source to describe the opioid epidemic, including fatal and nonfatal events, on a national level (4-6). Using data from the National Emergency Medical Services Information System (NEMSIS),^† the trend in rate of EMS naloxone administration events from 2012 to 2016 was compared with opioid overdose mortality rates from National Vital Statistics System multiple cause-of-death mortality files. During 2012-2016, the rate of EMS naloxone administration events increased 75.1%, from 573.6 to 1004.4 administrations per 100,000 EMS events, mirroring the 79.7% increase in opioid overdose mortality from 7.4 deaths per 100,000 persons to 13.3. A bimodal age distribution of patients receiving naloxone from EMS parallels a similar age distribution of deaths, with persons aged 25-34 years and 45-54 years most affected. However, an accurate estimate of the complete injury burden of the opioid epidemic requires assessing nonfatal overdoses in addition to deaths. Evaluating and monitoring nonfatal overdose events via the novel approach of using EMS data might assist in the development of timely interventions to address the evolving opioid crisis.

Ventilator use by emergency medical services during 911 calls in the United States

BACKGROUND

Emergency and transport ventilators use in the prehospital field is not well described. This study examines trends of ventilator use by EMS agencies during 911 calls in the United States and identifies factors associated with this use.

METHODS

This retrospective study used four consecutive releases of the US National Emergency Medical Services Information System (NEMSIS) public research dataset (2011-2014) to describe scene EMS activations (911 calls) with and without reported ventilator use.

RESULTS

Ventilator use was reported in 260,663 out of 28,221,321 EMS 911 scene activations (0.9%). Patients with ventilator use were older (mean age 67±18years), nearly half were males (49.2%), mostly in urban areas (80.2%) and cared for by advanced life support (ALS) EMS services (89.5%). CPAP mode of ventilation was most common (71.6%). "Breathing problem" was the most common dispatch complaint for EMS activations with ventilator use (63.9%). Common provider impression categories included "respiratory distress" (72.5%), "cardiac rhythm disturbance" (4.6%), "altered level of consciousness" (4.3%) and "cardiac arrest"(4.0%). Ventilator use was consistently higher at the Specialty Care Transport (SCT) and Air Medical Transport (AMT) service levels and increased over the study period for both suburban and rural EMS activations. Significant factors for ventilator use included demographic characteristics, EMS agency type, specific complaints, provider's primary impressions and condition codes.

CONCLUSIONS

Providers at different EMS levels use ventilators during 911 scene calls in the US. Training of prehospital providers on ventilation technology is needed. The benefit and effectiveness of this intervention remain to be assessed.