The Association of Racial Residential Segregation and Survival After Out-of-Hospital Cardiac Arrest in the United States

Background

Residential segregation has been identified as drivers of disparities in health outcomes, but further work is needed to understand this association with clinical outcomes for out-of-hospital cardiac arrest (OHCA). We utilized Cardiac Arrest Registry to Enhance Survival (CARES) dataset to examine if there are differences in survival to discharge and survival with good neurological outcome, as well as likelihood of bystander CPR, using validated measures of racial, ethnic, and economic segregation.

Methods

We conducted a retrospective observational study using data from the Cardiac Arrest Registry to Enhance Survival (CARES) dataset to examine associations among adult OHCA patients. The primary predictor was the Index of Concentration at the Extremes (ICE), a validated measure that includes race, ethnicity, and income across three measures at the census tract level. The primary outcomes were survival to discharge and survival with good neurological status. A multivariable modified Poisson regression modeling approach with random effects at the EMS agency and hospital level was utilized.

Results

We identified 626,264 OHCA patients during the study period. The mean age was 62 years old (SD 17.2 years), and 35.7% (n =223,839) of the patients were female. In multivariable models, we observed an increased likelihood of survival to discharge and survival with good neurological outcome for those patients residing in predominately White population census tracts and higher income census tracts as compared to lower income Black and Hispanic/Latinx population census tracts (RR 1.24, CI 1.20-1.28) and a 32% increased likelihood of receiving bystander CPR in higher income census tracts as compared to reference (RR 1.32, CI 1.30-1.34).

Conclusions

In this study examining the association of measures of residential segregation and OHCA outcomes, there was an increased likelihood of survival to discharge, survival with good neurological status, and likelihood of receiving B-CPR for those patients residing in predominately White population and higher income census tracts when compared to predominately Black and/or Hispanic Latinx populations and lower income census tracts. This research suggests that areas impacted by residential and economic segregation are important targets for both public policy interventions as well as addressing disparities in care across the chain of survival for OHCA.

Racial and ethnic disparities in emergency department transfers to public hospitals

OBJECTIVE

To examine racial/ethnic differences in emergency department (ED) transfers to public hospitals and factors explaining these differences.

DATA SOURCES AND STUDY SETTING

ED and inpatient data from the Healthcare Cost and Utilization Project for Florida (2010-2019); American Hospital Association Annual Survey (2009-2018).

STUDY DESIGN

Logistic regression examined race/ethnicity and payer on the likelihood of transfer to a public hospital among transferred ED patients. The base model was controlled for patient and hospital characteristics and year fixed effects. Models II and III added urbanicity and hospital referral region (HRR), respectively. Model IV used hospital fixed effects, which compares patients within the same hospital. Models V and VI stratified Model IV by payer and condition, respectively. Conditions were classified as emergency care sensitive conditions (ECSCs), where transfer is protocolized, and non-ECSCs. We reported marginal effects at the means.

DATA COLLECTION/EXTRACTION METHODS

We examined 1,265,588 adult ED patients transferred from 187 hospitals.

PRINCIPAL FINDINGS

Black patients were more likely to be transferred to public hospitals compared with White patients in all models except ECSC patients within the same initial hospital (except trauma). Black patients were 0.5-1.3 percentage points (pp) more likely to be transferred to public hospitals than White patients in the same hospital with the same payer. In the base model, Hispanic patients were more likely to be transferred to public hospitals compared with White patients, but this difference reversed after controlling for HRR. Hispanic patients were - 0.6 pp to -1.2 pp less likely to be transferred to public hospitals than White patients in the same hospital with the same payer.

CONCLUSIONS

Large population-level differences in whether ED patients of different races/ethnicities were transferred to public hospitals were largely explained by hospital market and the initial hospital, suggesting that they may play a larger role in explaining differences in transfer to public hospitals, compared with other external factors.

Crossing the line: access to trauma care across state borders

Objective

This study investigates the challenge posed by state borders by identifying the population, injury, and geographic scope of areas of the country where the closest trauma center is out-of-state, and by collating state emergency medical services (EMS) policies relevant to cross-border trauma transport.

Methods

We identified designated levels I, II, and III trauma centers using data from American Trauma Society. ArcGIS was used to map the distance between US census block groups and trauma centers to identify the geographic areas for which cross-border transport may be most expedient. National Highway Traffic Safety Administration data were queried to quantify the proportion of fatal crashes occurring in the areas of interest. State EMS protocols were categorized by stance on cross-border transport.

Results

Of 237 596 included US census block groups, 18 499 (7.8%) were closest to an out-of-state designated level I or II trauma center. These census block groups accounted for 6.9% of the US population and 9.5% of all motor vehicle fatalities. With the inclusion of level III trauma centers, the number of US census block groups closest to an out-of-state designated level I, II, or III trauma center decreased to 13 690 (5.8%). These census block groups accounted for 5.1% of the US population and 7.1% of all motor vehicle fatalities. Of the 48 contiguous states, 30 encourage cross-border transport, 2 discourage it, 12 are neutral, and 4 leave it to local discretion.

Conclusion

Cross-border transport can expedite access to care in at least 5% of US census block groups. While few states discourage this practice, more robust policy guidance could reduce delays and enhance care.

Level of Evidence

III, Epidemiological.

Association of Racial Residential Segregation With Long-Term Outcomes and Readmissions After Out-of-Hospital Cardiac Arrest Among Medicare Beneficiaries

Background The national impact of racial residential segregation on out-of-hospital cardiac arrest outcomes after initial resuscitation remains poorly understood. We sought to characterize the association between measures of racial and economic residential segregation at the ZIP code level and long-term survival and readmissions after out-of-hospital cardiac arrest among Medicare beneficiaries. Methods and Results In this retrospective cohort study, using Medicare claims data, our primary predictor was the index of concentration at the extremes, a measure of racial and economic segregation. The primary outcomes were death up to 3 years and readmissions. We estimated hazard ratios (HRs) across all 3 types of index of concentration at the extremes measures for each outcome while adjusting for beneficiary demographics, treating hospital characteristics, and index hospital procedures. In fully adjusted models for long-term survival, we found a decreased hazard of death and risk of readmission for beneficiaries residing in the more segregated White communities  and higher-income ZIP codes compared with the more segregated Black communities and lower-income ZIP codes across all 3 indices of concentration at the extremes measures (race: HR, 0.87 [95% CI, 0.81-0.93]; income: HR, 0.75 [95% CI, 0.69-0.78]; and race+income: HR, 0.77 [95% CI, 0.72-0.82]). Conclusions We found a decreased hazard of death and risk for readmission for those residing in the more segregated White communities  and higher-income ZIP codes compared with the more segregated Black communities and lower-income ZIP codes when using validated measures of racial and economic segregation. Although causal pathways and mechanisms remain unclear, disparities in outcomes after out-of-hospital cardiac arrest are associated with the structural components of race and wealth and persist up to 3 years after discharge.

Non-shockable rhythms: A parametric model for the immediate probability of return of spontaneous circulation

BACKGROUND

Cardiac arrest can present with asystole, Pulseless Electrical Activity (PEA), or Ventricular Fibrillation/Tachycardia (VF/VT). We investigated the transition intensity of Return of spontaneous circulation (ROSC) from PEA and asystole during in-hospital resuscitation.

MATERIALS AND METHODS

We included 770 episodes of cardiac arrest. PEA was defined as ECG with >12 QRS complexes per min, asystole by an isoelectric signal >5 seconds. The observed times of PEA to ROSC transitions were fitted to five different parametric time-to-event models. At values ≤0.1, transition intensities roughly represent next-minute probabilities allowing for direct interpretation. Different entities of PEA and asystole, dependent on whether it was the primary or a secondary rhythm, were included as covariates.

RESULTS

The transition intensities to ROSC from primary PEA and PEA after asystole were unimodal with peaks of 0.12 at 3 min and 0.09 at 6 min, respectively. Transition intensities to ROSC from PEA after VF/VT, or following transient ROSC, exhibited high initial values of 0.32 and 0.26 at 3 minutes, respectively, but decreased. The transition intensity to ROSC from initial asystole and asystole after PEA were both about 0.01 and 0.02; while asystole after VF/VT had an intensity to ROSC of 0.15 initially which decreased. The transition intensity from asystole after temporary ROSC was constant at 0.08.

CONCLUSION

The immediate probability of ROSC develops differently in PEA and asystole depending on the preceding rhythm and the duration of the resuscitation attempt. This knowledge may aid simple bedside prognostication and electronic resuscitation algorithms for monitors/defibrillators.

Using medicare claims to estimate risk-adjusted performance of Pennsylvania trauma centers

Trauma centers use registry data to benchmark performance using a standardized risk adjustment model. Our objective was to utilize national claims to develop a risk adjustment model applicable across all hospitals, regardless of designation or registry participation. Patients from 2013-14 Pennsylvania Trauma Outcomes Study (PTOS) registry data were probabilistically matched to Medicare claims using demographic and injury characteristics. Pairwise comparisons established facility linkages and matching was then repeated within facilities to link records. Registry models were estimated using GLM and compared with five claims-based LASSO models: demographics, clinical characteristics, diagnosis codes, procedures codes, and combined demographics/clinical characteristics. Area under the curve and correlation with registry model probability of death were calculated for each linked and out-of-sample cohort. From 29 facilities, a cohort comprising 16,418 patients were linked between datasets. Patients were similarly distributed: median age 82 (PTOS IQR: 74-87 vs. Medicare IQR: 75-88); non-white 6.2% (PTOS) vs. 5.8% (Medicare). The registry model AUC was 0.86 (0.84-0.87). Diagnosis and procedure codes models performed poorest. The demographics/clinical characteristics model achieved an AUC = 0.84 (0.83-0.86) and Spearman = 0.62 with registry data. Claims data can be leveraged to create models that accurately measure the performance of hospitals that treat trauma patients.

Relationship of hepatitis C risk to hepatitis C test acceptance among adult patients participating in an ED hepatitis C screening programme

BACKGROUND

It is possible that adult ED patients consider their hepatitis C virus (HCV) risk factor history when deciding whether to accept HCV screening. To help address this question, we examined whether self-reporting any HCV risk was more common among ED patients who agreed than who declined HCV screening. Among ED patients who agreed to HCV screening, we also assessed if self-reporting any HCV risk was more common among those whose HCV antibody (Ab) and HCV viral load (VL) test results were positive.

METHODS

This study was conducted among adult patients ≥18 years old participating in a universal, ED-based HCV screening programme in New York City between 22 January 2019 and 9 April 2020. Participants were surveyed about their HCV risk factors. Differences in the frequencies of self-reporting any HCV risk were compared according to HCV screening acceptance and by HCV Ab and VL status.

RESULTS

Of the 4658 ED patients surveyed, 2846 (61%) accepted and 1812 (39%) declined HCV screening. Among these participants, 38% reported at least one HCV risk factor, most commonly injection drug use. Self-reporting any HCV risk was not more common among those who accepted versus declined HCV screening (40% vs 37%, p<0.7) but was more common among those with HCV Ab positive versus negative test results (36% vs 6%, p<0.001) and HCV VL positive versus negative results (95% vs 5%, p<0.001).

CONCLUSION

HCV risk factors were self-reported by more than one-third of ED patients but were not more commonly present among those who accepted HCV screening.

Timing and Outcomes After Coronary Angiography Following Out-of-Hospital Cardiac Arrest Without Signs of ST-Segment Elevation Myocardial Infarction

BACKGROUND

There is broad consensus that resuscitated out-of-hospital cardiac arrest (OHCA) patients with ST-segment elevation myocardial infarction (STEMI) should receive immediate coronary angiography (CAG); however, factors that guide patient selection and optimal timing of CAG for post-arrest patients without evidence of STEMI remain incompletely described.

OBJECTIVE

We sought to describe the timing of post-arrest CAG in actual practice, patient characteristics associated with decision to perform immediate vs. delayed CAG, and patient outcomes after CAG.

METHODS

We conducted a retrospective cohort study at seven U.S. academic hospitals. Resuscitated adult patients with OHCA were included if they presented between January 1, 2015 and December 31, 2019 and received CAG during hospitalization. Emergency medical services run sheets and hospital records were analyzed. Patients without evidence of STEMI were grouped and compared based on time from arrival to CAG performance into "early" (≤ 6 h) and "delayed" (> 6 h).

RESULTS

Two hundred twenty-one patients were included. Median time to CAG was 18.6 h (interquartile range [IQR] 1.5-94.6 h). Early catheterization was performed on 94 patients (42.5%) and delayed catheterization was performed on 127 patients (57.5%). Patients in the early group were older (61 years [IQR 55-70 years] vs. 57 years [IQR 47-65] years) and more likely to be male (79.8% vs. 59.8%). Those in the early group were more likely to have clinically significant lesions (58.5% vs. 39.4%) and receive revascularization (41.5% vs. 19.7%). Patients were more likely to die in the early group (47.9% vs. 33.1%). Among survivors, there was no significant difference in neurologic recovery at discharge.

CONCLUSIONS

OHCA patients without evidence of STEMI who received early CAG were older and more likely to be male. This group was more likely to have intervenable lesions and receive revascularization.

Heart rate and QRS duration as biomarkers predict the immediate outcome from pulseless electrical activity

INTRODUCTION

Pulseless electrical activity (PEA) is commonly observed in in-hospital cardiac arrest (IHCA). Universally available ECG characteristics such as QRS duration (QRSd) and heart rate (HR) may develop differently in patients who obtain ROSC or not. The aim of this study was to assess prospectively how QRSd and HR as biomarkers predict the immediate outcome of patients with PEA.

METHOD

We investigated 327 episodes of IHCA in 298 patients at two US and one Norwegian hospital. We assessed the ECG in 559 segments of PEA nested within episodes, measuring QRSd and HR during pauses of compressions, and noted the clinical state that immediately followed PEA. We investigated the development of HR, QRSd, and transitions to ROSC or no-ROSC (VF/VT, asystole or death) in a joint longitudinal and competing risks statistical model.

RESULTS

Higher HR, and a rising HR, reflect a higher transition intensity ("hazard") to ROSC (p < 0.001), but HR was not associated with the transition intensity to no-ROSC. A lower QRSd and a shrinking QRSd reflect an increased transition intensity to ROSC (p = 0.023) and a reduced transition intensity to no-ROSC (p = 0.002).

CONCLUSION

HR and QRSd convey information of the immediateoutcome during resuscitation from PEA. These universally available and promising biomarkers may guide the emergency team in tailoring individual treatment.

Survival After Out-of-Hospital Cardiac Arrest: The Role of Racial Residential Segregation

Racial and racialized economic residential segregation has been empirically associated with outcomes across multiple health conditions but not yet explored in relation to out-of-hospital cardiac arrest (OHCA). We sought to examine if measures of racial and economic residential segregation are associated with differences in survival to discharge after OHCA for Black and White Medicare beneficiaries. Utilizing age-eligible Medicare fee-for-service claims data from 2013 to 2015, we identified OHCA claims and determined survival to discharge. The primary predictor, residential segregation, was calculated using the index of concentration at the extremes (ICE) for the beneficiary residential ZIP code. Multilevel modified Poisson regression models were used to determine the association of OHCA outcomes and ZIP code level ICE measures. In total, 194,263 OHCA cases were identified among beneficiaries residing in 75% of US ZIP codes. Black beneficiaries exhibited 12.1% survival to discharge, compared with 12.5% of White beneficiaries. In fully adjusted models of the three ICE measures accounting for differences in treating hospital characteristics, there was as high as a 28% (RR 1.28, CI 1.23-1.26) higher relative likelihood of survival to discharge in the most segregated White ZIP codes (Q5) as compared to the most segregated Black ZIP codes (Q1). Racial residential segregation is independently associated with disparities in OHCA outcomes; among Medicare beneficiaries who generated a claim after suffering an OHCA, ICE measures of racial segregation are associated with a lower likelihood of survival to discharge for those living in the most segregated Black and lower income quintiles compared to higher quintiles.

Emergency departments in the United States treating high proportions of patients with ambulatory care sensitive conditions: a retrospective cross-sectional analysis

Background

One in nine emergency department (ED) visits by Medicare beneficiaries are for ambulatory care sensitive conditions (ACSCs). This study aimed to examine the association between ACSC ED visits to hospitals with the highest proportion of ACSC visits (“high ACSC hospitals) and safety-net status.

Methods

This was a cross-sectional study of ED visits by Medicare fee-for-service beneficiaries ≥ 65 years using 2013–14 claims data, Area Health Resources File data, and County Health Rankings. Logistic regression estimated the association between an ACSC ED visit to high ACSC hospitals, accounting for individual, hospital, and community factors, including whether the visit was to a safety-net hospital. Safety net status was measured by Disproportionate Share Hospital (DSH) index patient percentage; public hospital status; and proportion of dual-eligible beneficiaries. Hospital-level correlation was calculated between ACSC visits, DSH index, and dual-eligible patients. We stratified by type of ACSC visit: acute or chronic.

Results

Among 5,192,729 ACSC ED visits, the odds of visiting a high ACSC hospital were higher for patients who were Black (1.37), dual-eligible (1.18), and with the highest comorbidity burden (1.26, p < 0.001 for all). ACSC visits had increased odds of being to high ACSC hospitals if the hospitals were high DSH (1.43), served the highest proportion of dual-eligible beneficiaries (2.23), and were for-profit (relative to non-profit) (1.38), and lower odds were associated with public hospitals (0.64) (p < 0.001 for all). This relationship was similar for visits to high chronic ACSC hospitals (high DSH: 1.59, high dual-eligibility: 2.60, for-profit: 1.41, public: 0.63, all p < 0.001) and to a lesser extent, high acute ACSC hospitals (high DSH: 1.02; high dual-eligibility: 1.48, for-profit: 1.17, public: 0.94, p < 0.001). The proportion of ACSC visits at all hospitals was weakly correlated with DSH proportion (0.2) and the proportion of dual-eligible patients (0.29), and this relationship was also seen for both chronic and acute ACSC visits, though stronger for the chronic ACSC visits.

Conclusion

Visits to hospitals with a high proportion of acute ACSC ED visits may be less likely to be to hospitals classified as safety net hospitals than those with a high proportion of chronic ACSC visits.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08240-7.

Clinical factors associated with significant coronary lesions following out-of-hospital cardiac arrest

OBJECTIVES

Out-of-hospital cardiac arrest (OHCA) afflicts >350,000 people annually in the United States. While postarrest coronary angiography (CAG) with percutaneous coronary intervention (PCI) has been associated with improved survival in observational cohorts, substantial uncertainty exists regarding patient selection for postarrest CAG. We tested the hypothesis that symptoms consistent with acute coronary syndrome (ACS), including chest discomfort, prior to OHCAs are associated with significant coronary lesions identified on postarrest CAG.

METHODS

We conducted a multicenter retrospective cohort study among eight regional hospitals. Adult patients who experienced atraumatic OHCA with successful initial resuscitation and subsequent CAG between January 2015 and December 2019 were included. We collected data on prehospital documentation of potential ACS symptoms prior to OHCA as well as clinical factors readily available during postarrest care. The primary outcome in multivariable regression modeling was the presence of significant coronary lesions (defined as >50% stenosis of left main or >75% stenosis of other coronary arteries).

RESULTS

Four-hundred patients were included. Median (interquartile range) age was 59 (51-69) years; 31% were female. At least one significant stenosis was found in 62%, of whom 71% received PCI. Clinical factors independently associated with a significant lesion included a history of myocardial infarction (adjusted odds ratio [aOR] = 6.5, [95% confidence interval {CI} = 1.3 to 32.4], p = 0.02), prearrest chest discomfort (aOR = 4.8 [95% CI = 2.1 to 11.8], p ≤ 0.001), ST-segment elevations (aOR = 3.2 [95% CI = 1.7 to 6.3], p < 0.001), and an initial shockable rhythm (aOR = 1.9 [95% CI = 1.0 to 3.4], p = 0.05).

CONCLUSIONS

Among survivors of OHCA receiving CAG, history of prearrest chest discomfort was significantly and independently associated with significant coronary artery lesions on postarrest CAG. This suggests that we may be able to use prearrest symptoms to better risk stratify patients following OHCA to decide who will benefit from invasive angiography.

Association of Neighborhood Gun Violence With Mental Health-Related Pediatric Emergency Department Utilization

IMPORTANCE

Many children and adolescents in the United States are exposed to neighborhood gun violence. Associations between violence exposure and children's short-term mental health are not well understood.

OBJECTIVE

To examine the association between neighborhood gun violence and subsequent mental health-related pediatric emergency department (ED) utilization.

DESIGN, SETTING, AND PARTICIPANTS

This location-based cross-sectional study included 128 683 ED encounters for children aged 0 to 19 years living in 12 zip codes in Philadelphia, Pennsylvania, who presented to an urban academic pediatric ED from January 1, 2014, to December 31, 2018. Children were included if they (1) had 1 or more ED visits in the 60 days before or after a neighborhood shooting and (2) lived within a quarter-mile radius of the location where this shooting occurred. Analysis began August 2020 and ended May 2021.

EXPOSURE

Neighborhood violence exposure, as measured by whether a patient resided near 1 or more episodes of police-reported gun violence.

MAIN OUTCOMES AND MEASURES

ED encounters for a mental health-related chief complaint or primary diagnosis.

RESULTS

A total of 2629 people were shot in the study area between 2014 and 2018, and 54 341 children living nearby had 1 or more ED visits within 60 days of a shooting. The majority of these children were Black (45 946 [84.5%]) and were insured by Medicaid (42 480 [78.1%]). After adjusting for age, sex, race and ethnicity, median household income by zip code, and insurance, children residing within one-eighth of a mile (2-3 blocks) of a shooting had greater odds of mental health-related ED presentations in the subsequent 14 days (adjusted odds ratio, 1.86 [95% CI, 1.20-2.88]), 30 days (adjusted odds ratio, 1.49 [95% CI, 1.11-2.03]), and 60 days (adjusted odds ratio, 1.35 [95% CI, 1.06-1.72]).

CONCLUSIONS AND RELEVANCE

Exposure to neighborhood gun violence is associated with an increase in children's acute mental health symptoms. City health departments and pediatric health care systems should work together to provide community-based support for children and families exposed to violence and trauma-informed care for the subset of these children who subsequently present to the ED. Policies aimed at reducing children's exposure to neighborhood gun violence and mitigating the mental symptoms associated with gun violence exposure must be a public health priority.

Nurtured in Nature: a Pilot Randomized Controlled Trial to Increase Time in Greenspace among Urban-Dwelling Postpartum Women

Spending time in nature is associated with numerous mental health benefits, including reduced depression and improved well-being. However, few studies examine the most effective ways to nudge people to spend more time outside. Furthermore, the impact of spending time in nature has not been previously studied as a postpartum depression (PPD) prevention strategy. To fill these gaps, we developed and pilot tested Nurtured in Nature, a 4-week intervention leveraging a behavioral economics framework, and included a Nature Coach, digital nudges, and personalized goal feedback. We conducted a randomized controlled trial among postpartum women (n = 36) in Philadelphia, PA between 9/9/2019 and 3/27/2020. Nature visit frequency and duration was determined using GPS data. PPD was measured using the Edinburgh Postnatal Depression Scale (EPDS). Participants were from low-income, majority Black neighborhoods. Compared to control, the intervention arm had a strong trend toward longer duration and higher frequency of nature visits (IRR 2.6, 95%CI 0.96-2.75, p = 0.059). When analyzing women who completed the intervention (13 of 17 subjects), the intervention was associated with three times higher nature visits compared to control (IRR 3.1, 95%CI 1.16-3.14, p = 0.025). No significant differences were found in the EPDS scores, although we may have been limited by the study's sample size. Nurture in Nature increased the amount of time postpartum women spent in nature, and may be a useful population health tool to leverage the health benefits of nature in majority Black, low-resourced communities.

In-hospital cardiac arrest in patients with coronavirus 2019

Background

Coronavirus Disease 2019 (COVID-19) has caused over 1 200 000 deaths worldwide as of November 2020. However, little is known about the clinical outcomes among hospitalized patients with active COVID-19 after in-hospital cardiac arrest (IHCA).

Aim

We aimed to characterize outcomes from IHCA in patients with COVID-19 and to identify patient- and hospital-level variables associated with 30-day survival.

Methods

We conducted a multicentre retrospective cohort study across 11 academic medical centres in the U.S. Adult patients who received cardiopulmonary resuscitation and/or defibrillation for IHCA between March 1, 2020 and May 31, 2020 who had a documented positive test for Severe Acute Respiratory Syndrome Coronavirus 2 were included. The primary outcome was 30-day survival after IHCA.

Results

There were 260 IHCAs among COVID-19 patients during the study period. The median age was 69 years (interquartile range 60–77), 71.5% were male, 49.6% were White, 16.9% were Black, and 16.2% were Hispanic. The most common presenting rhythms were pulseless electrical activity (45.0%) and asystole (44.6%). ROSC occurred in 58 patients (22.3%), 31 (11.9%) survived to hospital discharge, and 32 (12.3%) survived to 30 days. Rates of ROSC and 30-day survival in the two hospitals with the highest volume of IHCA over the study period compared to the remaining hospitals were considerably lower (10.8% vs. 64.3% and 5.9% vs. 35.7% respectively, p < 0.001 for both).

Conclusions

We found rates of ROSC and 30-day survival of 22.3% and 12.3% respectively. There were large variations in centre-level outcomes, which may explain the poor survival in prior studies.

Association of Gun Violence With Emergency Department Visits for Stress-Responsive Complaints

STUDY OBJECTIVE

We evaluate the association between living near a neighborhood shooting and emergency department (ED) utilization for stress-responsive complaints.

METHODS

In this location-based before-and-after neighborhood study, we examined variability in ED encounter volume for stress-responsive complaints after neighborhood shooting incidents around 2 academic hospitals. We included patients residing within 1/8- and 1/2-mile-diameter buffers around a shooting (place) if their ED encounter occurred 7, 30, or 60 days before or after the shooting (time). Prespecified outcomes were stress-responsive complaints (chest pain, lightheadedness, syncope, hypertension, shortness of breath, asthma, anxiety, depression, and substance use) based on prior literature for stress-responsive diseases. Conditional logistic regression was used to calculate the odds of presentation to the ED with a stress-responsive complaint after, compared with before, a neighborhood shooting incident.

RESULTS

Between January 2013 and December 2014, 513 shooting incidents and 19,906 encounters for stress-responsive complaints were included in the analysis. Mean age was 50.3 years (SD 22.3 years), 61.5% were women, and 91% were black. We found increased odds of presenting with syncope in 2 place-time buffers: 30 days in the 1/8-mile buffer (odds ratio 2.61; 99% confidence interval 1.2 to 5.67) and 60 days in 1/8-mile buffer (odds ratio 1.56; 99% confidence interval 0.99 to 2.46). No other chief complaints met our statistical threshold for significance.

CONCLUSION

This study evaluated the relationship between objectively measured gun violence exposure and short-term health effect at a microspatial scale. Overall, this was a study with largely negative results, and we did not find any consistent dose-response pattern in time or space regarding neighborhood shootings and stress-responsive presentations to the ED. Theoretic links make this relationship plausible, however, and further investigation is needed to understand the short-term health consequences of violence exposure, and whether those vary based on the circumstances that are experienced inherently by residents of a given neighborhood.

Inpatient hospital performance is associated with post-discharge sepsis mortality

Background

Post-discharge deaths are common in patients hospitalized for sepsis, but the drivers of post-discharge deaths are unclear. The objective of this study was to test the hypothesis that hospitals with high risk-adjusted inpatient sepsis mortality also have high post-discharge mortality, readmissions, and discharge to nursing homes.

Methods

Retrospective cohort study of age-qualifying Medicare beneficiaries with sepsis hospitalization between January 2013 and December 2014. Hospital survivors were followed for 180-days post-discharge, and mortality, readmissions, and new admission to skilled nursing facility were measured. Inpatient hospital-specific sepsis risk-adjusted mortality ratio (observed: expected) was the primary exposure.

Results

A total of 830,721 patients in the cohort were hospitalized for sepsis, with inpatient mortality of 20% and 90-day mortality of 48%. Higher hospital-specific sepsis risk-adjusted mortality was associated with increased 90-day post-discharge mortality (aOR 1.03 per each 0.1 increase in hospital inpatient O:E ratio, 95% CI 1.03–1.04). Higher inpatient risk adjusted mortality was also associated with increased probability of being discharged to a nursing facility (aOR 1.03, 95% CI 1.02–1.03) and 90-day readmissions (aOR 1.03, 95% CI 1.02–1.03).

Conclusions

Hospitals with the highest risk-adjusted sepsis inpatient mortality also have higher post-discharge mortality and increased readmissions, suggesting that post-discharge complications are a modifiable risk that may be affected during inpatient care. Future work will seek to elucidate inpatient and healthcare practices that can reduce sepsis post-discharge complications.

Observing the stages of bystander intervention in virtual reality simulation

BACKGROUND

Understanding bystander reactions to an emergency is an important component of effective training. Four stages of bystander intervention (BI) have been previously described: noticing the situation as a problem, interpreting when it is appropriate to intervene, recognizing personal responsibility to intervene, and knowing how to intervene. Using virtual reality (VR) to simulate emergencies such as sudden cardiac arrest (SCA) can be used to study these stages.

METHODS

In a secondary analysis of an observational cohort study, we analyzed bystander self-efficacy for stages of BI before and after simulated SCA. Each subject participated in a single-player, immersive, VR SCA scenario. Subjects interacted with simulated bystanders through voice commands ("call 911", "get an AED"). Actions taken in scenario, like performing CPR, were documented. Scenario BI actions were compared based on dichotomized comfort/discomfort.

RESULTS

From June 2016 to June 2017, 119 subjects participated. Average age was 37±14 years, 44% were female and 46% reported CPR training within 2 years. During the scenario, 98% "noticed the event" and "interpreted it as a problem", 78% "took responsibility", and 54% "possessed the necessary skills". Self-efficacy increased from pre- to post-scenario: noticing the event increased from 80% to 96%; interpreting as a problem increased from 86% to 97%; taking responsibility increased from 56% to 93%; possessing necessary skills increased from 47% to 63% (P<0.001).

CONCLUSION

Self-efficacy to respond to an SCA event increased pre- to post-scenario. Bystanders who reported feeling comfortable "taking responsibility to intervene" during an emergency were more likely to take action during a simulated emergency.

Impact of adrenaline dose and timing on out-of-hospital cardiac arrest survival and neurological outcomes

STUDY OBJECTIVE

The 2015 ILCOR Advanced Cardiovascular Life Support Guidelines recommend intravenous adrenaline (epinephrine) as a crucial pharmacologic treatment during cardiac arrest resuscitation. Some recent observational studies and clinical trials have questioned the efficacy of its use and suggested possible deleterious effects on overall survival and long-term outcomes. This study aimed to describe the association between time and dose of adrenaline on return of spontaneous circulation (ROSC) and neurologic function.

METHODS

We performed a retrospective analysis of the Penn Alliance for Therapeutic Hypothermia (PATH) data registry. The timing of the first dose of adrenaline and the total dose of adrenaline during cardiac arrests was compared between survivors to discharge and non-survivors for arrests lasting greater than 10 min.

RESULTS

The registry contained 5594 patients. After excluding patients with an in-hospital cardiac arrest, a non-shockable rhythm, or no adrenaline administration, 1826 were included in the final analysis. Survivors to discharge received adrenaline sooner (median 5.0 vs. 7.0 min, p = 0.022) and required a lower total dose than non-survivors (2.0 vs. 3.0 mg, p < 0.001). For survivors, there was no significant association between the time to first adrenaline dose and favorable neurological outcome as measured by Cerebral Performance Category (CPC). Among survivors, those that received less than 2 mg of adrenaline had a more favorable neurologic outcome than those administered > 3 mg. (CPC 1-2 16.6% vs. 12.5%, p = 0.004).

CONCLUSION

Early adrenaline administration is associated with a higher percentage of survival to discharge but not associated with favorable neurological outcome. Those patients with a favorable neurologic outcome received a lower total adrenaline dose prior to ROSC.

The association of layperson characteristics with the quality of simulated cardiopulmonary resuscitation performance

BACKGROUND

Few studies have examined the association of layperson characteristics with cardiopulmonary resuscitation (CPR) provision. Previous studies suggested provider characteristics, including age and gender, were associated with CPR quality, particularly chest compression (CC) depth. We sought to determine the association of subject characteristics, including age and gender with layperson CPR quality during an unannounced simulated CPR event. We hypothesized shallower CC depth in females, and older-aged subjects.

METHODS

As part of a larger multicenter randomized controlled trial of CPR training for cardiac patients' caregivers, CPR skills were assessed 6 months after training. We analyzed associations between subject characteristics and CC rate, CC depth and no-flow time. Each variable was analyzed independently; significant predictors determined via univariate analysis were assessed in a multivariate regression model.

RESULTS

A total of 521 laypersons completed a 6-month CPR skills assessment and were included in the analysis. Mean age was 51.8±13.7 years, 75% were female, 57% were Caucasian. Overall, mean CC rate was 88.5±25.0 per minute, CC depth was 50.9±2.0 mm, and mean no-flow time was 15.9±2.7 sec/min. CC depth decreased significantly in subjects >62 years (P<0.001). Male subjects performed deeper CCs than female subjects (47.5±1.7 vs. 41.9±0.6, P<0.001).

CONCLUSION

We found that layperson age >62 years and female gender are associated with shallower CC depth.

Recruitment for a hospital-based pragmatic clinical trial using volunteer nurses and students

BACKGROUND/AIMS

Recruitment of subjects is critical to the success of any clinical trial, but achieving this goal can be a challenging endeavor. Volunteer nurse and student enrollers are potentially an important source of recruiters for hospital-based trials; however, little is known of either the efficacy or cost of these types of enrollers. We assessed volunteer clinical nurses and health science students in their rates of enrolling family members in a hospital-based, pragmatic clinical trial of cardiopulmonary resuscitation education, and their ability to achieve target recruitment goals. We hypothesized that students would have a higher enrollment rate and are more cost-effective compared to nurses.

METHODS

Volunteer nurses and student enrollers were recruited from eight institutions. Participating nurses were primarily bedside nurses or nurse educators while students were pre-medical, pre-nursing, and pre-health students at local universities. We recorded the frequency of enrollees recruited into the clinical trial by each enroller. Enrollers' impressions of recruitment were assessed using mixed-methods surveys. Cost was estimated based on enrollment data. Overall enrollment data were analyzed using descriptive statistics and generalized estimating equations.

RESULTS

From February 2012 to November 2014, 260 hospital personnel (167 nurses and 93 students) enrolled 1493 cardiac patients' family members, achieving target recruitment goals. Of those recruited, 822 (55%) were by nurses, while 671 (45%) were by students. Overall, students enrolled 5.44 (95% confidence interval (CI): 2.88, 10.27) more subjects per month than nurses (p < 0.01). After consenting to participate in recruitment, students had a 2.85 (95% CI: 1.09, 7.43) increased chance of enrolling at least one family member (p = 0.03). Among those who enrolled at least one subject, nurses enrolled a mean of 0.51(95% CI: 0.42, 0.59) subjects monthly, while students enrolled 1.63 (95% CI: 1.37, 1.90) per month (p < 0.01). Of 198 surveyed hospital personnel (127 nurses, 71 students), 168/198 (85%) felt confident conducting enrollment. The variable cost per enrollee recruited was $25.38 per subject for nurses and $23.30 per subject for students.

CONCLUSIONS

Overall, volunteer students enrolled more subjects per month at a lower cost than nurses. This work suggests that recruitment goals for a pragmatic clinical trial can be successfully obtained using both nurses and students.

Dissemination of CPR video self-instruction materials to secondary trainees: Results from a hospital-based CPR education trial

BACKGROUND

Cardiopulmonary resuscitation (CPR) video self-instruction (VSI) materials have been promoted as a scalable approach to increase the prevalence of CPR skills among the lay public, in part due to the opportunity for secondary training (i.e., sharing of training materials). However, the motivations for, and barriers to, disseminating VSI materials to secondary trainees is poorly understood.

METHODS

This work represents an ancillary investigation of a prospective hospital-based CPR education trial in which family members of cardiac patients were trained using VSI. Mixed-methods surveys were administered to primary trainees six months after initial enrollment. Surveys were designed to capture motivations for, and barriers to, sharing VSI materials, the number of secondary trainees with whom materials were shared, and the settings, timing, and recipients of trainings.

RESULTS

Between 07/2012 and 05/2015, 653 study participants completed a six-month follow-up interview. Of those, 345 reported sharing VSI materials with 1455 secondary trainees. Materials were shared most commonly with family members. In a logistic regression analysis, participants in the oldest quartile (age >63 years) were less likely to share materials compared to those in the youngest quartile (age ≤ 44 years, OR 0.58, CI 0.37-0.90, p=0.02). Among the 308 participants who did not share their materials, time constraints was the most commonly cited barrier for not sharing.

CONCLUSIONS

VSI materials represent a strategy for secondary dissemination of CPR training, yet older individuals have a lower likelihood of sharing relative to younger individuals. Further work is warranted to remedy perceived barriers to CPR dissemination among the lay public using VSI approaches.

Impact of the 2010 resuscitation guidelines training on layperson chest compressions

BACKGROUND

Survival from cardiac arrest is sensitive to the quality of delivered CPR. In 2010, updated international resuscitation guidelines emphasized deeper chest compressions and faster rates, yet it is unknown whether training laypersons using updated guidelines resulted in changed CPR performance. We hypothesized that laypersons taught CPR using the 2010 guidelines performed deeper and faster compressions than those taught using the 2005 materials.

METHODS

This work represents a secondary analysis of a study conducted at eight hospitals where family members of hospitalized cardiac patients were trained in CPR. An initial cohort was trained using the 2005 guidelines, and a subsequent cohort was trained using the 2010 guideline materials. Post training, CPR skills were quantified using a recording manikin.

RESULTS

Between May 2009 to August 2013, 338 subjects completed the assessment. Among the subjects, 176 received 2005 training and 162 underwent 2010 training. The mean compression rate in the 2005 cohort was 87 (95%CI 83-90) per minute, and in the 2010 cohort was 86 (95%CI 83-90) per minute (P=ns), while the mean compression depth was 34 (95%CI 32-35) mm in the 2005 cohort and 46 (95%CI 44-47) mm in the 2010 cohort (P<0.01).

CONCLUSIONS

Training with the 2010 CPR guidelines resulted in a statistically significant increase in trainees' compression depth but there was no change in compression rate. Nevertheless, the majority of CPR performed by trainees in both cohorts was below the guideline recommendation, highlighting an important gap between training goals and trainee performance.

General practitioners' training for, interest in, and knowledge of sports medicine and its organisations

OBJECTIVES

To assess the training and interest of a group of general practitioners in the area of sport and exercise medicine, and the organisations representing the specialty.

DESIGN

A postal questionnaire using a Likert scale in a previously piloted set of questions.

SUBJECTS

275 general practitioners registered with the Northampton Regional Health Authority.

MAIN OUTCOME MEASUREMENTS

Responses to questions designed to assess training and interest in sport and exercise medicine.

RESULTS

A response rate of 87.6% was achieved. It was found that 72.7% of the responding general practitioners felt inadequately trained to practice sport and exercise medicine. Some 76.0% would welcome more training and 36.4% felt that their undergraduate orthopaedic training was of no use in primary care. Many (63.6%) of the general practitioners believed that the current NHS cannot sustain sport and exercise medicine, and there was uncertainty as to whether it is currently a recognised specialty, although 60.4% felt that it should be. General practitioners listed lack of facilities (53.1%), lack of training (42.9%), and lack of time (38.2%) as the main problems in practicing sport and exercise medicine in primary care within the current NHS.

CONCLUSIONS

General practitioners feel undertrained in sport and exercise medicine at both undergraduate and post-graduate level; they have a perceived need for more training and show an interest in the subject. There is scope for improving the value of undergraduate orthopaedic training. General practitioners wish to see sport and exercise medicine recognised as an NHS specialty but fear that this is not sustainable under current conditions. There is confusion among general practitioners about the current sport and exercise medicine organisations.