John F. Brown

Frequent Use of Emergency Medical Services by the Elderly: A Case-Control Study Using Paramedic Records

OBJECTIVEnTo identify the factors that lead to increased use of emergency medical services (EMS) by patients 65 years of age and older in an urban EMS system.nnnMETHODSnRetrospective, case-control study of frequent EMS use among elderly patients transported during one year in an urban EMS system. Three distinct groups were examined for transports that took place in 1999: (1) 1-3 transports per year (low use); (2) 4-9 times per year (high use); and (3) those transported 10+ times (very high use). This frequency-use indicator variable is the primary outcome measurement. Predictors included age, gender, preexisting medical diseases, ethnicity, number of medications, number of medical problems, primary physician, psychiatric diagnosis, and homelessness. Analysis of predictors was done using ordinal logistic regression model, and a global test of interaction terms.nnnRESULTSnMale gender, black ethnicity, homelessness, and a variety of types of medical problems were associated with increased use of EMS resources. The strongest single predictor of case status remained homelessness, which was nearly eight times as commonly associated with frequent EMS use than for the controls. The number of medical problems and medications also were significantly associated with EMS use in this patient population. There was a lack of association of alcohol, substance abuse, and psychiatric disorders with EMS use. Patients with asthma who did not have a primary care physician were more likely to use EMS services than were those who had a physician.nnnCONCLUSIONSnThis analysis highlights homelessness as being strongly associated with frequent EMS use among the elderly and downplays other associated factors, such as psychiatric disease and substance use. Medical illness severity, particularly asthma when no primary care physician is available, also appears to drive frequent EMS use. Both findings have implications in terms of targeting of public resources; providing housing to medically ill elderly and primary care to asthmatics in particular, may provide dividends not only in terms of social welfare and medical care, but in preventing frequent EMS use by the elderly.

EMS-STARS: Emergency Medical Services “Superuser” Transport Associations: An Adult Retrospective Study

Abstract Objective. Emergency medical services (EMS) superusers –those who use EMS services at extremely high rates –have not been well characterized. Recent interest in the small group of individuals who account for a disproportionate share of health-care expenditures has led to research on frequent users of emergency departments and other health services, but little research has been done regarding those who use EMS services. To inform policy and intervention implementation, we undertook a descriptive analysis of EMS superusers in a large urban community. In this paper we compare EMS superusers to low, moderate, and high users to characterize factors contributing to EMS use. We also estimate the financial impact of EMS superusers. Methods. We conducted a retrospective cross-sectional study based on 1 year of data from an urban EMS system. Data for all EMS encounters with patients age ≥18 years were extracted from electronic records generated on scene by paramedics. We identified demographic and clinical variables associated with levels of EMS use. EMS users were characterized by the annual number of EMS encounters: low (1), moderate (2–4), high (5–14), and superusers (≥15). In addition, we performed a financial analysis using San Francisco Fire Department (SFFD) 2009 charge and reimbursement data. Results. A total of 31,462 adults generated 43,559 EMS ambulance encounters, which resulted in 39,107 transports (a 90% transport rate). Encounters for general medical reasons were common among moderate and high users and less frequent among superusers and low users, while alcohol use was exponentially correlated with encounter frequency. Superusers were significantly younger than moderate EMS users, and more likely to be male. The superuser group created a significantly higher financial burden/person than any other group, comprising 0.3% of the study population, but over 6% of annual EMS charges and reimbursements. Conclusions. In this retrospective study, adult EMS superusers emerged as a distinct, predominantly male population and their EMS encounters were associated with alcohol use. Continued analysis of this unique, high-cost, and frequently transported population will likely illuminate specific intervention strategies.

Acute Stroke: Current Evidence-based Recommendations for Prehospital Care

Introduction In the United States, emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with a suspected stroke and to compare these recommendations against the current protocols used by the 33 EMS agencies in the state of California. Methods We performed a literature review of the current evidence in the prehospital treatment of a patient with a suspected stroke and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the stroke protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were the use of a stroke scale, blood glucose evaluation, use of supplemental oxygen, patient positioning, 12-lead electrocardiogram (ECG) and cardiac monitoring, fluid assessment and intravenous access, and stroke regionalization. Results Protocols across EMS agencies in California varied widely. Most used some sort of stroke scale with the majority using the Cincinnati Prehospital Stroke Scale (CPSS). All recommended the evaluation of blood glucose with the level for action ranging from 60 to 80mg/dL. Cardiac monitoring was recommended in 58% and 33% recommended an ECG. More than half required the direct transport to a primary stroke center and 88% recommended hospital notification. Conclusion Protocols for a patient with a suspected stroke vary widely across the state of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.

Ambulance need at mass gatherings

INTRODUCTIONnScant evidence exists to guide policy-making around public health needs during mass gatherings. In 2006, the City and County of San Francisco began requiring standby ambulances at all mass gatherings with attendance of >15,500 people. The objectives were to evaluate needs for ambulances at mass gatherings, and to make evidence-based recommendations for public health policy-makers. The hypothesis was that the needs for ambulances at mass gatherings can be estimated using community baseline data.nnnMETHODSnEmergency medical services plans were reviewed for all public events with an anticipated attendance of >1,000 people in San Francisco County during the 12-month period 01 August 2006 through 31 July 2007. Ambulance transport data were confirmed by event coordinators and ambulance company records, and the rate was calculated by dividing ambulance transports by event attendance. Baseline ambulance transport rate was calculated by dividing the annual ambulance transports in the countys computer-aided dispatch system by the census population estimate. The risk ratio was calculated using the risk of transport from a mass gathering compared with the baseline risk of ambulance transport for the local community. Significance testing and confidence intervals were calculated.nnnRESULTSnDescriptive information was available for 100% of events and ambulance transport data available for 97% of events. The majority of the mass gatherings (47 unique events; 59 event days) were outdoor, weekend festivals, parades, or concerts, though a large proportion were athletic events. The ambulance transport rate from mass gatherings was 1 per 59,000 people every six hours. Baseline ambulance transport rate in San Francisco was 1 per 20,000 people every six hours. The transport rate from mass gatherings was significantly lower than the community baseline (risk ratio [RR]=0.15, 95% CI=0.10-0.22, p<0.001). At events reserving a standby ambulance, 46% of ambulances were unused.nnnDISCUSSIONnSan Francisco mass gatherings appear to present a lower risk of ambulance transports compared to the community baseline, suggesting that the community baseline sets an appropriate standard for requiring standby ambulances at mass gatherings. The initial ambulance requirement policy in San Francisco may have been overly conservative.nnnCONCLUSIONSnLocal baseline data is a recommended starting point when setting policy for public health needs at mass gatherings.

Which emergency medical dispatch codes predict high prehospital nontransport rates in an urban community

Abstract Background. The Medical Priority Dispatch System (MPDS) is a commonly used computer-based emergency medical dispatch (EMD) system that is widely used to prioritize 9-1-1 calls and optimize resource allocation. There are five major priority classes used to dispatch 9-1-1 calls in the San Francisco System; Alpha codes are the lowest priority (lowest expected acuity) and Echo are the highest priority. Objective. We sought to determine which MPDS dispatch codes are associated with high prehospital nontransport rates (NTRs). Methods. All unique MPDS call categories from 2009 in a highly urbanized, two-tier advanced life support (ALS) system were sorted according to highest NTRs. There are many reasons for nontransport, such as “gone on arrival,” and “patient denied transport.” Those categories with greater than 100 annual calls were further evaluated. MPDS groups that included multiple categories with NTRs exceeding 25% were then identified and each category was analyzed. Results. EMS responded to a total of 81,437 calls in 2009, of which 18,851 were not transported by EMS. The majority of the NTRs were found among “cardiac/ respiratory arrest/death,” “assault/sexual assaults,” “unknown problem/man down,” “traffic/transportation accidents,” and “unconscious/fainting.” “Cardiac or respiratory arrest/death –obvious death” (9B1) had the highest overall nontransport rate, 99.25% (1/134), most likely due to declaration of death. “Unknown problem –man down –medical alert notification” had the second highest NTR, 67.22% (138/421). However, Echo priority codes had the highest overall nontransport rates (45.45%) and Charlie had the lowest (13.84%). Conclusions. The nontransport rates of individual MPDS categories vary considerably and should be considered in any system design. We identified 52 unique call categories to have a 25% or greater NTR, 18 of which exceeded 40%. The majority of NTRs occurred among the “cardiac/respiratory arrest/death,” “assault/sexual assaults,” “unknown problem/man down,” “traffic/transportation accidents,” and “unconscious/fainting” categories. The higher the priority code within each subset (AB vs. CDE), the less likely the patient was to be transported. Charlie priority codes had a lower NTR than Delta, and Delta was lower than Echo. Charlie codes were therefore the strongest predictors of hospital transport, while Echo codes (highest priority) were those with the highest nontransport rates and were the worst predictors of hospital transport in the emergent subset.

The HOME Team: Evaluating the Effect of an EMS-based Outreach Team to Decrease the Frequency of 911 Use Among High Utilizers of EMS.

OBJECTIVESnThe San Francisco Fire Departments (SFFD; San Francisco, California USA) Homeless Outreach and Medical Emergency (HOME) Team is the United States first Emergency Medical Services (EMS)-based outreach effort using a specially trained paramedic to redirect frequent users of EMS to other types of services. The effectiveness of this program at reducing repeat use of emergency services during the first seven months of the teams existence was examined.nnnMETHODSnA retrospective analysis of EMS use frequency and demographic characteristics of frequent users was conducted. Clients that used emergency services at least four times per month from March 2004 through May 2005 were contacted for intervention. Patterns for each frequent user before and after intervention were analyzed. Changes in EMS use during the 15-month study interval was the primary outcome measurement.nnnRESULTSnA total of 59 clients were included. The target population had a median age of 55.1 years and was 68% male. Additionally, 38.0% of the target population was homeless, 43.4% had no primary care, 88.9% had a substance abuse disorder at time of contact, and 83.0% had a history of psychiatric disorder. The HOME Team undertook 320 distinct contacts with 65 frequent users during the study period. The average EMS use prior to HOME Team contact was 18.72 responses per month (SD=19.40), and after the first contact with the HOME Team, use dropped to 8.61 (SD=10.84), P<.001.nnnCONCLUSIONnFrequent users of EMS suffer from disproportionate comorbidities, particularly substance abuse and psychiatric disorders. This population responds well to the intervention of a specially trained paramedic as measured by EMS usage. Tangherlini N , Villar J , Brown J , Rodriguez RM , Yeh C , Friedman BT , Wada P . The HOME Team: evaluating the effect of an EMS-based outreach team to decrease the frequency of 911 use among high utilizers of EMS. Prehosp Disaster Med. 2016;31(6):603-607.

Chest Pain of Suspected Cardiac Origin: Current Evidence-based Recommendations for Prehospital Care

Introduction In the United States, emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of chest pain of suspected cardiac origin and to compare these recommendations against the current protocols used by the 33 EMS agencies in the state of California. Methods We performed a literature review of the current evidence in the prehospital treatment of chest pain and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the chest pain protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were use of supplemental oxygen, aspirin, nitrates, opiates, 12-lead electrocardiogram (ECG), ST segment elevation myocardial infarction (STEMI) regionalization systems, prehospital fibrinolysis and β-blockers. Results The protocols varied widely in terms of medication and dosing choices, as well as listed contraindications to treatments. Every agency uses oxygen with 54% recommending titrated dosing. All agencies use aspirin (64% recommending 325mg, 24% recommending 162mg and 15% recommending either), as well as nitroglycerin and opiates (58% choosing morphine). Prehospital 12-Lead ECGs are used in 97% of agencies, and all but one agency has some form of regionalized care for their STEMI patients. No agency is currently employing prehospital fibrinolysis or β-blocker use. Conclusion Protocols for chest pain of suspected cardiac origin vary widely across California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.

Altered Mental Status: Current Evidence-based Recommendations for Prehospital Care

Introduction In the United States emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with an acute change in mental status and to compare these recommendations against the current protocols used by the 33 EMS agencies in the State of California. Methods We performed a literature review of the current evidence in the prehospital treatment of a patient with altered mental status (AMS) and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the AMS protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were patient assessment, point-of-care tests, supplemental oxygen, use of standardized scoring, evaluating for causes of AMS, blood glucose evaluation, toxicological treatment, and pediatric evaluation and management. Results Protocols across 33 EMS agencies in California varied widely. All protocols call for a blood glucose check, 21 (64%) suggest treating adults at <60mg/dL, and half allow for the use of dextrose 10%. All the protocols recommend naloxone for signs of opioid overdose, but only 13 (39%) give specific parameters. Half the agencies (52%) recommend considering other toxicological causes of AMS, often by using the mnemonic AEIOU TIPS. Eight (24%) recommend a 12-lead electrocardiogram; others simply suggest cardiac monitoring. Fourteen (42%) advise supplemental oxygen as needed; only seven (21%) give specific parameters. In terms of considering various etiologies of AMS, 25 (76%) give instructions to consider trauma, 20 (61%) to consider stroke, and 18 (55%) to consider seizure. Twenty-three (70%) of the agencies have separate pediatric AMS protocols; others include pediatric considerations within the adult protocol. Conclusion Protocols for patients with AMS vary widely across the State of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.

Prehospital Care for the Adult and Pediatric Seizure Patient: Current Evidence Based Recommendations

Introduction We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of adult and pediatric patients with a seizure and to compare these recommendations against the current protocol used by the 33 emergency medical services (EMS) agencies in California. Methods We performed a review of the evidence in the prehospital treatment of patients with a seizure, and then compared the seizure protocols of each of the 33 EMS agencies for consistency with these recommendations. We analyzed the type and route of medication administered, number of additional rescue doses permitted, and requirements for glucose testing prior to medication. The treatment for eclampsia and seizures in pediatric patients were analyzed separately. Results Protocols across EMS Agencies in California varied widely. We identified multiple drugs, dosages, routes of administration, re-dosing instructions, and requirement for blood glucose testing prior to medication delivery. Blood glucose testing prior to benzodiazepine administration is required by 61% (20/33) of agencies for adult patients and 76% (25/33) for pediatric patients. All agencies have protocols for giving intramuscular benzodiazepines and 76% (25/33) have protocols for intranasal benzodiazepines. Intramuscular midazolam dosages ranged from 2 to 10 mg per single adult dose, 2 to 8 mg per single pediatric dose, and 0.1 to 0.2 mg/kg as a weight-based dose. Intranasal midazolam dosages ranged from 2 to 10 mg per single adult or pediatric dose, and 0.1 to 0.2 mg/kg as a weight-based dose. Intravenous/intrasosseous midazolam dosages ranged from 1 to 6 mg per single adult dose, 1 to 5 mg per single pediatric dose, and 0.05 to 0.1 mg/kg as a weight-based dose. Eclampsia is specifically addressed by 85% (28/33) of agencies. Forty-two percent (14/33) have a protocol for administering magnesium sulfate, with intravenous dosages ranging from 2 to 6 mg, and 58% (19/33) allow benzodiazepines to be administered. Conclusion Protocols for a patient with a seizure, including eclampsia and febrile seizures, vary widely across California. These recommendations for the prehospital diagnosis and treatment of seizures may be useful for EMS medical directors tasked with creating and revising these protocols.

Translation of EMS: Clinical Practice and System Oversight from Core Content Study Guide to Best Practices Implementation in an Urban EMS System

Abstract Since 2009, the seminal text in emergency medical services (EMS) medicine has been used to guide the academic development of the new subspecialty but direct application of the material into EMS oversight has not been previously described. The EMS/Disaster Medicine fellowship program at our institution scheduled a monthly meeting to systematically review the text and develop a study guide to assist the fellow and affiliated faculty in preparation for the board examination. In addition to the summary of chapter content, the review included an assessment of areas from each chapter subject where our EMS system did not exhibit recommended characteristics. A matrix was developed in the form of a gap analysis to include specific recommendations based on each perceived gap. Initial review and completion dates for each identified gap enable tracking and a responsible party. This matrix assisted the fellow with development of projects for EMS system improvement in addition to focusing and prioritizing the work of other interested physicians working in the system. By discussing expert recommendations in the setting of an actual EMS system, the faculty can teach the fellow how to approach system improvements based on prior experiences and current stakeholders. This collaborative environment facilitates system-based practice and practice-based learning, aligning with ACGME core competencies. Our educational model has demonstrated the success of translating the text into action items for EMS systems. This model may be useful in other systems and could contribute to the development of EMS system standards nationwide.