Age‐based centiles for diastolic blood pressure among children in the out‐of‐hospital emergency setting

Abstract Objective To compare Pediatric Advanced Life Support (PALS) diastolic blood pressure (DBP) criteria to empirically derived DBP criteria for the prediction of out‐of‐hospital interventions in children. Methods We performed a retrospective study of pediatric (90th centile). The accuracy of low DBP for out‐of‐hospital interventions between the two criteria was similar. Conclusion PALS criteria for DBP classified a high proportion of children as having abnormal vital signs, particularly with diastolic hypertension. Empirically derived DBP thresholds more accurately predict the delivery of key out‐of‐hospital interventions. If externally validated, correlated to in‐hospital outcomes, and combined with thresholds for other vital signs, these may better predict the need for out‐of‐hospital interventions

A methodology for the public health surveillance and epidemiologic analysis of outdoor falls that require an emergency medical services response

Abstract Background Falls are a common cause of injury with significantly associated medical costs yet public health surveillance of injuries from falls is underdeveloped. In addition, the epidemiologic understanding of outdoor falls, which have been reported to account for 47% of all injurious falls, is scant. Here we present methods to use emergency medical services (EMS) data as a public health surveillance tool for fall injuries, including those that occur secondary to syncope and heat illness, with a focus on the scope and epidemiology of outdoor fall injuries. Methods Using the 2019 National Emergency Medical Services Information System (NEMSIS) data, we developed an approach to identify EMS encounters for fall injuries, syncope and heat illness. NEMSIS variables used in our algorithm included the EMS respondent’s impression of the encounter, the reported major symptoms and the cause of injury. With these data we identified injuries from falls and, using the NEMSIS data on the location of the encounter, we identified fall injuries as occurring indoors or outdoors. We present the descriptive epidemiology of the identified patients. Results There were 1,854,909 injuries from falls that required an EMS response identified in the NEMSIS data, with 4% of those injuries secondary to episodes of syncope (n = 73,126) and heat illness. Sufficient data were available from 94% of injurious falls that they could be assigned to indoor or outdoor locations, with 9% of these fall injuries occurring outdoors. Among fall injuries identified as occurring outdoors, 85% occurred on streets and sidewalks. Patient age was the primary sociodemographic characteristic that varied by location of the injurious fall. Sixty-six percent of fall injuries that occurred indoors were among those age 65 years or older, while this figure was 34% for fall injuries occurring outdoors on a street or sidewalk. Conclusion The occurrence of outdoor fall injuries identified in the NEMSIS data were substantially lower than reported in other data sets. However, numerically fall injuries occurring outdoors represent a substantial public health burden. The strengths and weaknesses of using this approach for routine public health surveillance of injuries from falls, syncope and heat illness are discussed

Defining priorities for emergency medical services education research: A modified Delphi study

Abstract Objective As out‐of‐hospital medicine evolves, emergency medical services (EMS) education practices must also be updated to ensure that EMS professionals acquire and maintain the skills needed to best serve patients. We aimed to identify and rank the top 10 research priorities related to EMS education in the United States. Methods We conducted a convenience survey of EMS educators to identify challenges facing EMS education before leveraging a purposefully selected panel of EMS educators to prioritize research gaps through a modified Delphi approach. Data were collected electronically (March 2021–June 2021) over 4 survey rounds consisting of idea generation (Rounds 1 and 2), importance scoring (Round 3), and consensus ranking (Round 4). At the end of Round 4, composite scores were used to generate a list of 10 prioritized research gaps related to EMS education. Results In the pre‐Delphi survey, 463 EMS educators identified 2055 challenges facing EMS education. We recruited 32 EMS education experts as Delphi panelists and 28 completed all 4 rounds. Panelists submitted 77 knowledge gaps. The top 10 knowledge gaps included defining competency of EMS learners and educators, association of curricula and accreditation requirements with real‐world practice, the effects of diversity and cultural humility among educators and learners on equitable patient care, evidence‐based teaching methods, and public perception of the EMS profession and education system. Conclusions Although 10 gaps were prioritized, panelists deemed all 77 gaps as having considerable importance for EMS education. This suite of knowledge gaps is intended to guide researchers and research‐funding bodies for future resource allocation

Real-World Midazolam Use and Outcomes With Out-of-Hospital Treatment of Status Epilepticus in the United States.

STUDY OBJECTIVE: Guidelines recommend 10-mg intramuscular midazolam as the first-line treatment option for status epilepticus. However, in real-world practice, it is frequently administered intranasally or intravenously and is dosed lower. Therefore, we used conventional and instrumental variable approaches to examine the effectiveness of midazolam in a national out-of-hospital cohort. METHODS: This retrospective cohort study of adults with status epilepticus used the ESO Data Collaborative research dataset (January 1, 2019, to December 31, 2019). The exposures were the route and dose of midazolam. We performed hierarchical logistic regression and 2-stage least squares regression using agency treatment patterns as an instrument to examine our outcomes, rescue therapy, and ventilatory support. RESULTS: There were 7,634 out-of-hospital encounters from 657 EMS agencies. Midazolam was administered intranasally in 20%, intravenously in 46%, and intramuscularly in 35% of the encounters. Compared with intramuscular administration, intranasal midazolam increased (risk difference [RD], 6.5%; 95% confidence interval [CI], 2.4% to 10.5%) and intravenous midazolam decreased (RD, -11.1%; 95% CI, -14.7% to -7.5%) the risk of rescue therapy. The differences in ventilatory support were not statistically significant (intranasal RD, -1.5%; 95% CI, -3.2% to 0.3%; intravenous RD, -0.3%; 95% CI, -1.9% to 1.2%). Higher doses were associated with a lower risk of rescue therapy (RD, -2.6%; 95% CI, -3.3% to -1.9%) and increased ventilatory support (RD, 0.4%; 95% CI, 0.1% to 0.7%). The instrumental variable analysis yielded similar results, except that dose was not associated with ventilatory support. CONCLUSION: The route and dose of midazolam affect clinical outcomes. Compared with intramuscular administration, intranasal administration may be less effective and intravenous administration more effective in terminating status epilepticus, although the differences between these and previous results may reflect the nature of real-world data as opposed to randomized data

Emergency medical services clinicians in the United States are increasingly exposed to death

Abstract Introduction Exposure to patient death places healthcare workers at increased risk for burnout and traumatic stress, yet limited data exist exploring exposure to death among emergency medical services (EMS) clinicians. Our objective was to describe changes in EMS encounters involving on‐scene death from 2018 to 2021. Methods We retrospectively analyzed deidentified EMS records for 9‐1‐1 responses from the ESO Data Collaborative from 2018 to 2021. We identified cases where patient dispositions of death on scene, with or without attempted resuscitation, and without EMS transport. A non‐parametric test of trend was used to assess for monotonic increase in agency‐level encounters involving on‐scene death and the proportion of EMS clinicians exposed to ≥1 on‐scene death. Results We analyzed records from 1109 EMS agencies. These agencies responded to 4,286,976 calls in 2018, 5,097,920 calls in 2019, 4,939,651 calls in 2020, and 5,347,340 calls in 2021.The total number of encounters with death on scene rose from 49,802 in 2018 to 60,542 in 2019 to 76,535 in 2020 and 80,388 in 2021. Agency‐level annual counts of encounters involving death on scene rose from a median of 14 (interquartile range [IQR], 4–40) in 2018 to 2023 (IQR, 6–63) in 2021 (P‐trend < 0.001). In 2018, 56% of EMS clinicians responded to a call with death on scene, and this number rose to 63% of EMS clinicians in 2021 (P‐trend < 0.001). Conclusion From 2018 to 2021, EMS clinicians were increasingly exposed to death. This trend may be driven by COVID‐19 and its effects on the healthcare system and reinforces the need for evidence‐based death notification training to support EMS clinicians

Social Determinants of Health in EMS Records: A Mixed-methods Analysis Using Natural Language Processing and Qualitative Content Analysis

Introduction: Social determinants of health (SDoH) are known to impact the health and well-being of patients. However, information regarding them is not always collected in healthcare interactions, and healthcare professionals are not always well-trained or equipped to address them. Emergency medical services (EMS) professionals are uniquely positioned to observe and attend to SDoH because of their presence in patients’ environments; however, the transmission of that information may be lost during transitions of care. Documentation of SDoH in EMS records may be helpful in identifying and addressing patients’ insecurities and improving their health outcomes. Our objective in this study was to determine the presence of SDoH information in adult EMS records and understand how such information is referenced, appraised, and linked to other determinants by EMS personnel.Methods: Using EMS records for adult patients in the 2019 ESO Data Collaborative public-use research dataset using a natural language processing (NLP) algorithm, we identified free-text narratives containing documentation of at least one SDoH from categories associated with food, housing, employment, insurance, financial, and social support insecurities. From the NLP corpus, we randomly selected 100 records from each of the SDoH categories for qualitative content analysis using grounded theory.Results: Of the 5,665,229 records analyzed by the NLP algorithm, 175,378 (3.1%) were identified as containing at least one reference to SDoH. References to those SDoH were centered around the social topics of accessibility, mental health, physical health, and substance use. There were infrequent explicit references to other SDoH in the EMS records, but some relationships between categories could be inferred from contexts. Appraisals of patients’ employment, food, and housing insecurities were mostly negative. Narratives including social support and financial insecurities were less negatively appraised, while those regarding insurance insecurities were mostly neutral and related to EMS operations and procedures.Conclusion: The social determinants of health are infrequently documented in EMS records. When they are included, they are infrequently explicitly linked to other SDoH categories and are often negatively appraised by EMS professionals. Given their unique position to observe and share patients’ SDoH information, EMS professionals should be trained to understand, document, and address SDoH in their practice