Aim The COVID-19 pandemic has significantly impacted Emergency Medical Services (EMS) operations throughout the country. Some studies described variation in total volume of out-of-hospital cardiac arrests (OHCA) during the pandemic. We aimed to describe the changes in volume and characteristics of OHCA patients and resuscitations in one urban EMS system. Methods We performed a retrospective cohort analysis of all recorded atraumatic OHCA in Marion County, Indiana, from January 1, 2019 to June 30, 2019 and from January 1, 2020 to June 30, 2020. We described patient, arrest, EMS response, and survival characteristics. We performed paired and unpaired t -tests to evaluate the changes in those characteristics during COVID-19 as compared to the prior year. Data were matched by month to control for seasonal variation. Results The total number of arrests increased from 884 in 2019 to 1034 in 2020 ( p = 0.016). Comparing 2019 to 2020, there was little difference in age [median 62 (IQR 59–73) and 60 (IQR 47–72), p = 0.086], gender (38.5% and 39.8% female, p = 0.7466, witness to arrest (44.3% and 39.6%, p = 0.092), bystander AED use (10.1% and 11.4% p = 0.379), bystander CPR (48.7% and 51.4%, p = 0.242). Patients with a shockable initial rhythm (19.2% and 15.4%, p = 0.044) both decreased in 2020, and response time increased by 18 s [6.0 min (IQR 4.5–7.7) and 6.3 min (IQR 4.7–8.0), p = 0.008]. 47.7% and 54.8% ( p = 0.001) of OHCA patients died in the field, 19.7% and 19.3% ( p = 0.809) died in the Emergency Department, 21.8% and 18.5% ( p = 0.044) died in the hospital, 10.8% and 7.4% ( p = 0.012) were discharged from the hospital, and 9.3% and 5.9% ( p = 0.005) were discharged with Cerebral Performance Category score ≤ 2. Conclusion Total OHCA increased during the COVID-19 pandemic when compared with the prior year. Although patient characteristics were similar, initial shockable rhythm, and proportion of patients who died in the hospital decreased during the pandemic. Further investigation will explore etiologies of those findings.

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The emergence of thrombectomy for large vessel occlusions has increased the importance of accurate prehospital identification and triage of acute ischemic stroke (AIS). Despite available clinical scores, prehospital identification is suboptimal. Our objective was to improve the sensitivity of prehospital AIS identification by combining dispatch information with paramedic impression. We performed a retrospective cohort review of emergency medical services and hospital records of all patients for whom a stroke alert was activated in 1 urban, academic emergency department from January 1, 2018, to December 31, 2019. Using admission diagnosis of acute stroke as outcome, we calculated the sensitivity and specificity of dispatch and paramedic impression in identifying AIS and large vessel occlusion. We identified factors that, when included together, would improve the sensitivity of prehospital AIS identification. Two-hundred twenty-six stroke alerts were activated by emergency department physicians after transport by Indianapolis emergency medical services. Forty-four percent (99/226) were female, median age was 58 years (interquartile range, 50–67 years), and median National Institutes of Health Stroke Scale was 6 (interquartile range, 2–12). Paramedics demonstrated superior sensitivity (59% vs. 48%) but inferior specificity (56% vs. 73%) for detection of stroke as compared with dispatch. A strategy incorporating dispatch code of stroke, or paramedic impression of altered mental status or weakness in addition to stroke, would be 84% sensitive and 27% specific for identification of stroke. To optimize rapid and sensitive stroke detection, prehospital systems should consider inclusion of patients with dispatch code of stroke and provider impression of altered mental status or generalized weakness.

Introduction Early diagnosis and optimization of heart failure therapies in patients with acute heart failure (AHF), including in the prehospital setting, is crucial to improving outcomes. However, making the diagnosis of AHF in the prehospital setting is difficult. The goal of this study was to evaluate the accuracy of prehospital diagnosis (AHF versus not heart failure [HF]) in patients with acute dyspnea when compared to final hospital diagnosis. Methods We conducted a retrospective study of adult patients transported by emergency medical services (EMS) with a primary or secondary complaint of shortness of breath. Patients were identified through an EMS electronic database (ESO) and matched to their hospital encounter. ESO was reviewed for prehospital diagnosis and management. Hospital electronic medical records were reviewed to determine final hospital diagnosis, management in the emergency department and hospital, disposition, and length of stay. The primary outcome compared prehospital diagnosis to final hospital diagnosis, which served as our criterion standard. Results Of 199 included patients, 50 (25%) had a final diagnosis of AHF. Prehospital paramedic sensitivity and accuracy for AHF were 14% (7/50; confidence interval [CI] 0.06-0.26) and 77% (CI 0.70-0.82), respectively. In the 50 patients with AHF, 14 (28%) received nitroglycerin in the prehospital setting, while 27 (54.0%) patients were inappropriately treated with albuterol. Conclusion Prehospital paramedics had poor sensitivity and moderate accuracy for the diagnosis of AHF. A small percentage of patients ultimately diagnosed with AHF had HF therapy initiated in the prehospital setting. This data highlights the fact that AHF is difficult to diagnose in the prehospital setting and is commonly missed.

In many systems, patients with large vessel occlusion (LVO) strokes experience delays in transport to thrombectomy-capable centers. This pilot study examined use of a novel emergency medical services (EMS) protocol to expedite transfer of patients with LVOs to a comprehensive stroke center (CSC). From October 1, 2020 to February 22, 2021, Indianapolis EMS piloted a protocol, in which paramedics, after transporting a patient with a possible stroke remained at the patient’s bedside until released by the emergency department or neurology physician. In patients with possible LVO, EMS providers remained at the bedside until the clinical assessment and CT angiography (CTA) were complete. If indicated, the paramedics at bedside transferred the patient, via the same ambulance, to a nearby thrombectomy-capable CSC with which an automatic transfer agreement had been arranged. This five-month mixed methods study included case-control assessment of use of the protocol, number of transfers, safety during transport, and time saved in transfer compared to emergent transfers via conventional interfacility transfer agencies. In qualitative analysis EMS providers, and ED physicians and neurologists at both sending and receiving institutions, completed e-mail surveys on the process, and offered suggestions for process improvement. Responses were coded with an inductive content analysis approach. The protocol was used 42 times during the study period; four patients were found to have LVOs and were transferred to the CSC. There were no adverse events. Median time from decision-to-transfer to arrival at the CSC was 27.5 minutes (IQR 24.5–29.0), compared to 314.5 minutes (IQR 204.0–459.3) for acute non-stroke transfers during the same period. Major themes of provider impressions included: incomplete awareness of the protocol, smooth process, challenges when a stroke alert was activated after EMS left the hospital, greater involvement of EMS in patient care, and comments on communication and efficiency. This pilot study demonstrated the feasibility, safety, and efficiency of a novel approach to expedite endovascular therapy for patients with LVOs.

Background: Emergency medical services (EMS) professionals demonstrate low adherence to physical activity guidelines and experience a high prevalence of obesity and incidence of injury. The authors investigate the barriers to participating in physical activity among EMS professionals. Methods: The EMS professionals employed by 15 North Carolina EMS agencies were surveyed with validated items. Multivariable logistic regression models were used to estimate the odds (odds ratio, 95% confidence interval) of not meeting physical activity guidelines for each barrier to being active, controlling for age, sex, body mass index category, race/ethnicity, certification and education level, and work hours. Results: A total of 1367 EMS professionals were invited to participate, and 359 complete responses were recorded. Half of the respondents (48.2%) met Centers for Disease Control and Prevention physical activity guidelines. According to standard body mass index categories, 55.9% were obese. There were increased odds of not meeting physical activity guidelines for the following barriers: lack of energy (5.32, 3.12–9.09), lack of willpower (4.31, 2.57–7.22), lack of time (3.55, 2.12–5.94), social influence (3.02, 1.66–5.48), and lack of resources (2.14, 1.12–4.11). The barriers of fear of injury and lack of skill were not associated with meeting physical activity guidelines. Conclusion: Half of EMS professionals did not meet physical activity guidelines, and the majority were obese. Significant associations exist between several modifiable barriers and not meeting physical activity guidelines.

Background The diagnostic performance of the high-sensitivity troponin T (hs-cTnT) European Society of Cardiology (ESC) 0/1-hour algorithm in sex and race subgroups is unclear, particularly in U.S. Emergency Department (ED) patients. Methods A pre-planned subgroup analysis of the STOP-CP cohort study was conducted. Participants with 0- and 1-hour hs-cTnT measures (Roche Diagnostics; Basel, Switzerland), prospectively enrolled at eight U.S. EDs from 1/2017-9/2018, were stratified into rule-out, observation, and rule-in zones using the hs-cTnT ESC 0/1 algorithm. The primary outcome was adjudicated 30-day cardiac death or MI. Rates of patient stratification to each ESC 0/1 zone and the proportion with 30-day cardiac death or MI in each zone were compared between subgroups with Fisher's-exact tests. The negative predictive value (NPV) of the ESC 0/1 rule-out zone for 30-day cardiac death or MI was calculated and compared between subgroups using Fisher's exact tests. Results Of the 1422 patients enrolled, 54.2% (770/1422) were male and 58.1% (826/1422) white with a mean age of 57.6 ± 12.8 years. At 30 days, cardiac death or MI occurred in 12.9% (183/1422) of participants. The ESC 0/1-h algorithm ruled-out more women than men [66.9% (436/652) vs 50.0% (385/770); p<0.001] and a similar proportion of white vs non-white patients [59.3% (490/826) vs 55.5% (331/596); p=0.16]. Among patients stratified to the rule-out zone, 30-day cardiac death or MI occurred in 1.1% (5/436) of women vs 2.1% (8/436) of men (p=0.40) and 1.2% (4/331) of non-white patients vs 1.8% (9/490) of white patients (p=0.58). The NPV for 30-day cardiac death or MI was similar among women vs men [98.9% (95%CI 97.3-99.6) vs 97.9% (95%CI 95.9-99.1); p = 0.40] and among white vs non-white patients [98.8% (95%CI 96.9-99.7) vs 98.2% (95%CI 96.5-99.2); p=0.39]. Conclusions The ESC 0/1-h hs-cTnT algorithm ruled-out more women than men, but achieved similar NPV for 30-day cardiac death or MI in all subgroups. NPVs <99% in each subgroup suggests the hs-cTnT ESC 0/1-h algorithm may not be safe for U.S. ED use.