Rebecca E. Cash

To the Editor: Missed Opportunities for Prehospital Transfusion in Pediatric TraumaWe commend Ramgopal et al. for exploring an important area of research around prehospital blood transfusion in chi...

Older adults account for a substantial proportion of emergency medical services (EMS) utilization. National analyses suggest that approximately 40% of EMS responses involve adults aged 65 years and...

Emergency medical services (EMS) in the United States (U.S.) are decentralized, resulting in more than 20,000 agencies with variable funding and governance (1), patient care protocols (2–8), and pa...

Providing high quality, evidence-based clinical care in the prehospital setting and establishing efficient and highly reliable prehospital systems of care has been identified as a priority for elev...

INTRODUCTIONLong-term disability from stroke can be reduced with timely access to reperfusion interventions (1-10). The benefits of reperfusion with thrombolytic and endovascular thrombectomy (EVT)...

We aimed to provide the first national study of out-of-hospital cardiac arrests (OHCA) witnessed by emergency medical services (EMS) during interfacility transport (IFT). We used a nationwide prehospital patient care report dataset from 2023 to complete a cross-sectional observational study of EMS encounters for IFT during which OHCA occurred. Descriptive statistics were computed, stratified by level of EMS care provided. Multivariable logistic regression analysis was completed to evaluate factors associated with return of spontaneous circulation (ROSC) at the end of the IFT encounter upon transfer of care to the receiving facility. Finally, we completed a similar multivariable logistic regression analysis restricted to the subgroup of patients with an unshockable initial rhythm. A total of 1,466 OHCA incidents occurred during an IFT with EMS: 7.5% with basic life support (BLS), 53.6% with advanced life support (ALS), and 38.9% with critical care transport (CCT). Among these incidents 11.8% were associated with trauma, 9.2% involved cardiopulmonary resuscitation (CPR) prior to EMS unit arrival, 14.7% involved a mechanical device to perform CPR, 22.2% had a shockable initial rhythm, and 58.1% were transported via ground as opposed to air. At the conclusion of the IFT EMS encounter, 50.3% had sustained ROSC. Geriatric age (aOR 0.64, 95%CI 0.44-0.94), BLS care (aOR 0.45, 95%CI 0.22-0.90), and ground transport (aOR 0.58, 95%CI 0.38-0.89) were associated with worse outcomes on adjusted analysis, whereas shockable initial rhythm (aOR 3.86, 95%CI 2.42-6.36) and CCT care (aOR 2.21, 95%CI 1.42-3.48) were associated with better outcomes. The sub-analysis for OHCA during IFT with an unshockable initial rhythm also showed greater odds of ROSC when managed by CCT relative to ALS (aOR 2.65, 95%CI 1.64-4.33) while adjusting for other key factors. Using a large nationwide sample of OHCA incidents that occurred during IFT, we found that higher level of EMS care was associated with superior short-term outcomes while controlling for other key factors. These findings underscore the importance of accurate patient triage at sending facilities and the value of CCT for high-risk patients.

Air medical transport (AMT) improves survival for selected trauma patients. Improving AMT triage is limited by a lack of evidence and a standardized definition for which patients and circumstances may warrant AMT. Our objective was to develop a consensus-based definition of AMT need. We recruited a multidisciplinary, nationally representative panel with expertise in AMT from trauma surgery, anesthesiology, critical care, emergency medicine, and emergency medical services (EMS). Panelists were presented with criteria from the literature representing the potential for AMT need that included patient injuries, time-sensitive interventions, and system factors. Panelists voted over 4 rounds to refine and select (≥70% agreement) a final set of criteria using a web-based Delphi methodology, including potential criteria combinations. A total of 32 of 45 (71.1%) invited panelists agreed to participate. From 66 initial criteria, panelists reached consensus on 18 patient factors, 6 time-sensitive interventions, 3 system factors, and 7 combinations of criteria. Two key themes emerged: the need for specialized care from air medical crews that may not be available from ground ambulance clinicians, as well as overall prehospital time-savings. After narrative feedback and refinement to eliminate redundant and overlapping criteria, an algorithm for AMT need was developed along with a decision flow diagram suitable for educational dissemination. We developed a consensus-based definition of AMT need for trauma patients that can be operationalized for AMT triage. Further validation of this concept with patient outcomes and identifying implementation barriers will contribute to field deployment of a useful AMT triage tool for EMS clinicians.

Background: Our objective was to describe emergency medical services (EMS) transport destination practices for patients with suspected stroke using a novel linked data set of EMS patient care data and verified emergency department (ED) stroke‐related capabilities. Methods: This was a cross‐sectional evaluation of EMS 9‐1‐1 encounters for patients with suspected stroke from 2019 to 2021 from the ESO Data Collaborative, linked to verified ED capabilities from the 2021 National ED Inventory‐USA survey. Our primary outcome was transport to an ED with any stroke care capabilities. We used mixed effects logistic regression models with a random intercept for agency to estimate the odds of transport to an ED with stroke care capabilities. We used intraclass correlation coefficients and median odds ratios (ORs) to quantify the contribution of covariates and variability between EMS agencies. Results: The analytic sample included 314 642 encounters (median age 72 years, 53% female) from 1781 EMS agencies, including 719 (40%) agencies primarily serving rural areas. Overall, 32 142 (10%) patients were transported to facilities lacking verified stroke care capabilities. There was significant between‐agency variation, with median ORs consistently >2.0 (eg, fully adjusted model, median OR, 3.91 [95% CI, 3.71–4.11]). Rural, versus urban, location was associated with lower odds of transport to an ED with stroke care capabilities (OR, 0.15 [95% CI, 0.14–0.17]). Conclusions: In this analysis of EMS encounters, 1 in 10 patients with suspected stroke was transported to a facility without verified stroke care capabilities. Variation across EMS agencies and lower odds of appropriate routing in rural settings highlight critical gaps in prehospital stroke systems of care.