Jeremy T. Cushman

INTRODUCTIONPrehospital medication dosing errors in pediatric patients are a common occurrence. Published rates of pediatric medication error range from 36 to 49% in the emergency medical services ...

When emergency medical services (EMS) clinicians provide mobilization assistance to geriatric fall patients without transport, this is often coded as a "lift assist." Previous research has shown many of these patients are subsequently transported, suggesting the "lift assist" may signal the presence of underlying medical illness or decline in functional condition. Understanding the timeline for repeat visits requiring transport is critical to improvement initiatives seeking to reduce diagnostic delays for this population. The primary objective of this study was to describe the timeline and factors associated with subsequent transport following an index EMS encounter for lift assist. This was a retrospective analysis of one year (2022) of patient encounters in a suburban EMS system with ∼120K dispatches per year. Patients ≥ 60 years of age were included if they had at least one repeat EMS encounter within 7 days of a non-transport with a primary impression of lift assist. The population was described using descriptive statistics. Associations between assessment completeness and abnormal vital signs with odds of subsequent transport versus non-transport were evaluated using logistic regression analysis. In total, 1054 EMS encounters were analyzed, accounting for 574 repeat encounters involving 428 unique patients and 480 patient clusters. Number of repeat encounters within 7 days ranged from one to six, with 84%(n = 406) having only one. Of initial EMS encounters, 14% were missing at least one vital sign, and abnormal vital signs were observed ((HR > 100:10% (n = 459), SBP < 110:8%(n = 448), SpO2 < 90%:4%(n = 425)). On repeat encounter, patients were transported in 76% of cases. The primary impression indicated a medical etiology in 61% of repeat encounters and 1% were for cardiac arrest.. Median time to first repeat encounter resulting in transport was 1.13 days (IQR 0.33 to 3.33 days). No association was found between abnormal vital signs or ambulation assessment with odds of transport on subsequent encounter. Most repeat patient encounters following index lift assist occur within 72 hours and result in transport, most commonly for presumed medical etiology. Ambulation assessment, abnormal or missing vital signs were not associated with increased odds of transport on repeat visits in this limited patient sample.

Background: Older adults frequently return to the emergency department (ED) within 30 days of a visit. High-risk patients can differentially benefit from transitional care interventions. Latent class analysis (LCA) is a model-based method used to segment the population and test intervention effects by subgroup. Objectives: We aimed to identify latent classes within an older adult population from a randomized controlled trial evaluating the effectiveness of an ED-to-home transitional care program and test whether class membership modified the intervention effect. Research Design: Participants were randomized to receive the Care Transitions Intervention or usual care. Study staff collected outcomes data through medical record reviews and surveys. We performed LCA and logistic regression to evaluate the differential effects of the intervention by class membership. Subjects: Participants were ED patients (age 60 y and above) discharged to a community residence. Measures: Indicator variables for the LCA included clinically available and patient-reported data from the initial ED visit. Our primary outcome was ED revisits within 30 days. Secondary outcomes included ED revisits within 14 days, outpatient follow-up within 7 and 30 days, and self-management behaviors. Results: We interpreted 6 latent classes in this study population. Classes 1, 4, 5, and 6 showed a reduction in ED revisit rates with the intervention; classes 2 and 3 showed an increase in ED revisit rates. In class 5, we found evidence that the intervention increased outpatient follow-up within 7 and 30 days (odds ratio: 1.81, 95% CI: 1.13–2.91; odds ratio: 2.24, 95% CI: 1.25–4.03). Conclusions: Class membership modified the intervention effect. Population segmentation is an important step in evaluating a transitional care intervention.

Pharmacist collaboration with medical directors and practitioners operating in the emergency medical services (EMS) system can improve overall care, optimize the medication formulary, and decrease medication‐related risk. However, to achieve this, pharmacists must have a fundamental understanding of the prehospital medicine environment. We describe a comprehensive prehospital medicine postgraduate training experience for postgraduate year two (PGY2) emergency medicine (EM) pharmacy residents. A detailed description of the prehospital medicine learning experience (LE) is provided that includes an immersive schedule with diverse EMS exposure, attendance at dedicated EMS‐specific medical resident conferences, didactic and self‐learning requirements, and a scholarly EMS project. Information regarding how this LE is organized and evaluated, as well as challenges and future directions are provided. Program success is highlighted with the reporting of 20 scholarly projects completed by PGY2 EM pharmacy residents from 2006 through 2022 in collaboration with EMS and the Division of Prehospital Medicine. A collaborative and immersive prehospital medicine LE for PGY2 EM pharmacy residents can be mutually beneficial for the training of the pharmacy resident, scholarly productivity supporting regional and statewide change, and EMS personnel.

Introduction: Tranexamic acid (TXA) is an antifibrinolytic agent shown to reduce morbidity and mortality in hemorrhagic shock. It has potential use in prehospital and wilderness medicine; however, in these environments, TXA is likely to be exposed to fluctuating and extreme temperatures. If TXA degrades under these conditions, this may reduce antifibrinolytic effects.Problem: This study sought to determine if repetitive temperature derangement causes degradation of TXA.Methods: Experimental samples underwent either seven days of freeze/thaw or heating cycles and then were analyzed via mass spectrometry for degradation of TXA. An internal standard was used for comparison between experimental samples and controls. These samples were compared to room temperature controls to determine if fluctuating extreme temperatures cause degradation of TXA.Results: The coefficient of variability of ratios of TXA to internal standard within each group (room temperature, freeze, and heated) was less than five percent. An independent t-test was performed on freeze/thaw versus control samples (t = 2.77; P = .17) and heated versus control samples (t = 2.77; P = .722) demonstrating no difference between the groups.Conclusion: These results suggest that TXA remains stable despite repeated exposure to extreme temperatures and does not significantly degrade. These findings support the stability of TXA and its use in extreme environments.

Background Emergency Medical Services (EMS) providers must be able to identify the most appropriate destination facility when treating children with potentially severe medical illnesses. Currently, no validated tool exists to assist EMS providers in identifying children who need transport to a hospital with higher‐level pediatric care. In order for such a tool to be developed, a criterion standard needs to be defined that identifies children who received higher‐level pediatric medical care. Objective To develop a consensus‐based criterion standard for children with a medical complaint who need a hospital with higher‐level pediatric resources. Methods Eleven local and national experts in EMS, emergency medicine (EM), and pediatric EM were recruited. Initial discussions identified themes for potential criteria. These themes were used to develop specific criteria that were included in a modified Delphi survey, which was electronically delivered. The criteria were refined iteratively based on participant responses. To be included, a criterion required at least 80% agreement amongst participants. If an item had less than 50% agreement, it was removed. Criterion with 50%‐79% agreement was modified based on participant suggestions and included on the next survey, along with any new suggested criteria. Voting continued until no new criteria were suggested and all criteria received at least 80% agreement. Results All 11 recruited experts participated in all 7 voting rounds. After the 7th vote, there was agreement on each item and no new criteria were suggested. The recommended criterion standard included 13 items that apply to patients 14 years old or younger. They included: IV antibiotics for suspicion of sepsis or a seizure treated with 2 different classes of anticonvulsive medications within 2 hours; airway management, blood product administration, CPR, electrical therapy, administration of specific IV/IO drugs or respiratory assistance within 4 hours; interventional radiology or surgery within 6 hours; ICU admission, specific comorbid conditions with 2 or more abnormal vital signs, and technology‐assisted children seen for device malfunction. Conclusion We developed a 13‐item consensus‐based criterion standard definition for identifying children with medical complaints who need the resources of a hospital equipped to provide higher‐level pediatric services. This criterion standard will allow us to create a tool to improve pediatric patient care by assisting EMS providers in identifying the most appropriate destination facility for ill children.

Introduction: Ischemic stroke treatment is time-sensitive, and barriers to providing prehospital care encountered by Emergency Medical Services (EMS) providers have been under-studied. Hypothesis/Problem: This study described barriers to providing prehospital care, identified predictors of these barriers, and assessed the impact of these barriers on EMS on-scene time and administration of tissue plasminogen activator (tPA) in the emergency department (ED). Methods: A retrospective cohort study was performed using the Get With The Guidelines-Stroke (GWTG-S; American Heart Association [AHA]; Dallas, Texas USA) registry at two hospitals to identify ischemic stroke patients arriving by EMS. Variables were abstracted from prehospital and hospital medical records and merged with registry data. Barriers to care were grouped into themes. Logistic regression was used to identify predictors of barriers to care, and bi-variate tests were used to assess differences in EMS on-scene time and the proportion of patients receiving tPA between patients with and without barriers. Results: Barriers to providing prehospital care were documented for 15.5% of patients: 29.6% related to access, 26.7% communication, 23.0% extrication and transportation, 20.0% refusal, and 14.1% assessment/management. Non-white and non-black race (OR: 3.69; 95% CI, 1.63-8.36) and living alone (OR: 1.53; 95% CI, 1.05-2.23) were associated with greater odds of barriers to providing care. The EMS on-scene time was ≥15 minutes for 70.4% of patients who had a barrier to care, compared with 49.0% of patients who did not (P<.001). There was no significant difference in the proportion of patients who were administered tPA between those with and without barriers to care (14.1% vs 19.2%; P=.159). Conclusions: Barriers to providing prehospital care were documented for a sizable proportion of ischemic stroke patients, with the majority related to patient access and communication, and occurred more frequently among non-white and non-black patients and those living alone. Although EMS on-scene time was longer for patients with barriers to care, the proportion of patients receiving tPA in the ED did not differ. Li T , Cushman JT , Shah MN , Kelly AG , Rich DQ , Jones CMC . Barriers to providing prehospital care to ischemic stroke patients: predictors and impact on care. Prehosp Disaster Med. 2018;33(5):501–507.