Daniel Johnson

Objective: To evaluate the effectiveness and implementation of a multicomponent intervention to address the burden of drug use–related infectious diseases and overdose in rural settings. Design: Single-arm hybrid implementation-effectiveness design. Setting: Rural area comprising the Illinois counties of the Delta Regional Authority. Participants: People who use opioids and/or stimulants nonmedically. Intervention: Expansion of community-based harm reduction services, capacity-building for opioid use disorder and hepatitis C treatment. Main Outcome Measures: Harm reduction service expansion intervention Reach, Effectiveness (injection equipment sharing), Adoption and Cost (per participant and budget impact analysis). Results: Three hundred six people who use drugs were enrolled. Of the 207 of who were not previously engaged in harm reduction services, 121 (59%) accepted referral and were retained in services at 6 months past study enrollment (intervention reach). In regards to intervention efficacy, among these individuals, 41 (35%) completed follow-up surveys; compared with their baseline self-report, there was a significant increase in obtaining sterile equipment from the harm reduction organization (43.9% vs. 68.3%, P = 0.03) and decrease in sharing injection equipment (46.3%–19.5%, P = .02). The harm reduction organization experienced an increase of approximately 100–550 program participants and an increase in service delivery area coverage from 1258 to 5509 square miles after intervention implementation (adoption). Cost per participant served by the harm reduction organization was $1486 per year, with annual budget impact to the program of $817 295. In regards to treatment capacity building, a total of 80 providers in the study area completed training in opioid use and/or hepatitis C management. Conclusion: The pragmatic evaluation of harm reduction service expansion supported by a suite of implementation strategies serves to inform the practical considerations and decision-making by community-based organizations seeking to increase services in rural areas heavily affected by substance use, overdose, and related infectious diseases.

Interleukin-12 receptor β1 (IL-12Rβ1) deficiency is the most common genetic form of Mendelian susceptibility to mycobacterial disease globally, often presenting as disseminated Bacillus Calmette-Guérin (BCG) infection. In North America, however, where BCG is not used, it manifests with other bacterial or fungal infections, highlighting distinct, sometimes unrecognized, presentations of IL-12Rβ1 deficiency in this geographic area.

Objective: Heart failure (HF) patients are at high risk for 30-day hospital readmission which is a negative predictor of patient-centered outcomes. Community paramedicine (CP) has emerged with a goal of reducing readmissions and currently no model exists to accurately predict those at highest risk. We seek to analyze factors associated with readmission among participants in a CP program. Methods: Design: A retrospective review of consecutive patients with a HF-related diagnosis who received a home visit by a community paramedic after a hospital admission. Setting: A suburban, academic medical center with an established CP program. Inclusion criteria: All patients with a HF-related diagnosis who received a home visit over the study period. Factors including age, sex, hospital length of stay, time to home visit, discharge destination, participation in other transitional care/home health programs, chronicity of heart failure, care team, and perceived risk of readmission by the community paramedics at the time of home visit were retrospectively reviewed and analyzed. The outcome of interest was 30-day, all-cause readmissions. Results: From 4/7/2017 to 4/6/2018 there were 592 patients who received home visits. The median age was 70 [IQR 60-79] and 41.9% were female. The overall 30-day readmission rate was 11%. For readmitted patients, the median time to home visit was 6 days [IQR 4-11] versus 10 days [IQR 5-23] for those not readmitted (p=<0.01). Patients deemed to be at risk for readmission by the community paramedics were readmitted more often than those who were not (OR 2.68, 95% CI [1.59-4.52]). Conclusion: Along with time to home visit, perceived risk of 30-day readmission at the time of a home visit by a community paramedic correlated with rates of readmission. In the HF population, comprehensive models to predict 30-day readmission might be improved by including a subjective assessment by a trained clinician.

Introduction: Many emergency medical services (EMS) systems in the United States utilize statewide protocols, but the number, type, and role of these systems in prehospital decision-making are largely unknown. Study Objective: To characterize statewide protocols and determine their role in prehospital decision-making. Methods: All states were queried for the presence of mandatory statewide Advanced Life Support (ALS)-level EMS protocols. Protocols were categorized as diagnosis-based, symptom-based, procedural, or non-clinical by two fellowship-trained EMS physicians. A data abstraction guide with category examples was included. Discrepancies were resolved by a third blinded EMS physician. The number and type of protocols were compiled, and simple statistics and chi-squared analysis were used to evaluate state-by-state variation. Results: Nine states have mandatory statewide ALS protocols, totaling 804 individual protocols, including 672 (83.6%) clinical and 132 (16.4%) non-clinical protocols. Symptom-based protocols accounted for 59.5% of the clinical protocols, while 13.2% were diagnosis-based and 27.2% procedural. Per state, there was a median interquartile range (IQR) of 46 (14.5) symptom-based, 8 (8) diagnosis-based, and 17 (22.5) procedural protocols. There was significant variation in the type and number of protocols by state (p < 0.001). Conclusion: Significant variation exists in statewide EMS protocols. While many are symptom-based, a notable portion are diagnosis-based, challenging the notion that paramedics cannot diagnose. These findings suggest a need for higher-level clinical decision-making in EMS. Further research is warranted at other EMS training levels and to inform EMS training programs.

Introduction: Suicide is the second leading cause of death in persons aged 10–34 in the US. Despite the availability of evidence-based suicide screening tools and interventions, there is a gap in suicide prevention knowledge among non-psychiatric healthcare providers. This study examined a novel education program, Project ECHO ^® , focused on suicide prevention. Project ECHO ^® delivers subspecialized medical knowledge via teleconferencing to primary care providers and behavioral health providers. Methods: The ECHO-Chicago Suicide Prevention program encompassed three series with 10 (behavioral health providers & primary care providers) or 9 (pediatric primary care providers) one-hour sessions in 2023–2024. Each session was comprised of expert-led didactics and participant-led case discussions. Topics included suicide epidemiology, secondary stress, zero suicide model, screening, cultural competency, safety planning, follow-up, and post-acute care transitions. Pre- and post-series surveys were used to evaluate the education program. Free text responses were analyzed using thematic coding. Results: In total, 106 participants participated in the program; 79 (75%) completed both the pre- and post-series surveys. Overall mean self-efficacy scores increased from 4.1 to 5.4 ( p < 0.0001) in the behavioral health providers/primary care providers series and from 3.3 to 5.2 ( p < 0.0001) in the pediatric primary care providers series. Participants reported an improved ability to manage complex cases and an increased quality of care. Qualitative analysis suggested clinicians benefited from learning specific screening tools and soft skills, including patient communication. Discussion: As an affordable, scalable model, our novel curriculum has the potential to improve suicide prevention knowledge and practices amongst pediatric, adult, behavioral health, and interdisciplinary providers.

Objective: The aim of this study is to describe the frequency and type of advanced (ALS) interventions performed by emergency medical services (EMS) providers while caring for undifferentiated chest pain patients. Methods: This pilot study is a retrospective review of advanced interventions performed on consecutive adult patients transported by EMS with a provider impression of non-traumatic chest pain and treated under the suspected acute coronary syndrome statewide protocol from July 2013 through January 2022. The EMS system studied is a hospital-based agency which serves a large suburban to rural population in central Pennsylvania. Advanced interventions were defined a priori and included STEMI activation. Results: During the study period, there were 2 456 EMS transports out of 97 877 which met study inclusion criteria. A total of 121 advanced interventions were performed on 101 (4.1%) of these patients, the majority 79 (3.2%) of which were prehospital notification of STEMI activations. Intravenous medications were administered 25 times to 22 (0.9%) patients and advanced procedures were performed 17 times on 7 (0.3%) patients. Several patients received more than one intervention and/or medication. Patients between 60 and 65 years of age accounted for the highest number of activations (283, 11.5%) and received the largest number of interventions (28, 9.9%). Only eight patients were below the age of 45 and all were STEMI activations only. Conclusion: We found that less than 5% of included patients transported by EMS required advanced interventions with the majority of these being STEMI activations not requiring any additional interventions. Further investigation is required to determine if certain characteristics or risk-factors predict the need for out-of-hospital advanced interventions and ALS transport.

Introduction Participation in community paramedicine (CP) programs, sometimes referred to as Mobile Integrated Healthcare (MIH), may improve patient-centered outcomes and reduce hospital readmissions. The objective of this study was to correlate patient and system-specific factors with successful enrollment in a CP program for heart failure. Methods We conducted a retrospective review of patients enrolled in a CP program after hospitalization for a heart failure-related diagnosis. All patients greater than 18 years of age referred to the CP program with a heart-failure-related diagnosis were included. Factors including age, sex, hospital length of stay, enrollment method, concurrent use of transitional care services, care team, and service line referral were collected. The primary outcome was successful enrollment which led to an initial home visit. Chi-square and t-tests were performed to determine if the outcome differed between cohorts. Results A total of 908 patients met the inclusion criteria, and 677 (74.7%) received home visits. Increased participation was noted in patients enrolled in person (81.1% vs. 66%, p<0.01) and those also receiving transitional care services (78.9% vs. 62.5%, p<0.01). Conclusion We conclude that efforts should be made to contact patients in person, prior to hospital discharge, who are eligible for CP services.