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In patients with out-of-hospital cardiac arrest (OHCA) who attain return of spontaneous circulation (ROSC), rearrest while in the prehospital setting represents a significant barrier to survival. To date, there are limited data to guide prehospital emergency medical services (EMS) management immediately following successful resuscitation resulting in ROSC and prior to handoff in the emergency department. Post-ROSC care encompasses a multifaceted approach including hemodynamic optimization, airway management, oxygenation, and ventilation. We sought to develop an evidenced-based, goal-directed bundle of care targeting specified vital parameters in the immediate post-ROSC period, with the goal of decreasing the incidence of rearrest and improving survival outcomes. Here, we describe the rationale and development of this goal-directed bundle of care, which will be adopted by several EMS agencies within California. We convened a group of EMS experts, including EMS Medical Directors, quality improvement officers, data managers, educators, EMS clinicians, emergency medicine clinicians, and resuscitation researchers to develop a goal-directed bundle of care to be applied in the field during the period immediately following ROSC. This care bundle includes guidance for prehospital personnel on recognition of impending rearrest, hemodynamic optimization, ventilatory strategies, airway management, and diagnosis of underlying causes prior to the initiation of transport.

OBJECTIVES: Despite the significant disease burden due to cardiac arrest, there is a relative paucity of randomized controlled trials (RCTs) to inform definitive management. We aimed to evaluate the current scope of cardiac arrest RCTs published between 2015 and 2022. METHODS: We conducted a search in October 2023 of MEDLINE, Embase, and Web of Science for cardiac arrest RCTs. We included trials published between 2015 and 2022 enrolling human subjects suffering from non-traumatic cardiac arrest. Descriptive statistics were reported and the Mann Kendall test was used to evaluate for temporal trends in the number of trials published annually. RESULTS: We identified 1764 unique publications, 87 RCTs were included after title/abstract and full-text review. We found no significant increase in trials published annually (eight in 2015 and 16 in 2022, p = 1.0). Geographic analysis of study centers found 31 countries represented; Denmark (n = 13, 15%) and the United States (n = 9, 10%) conducted the majority of trials. Nearly all trials included adults (n = 84, 97%) and few included children (n = 9, 10%). The majority of trials focused on out-of-hospital cardiac arrest (n = 62, 71%). Thirty-eight (44%) trials used an intervention characterized as a process improvement; 28 (32%) interventions were characterized as a drug and 20 (23%) as a device. Interventions were implemented with similar frequency in the prehospital (33%) and intensive care unit (38%) setting, as well as similarly between the intra-arrest (53%) and post-arrest (46%) periods. Twenty (27%) trials selected a primary outcome of survival at ≥ 28 days. CONCLUSIONS: Publication of cardiac arrest RCTs remained constant between 2015 and 2022. We identified significant gaps including a lack of trials examining in-hospital cardiac arrest and pediatric patients.

BACKGROUND: Artificial intelligence (AI) has transformative potential to support prehospital clinicians, emergency physicians, and trauma surgeons in acute traumatic injury care. This scoping review examines the literature evaluating AI models using prehospital features to support early traumatic injury care. METHODS: We conducted a systematic search in August 2023 of PubMed, Embase, and Web of Science. Two independent reviewers screened titles/abstracts, with a third reviewer for adjudication, followed by a full-text analysis. We included original research and conference presentations evaluating AI models-machine learning (ML), deep learning (DL), and natural language processing (NLP)-that used prehospital features or features available immediately upon emergency department arrival. Review articles were excluded. The same investigators extracted data and systematically categorized outcomes to ensure consistency and transparency. We calculated kappa for interrater reliability and descriptive statistics. RESULTS: We identified 1050 unique publications, with 49 meeting inclusion criteria after title and abstract review (kappa 0.58) and full-text review. Publications increased annually from 2 in 2007 to 10 in 2022. Geographic analysis revealed a 61% focus on data from the United States. Studies were predominantly retrospective (88%), used local (45%) or national level (41%) data, focused on adults only (59%) or did not specify adults or pediatrics (27%), and 57% encompassed both blunt and penetrating injury mechanisms. The majority used machine learning (88%) alone or in conjunction with DL or NLP, and the top three algorithms used were support vector machine, logistic regression, and random forest. The most common study objectives were to predict the need for critical care and life-saving interventions (29%), assist in triage (22%), and predict survival (20%). CONCLUSIONS: A small but growing body of literature described AI models based on prehospital features that may support decisions made by dispatchers, Emergency Medical Services clinicians, and trauma teams in early traumatic injury care.

BACKGROUND: Artificial intelligence (AI) has demonstrated significant potential in supporting emergency medical services personnel during out-of-hospital cardiac arrest (OHCA) care; however, the extent of research evaluating this topic is unknown. This scoping review examines the breadth of literature on the application of AI in early OHCA care. METHODS: We conducted a search of PubMed®, Embase, and Web of Science in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. Articles focused on non-traumatic OHCA and published prior to January 18th, 2023 were included. Studies were excluded if they did not use an AI intervention (including machine learning, deep learning, or natural language processing), or did not utilize data from the prehospital phase of care. RESULTS: Of 173 unique articles identified, 54 (31%) were included after screening. Of these studies, 15 (28%) were from the year 2022 and with an increasing trend annually starting in 2019. The majority were carried out by multinational collaborations (20/54, 38%) with additional studies from the United States (10/54, 19%), Korea (5/54, 10%), and Spain (3/54, 6%). Studies were classified into three major categories including ECG waveform classification and outcome prediction (24/54, 44%), early dispatch-level detection and outcome prediction (7/54, 13%), return of spontaneous circulation and survival outcome prediction (15/54, 20%), and other (9/54, 16%). All but one study had a retrospective design. CONCLUSIONS: A small but growing body of literature exists describing the use of AI to augment early OHCA care.

The incidence of both out-of-hospital and in-hospital cardiac arrest increased during the coronavirus disease 2019 (COVID-19) pandemic. Patient survival and neurologic outcome after both out-of-hospital and in-hospital cardiac arrest were reduced. Direct effects of the COVID-19 illness combined with indirect effects of the pandemic on patient's behavior and health care systems contributed to these changes. Understanding the potential factors offers the opportunity to improve future response and save lives.

BACKGROUND: Our objective was to assess the association between intensive care unit (ICU)-free days and patient outcomes in pediatric prehospital care and to evaluate whether ICU-free days is a more sensitive outcome measure for emergency medical services research in this population. METHODS: This study used data from a previous pediatric prehospital trial. The original study enrolled patients ≤12 years of age and compared bag-valve-mask-ventilation (BVM) versus endotracheal intubation (ETI) during prehospital resuscitation. For the current study, we defined ICU-free days as 30 minus the number of days in the ICU (range, 0-30 days) and assigned 0 ICU-free days for death within 30 days. We compared ICU-free days between the original study treatment groups (BVM vs ETI) and with the original trial outcomes of survival to hospital discharge and Pediatric Cerebral Performance Category (PCPC). RESULTS: Median ICU-free days for the BVM group (n = 404) versus ETI group (n = 416) was not statistically different: 0 ICU-free days (interquartile range, 0-10) versus 0 (0-0), P = 0.219. Median ICU-free days were greater for BVM group in 3 subgroups: foreign body aspiration 30 (0-30) versus 0 (0-21), P = 0.028; child maltreatment 0 (0-14.2) versus 0 (0-0), P = 0.004; and respiratory arrest 25 (1-29) versus 7.5 (0-27.7), P = 0.015. In the original trial, neither survival nor PCPC demonstrated differences in all 3 subgroups-survival was greater with BVM for child maltreatment and respiratory arrest and favorable PCPC was greater with BVM for foreign body aspiration. Overall, in the current study, patients with more ICU-free days also had greater survival to hospital discharge and more favorable PCPC scores. CONCLUSIONS: This initial study of the association between ICU-free days and patient outcomes during prehospital pediatric resuscitation appears to support the use of ICU-free days as a clinical endpoint in this population. ICU-free days may be more sensitive than either mortality or PCPC alone while capturing aspects of both measures.

IntroductionEmergency medical services (EMS) fellowships are growing in significance within the United States prehospital health care system. While fellowships represent a cornerstone of EMS subspecialty education, an individual learner's experiences are limited by local resources and practices. California EMS fellowships have developed an innovative method for expanding fellows' educational experiences outside their immediate programs.The innovative education methodEach month, fellows, fellowship directors, and local EMS medical directors from throughout the state participate in a video conference. This meeting is divided into four distinct components: book chapter presentation, board-style question review, call review, and an EMS literature review.Chapter reviewThe two-volume text Emergency Medical Services: Clinical Practice and Systems Oversight has been categorized into 12 modules, one for each month of the fellowship. Every meeting, one fellow prepares a didactic presentation summarizing the highlights from that month's chapters.Question reviewFellows each create five multiple-choice questions and answers, based on the section reading. Questions are assessed by the group, both for informational content and for appropriate formatting. After completion, these questions are submitted for future review for the EMS fellowship in-service examination.Call reviewBased on that month's module topics, a call is chosen and reviewed. Regional protocol and practice differences from different systems are discussed. The online medical oversight provided and the prehospital provider performance are evaluated by the group.Literature reviewFellows not assigned to present a call or didactic segment each choose one paper focusing on a subject relevant to the module or call. Strengths of the study design, analysis, outcomes, and relevance to EMS practice are discussed.OutcomesFellows and experienced EMS attendings are exposed to different protocol and system approaches in an interactive and accessible format. This partnership expands educational opportunities for fellows and promotes collaboration across EMS systems.

Introduction: The development of cardiac arrest centers and regionalization of systems of care may improve survival of patients with out-of-hospital cardiac arrest (OHCA). This survey of the local EMS agencies (LEMSA) in California was intended to determine current practices regarding the treatment and routing of OHCA patients and the extent to which EMS systems have regionalized OHCA care across California.  Methods: We surveyed all of the 33 LEMSA in California regarding the treatment and routing of OHCA patients according to the current recommendations for OHCA management.  Results: Two counties, representing 29% of the California population, have formally regionalized cardiac arrest care. Twenty of the remaining LEMSA have specific regionalization protocols to direct all OHCA patients with return of spontaneous circulation to designated percutaneous coronary intervention (PCI)-capable hospitals, representing another 36% of the population. There is large variation in LEMSA ability to influence inhospital care. Only 14 agencies (36%), representing 44% of the population, have access to hospital outcome data, including survival to hospital discharge and cerebral performance category scores.  Conclusion: Regionalized care of OHCA is established in two of 33 California LEMSA, providing access to approximately one-third of California residents. Many other LEMSA direct OHCA patients to PCI-capable hospitals for primary PCI and targeted temperature management, but there is limited regional coordination and system quality improvement. Only one-third of LEMSA have access to hospital data for patient outcomes.

We evaluated the first-medical-contact-to-balloon (FMC2B) time after implementation of a "Call 911" protocol for ST-segment-elevation myocardial infarction (STEMI) interfacility transfers in a regional system. This is a retrospective cohort study of consecutive patients with STEMI requiring interfacility transfer from a STEMI referring hospital, to one of 35 percutaneous coronary intervention-capable STEMI receiving centers (SRCs). The Call 911 protocol allows the referring physician to activate 911 to transport a patient with STEMI to the nearest SRC for primary percutaneous coronary intervention. Patients with interfacility transfers were identified over a 4-year period (2011-2014) from a registry to which SRCs report treatment and outcomes for all patients with STEMI transported via 911. The primary outcomes were median FMC2B time and the proportion of patients achieving the 120-minute goal. FMC2B for primary 911 transports were calculated to serve as a system reference. There were 2471 patients with STEMI transferred to SRCs by 911 transport during the study period, of whom 1942 (79%) had emergent coronary angiography and 1410 (73%) received percutaneous coronary intervention. The median age was 61 years (interquartile range [IQR] 52-71) and 73% were men. The median FMC2B time was 111 minutes (IQR 88-153) with 56% of patients meeting the 120-minute goal. The median STEMI referring hospital door-in-door-out time was 53 minutes (IQR 37-89), emergency medical services transport time was 9 minutes (IQR 7-12), and SRC door-to-balloon time was 44 minutes (IQR 32-60). For primary 911 patients (N=4827), the median FMC2B time was 81 minutes (IQR 67-97). Using a Call 911 protocol in this regional cardiac care system, patients with STEMI requiring interfacility transfers had a median FMC2B time of 111 minutes, with 56% meeting the 120-minute goal.

The purpose of this study was to evaluate sex differences in out-of-hospital cardiac arrest (OHCA) characteristics, interventions, and outcomes. This is a retrospective analysis from a regionalized cardiac arrest system. Data on patients treated for OHCA are reported to a single registry, from which all adult patients were identified from 2011 through 2014. Characteristics, treatment, and outcomes were evaluated with stratification by sex. The adjusted odds ratio (OR) for survival with good neurological outcome (cerebral performance category 1 or 2) was calculated for women compared to men. There were 5174 out-of-hospital cardiac arrests (OHCAs; 3080 males and 2094 females). Women were older, median 71 (interquartile range [IQR], 59-82) versus 66 years (IQR, 55-78). Despite similar frequency of witnessed arrest, women were less likely to present with a shockable rhythm (22% vs 35%; risk difference [RD], 13%; 95% CI, 11-15), have ST-segment elevation myocardial infarction (23% vs 32%; RD, 13%; 95% CI, 7-11), or receive coronary angiography (11% vs 25%; RD, 14%; 95% CI, 12-16), percutaneous coronary intervention (5% vs 14%; RD, 9%; 95% CI, 7-11), or targeted temperature management (33% vs 40%; RD, 7%; 95% CI, 4-10). Women had decreased survival to discharge (33% vs 40%; RD, 7%; 95% CI, 4-10) and a lower proportion of good neurological outcome (16% vs 24%; RD, 8%; 95% CI, 6-10). In multivariable modeling, female sex was not associated with decreased survival with good neurological outcome (OR, 0.9; 95% CI, 0.8-1.1). Sex-related differences in OHCA characteristics and treatment are predictors of survival outcome disparities. With adjustment for these factors, sex was not associated with survival or neurological outcome after OHCA.

INTRODUCTION: Comprehensive stroke systems of care include routing to the nearest designated stroke center hospital, bypassing non-designated hospitals. Routing protocols are implemented at the state or county level and vary in qualification criteria and determination of destination hospital. We surveyed all counties in the state of California for presence and characteristics of their prehospital stroke routing protocols. METHODS: Each countys local emergency medical services agency (LEMSA) was queried for the presence of a stroke routing protocol. We reviewed these protocols for method of stroke identification and criteria for patient transport to a stroke center. RESULTS: Thirty-three LEMSAs serve 58 counties in California with populations ranging from 1,175 to nearly 10 million. Fifteen LEMSAs (45%) had stroke routing protocols, covering 23 counties (40%) and 68% of the state population. Counties with protocols had higher population density (1,500 vs. 140 persons per square mile). In the six counties without designated stroke centers, patients meeting criteria were transported out of county. Stroke identification in the field was achieved using the Cincinnati Prehospital Stroke Screen in 72%, Los Angeles Prehospital Stroke Screen in 7% and a county-specific protocol in 22%. CONCLUSION: California EMS prehospital acute stroke routing protocols cover 68% of the state population and vary in characteristics including activation by symptom onset time and destination facility features, reflecting matching of system design to local geographic resources.

Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel made specific recommendations on the different PICO (population, intervention, comparison, outcome) questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations. The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies. [ABSTRACT FROM AUTHOR]

EMS frequently encounter patients who decline transport, yet there are little data to inform the safety of patient and/or paramedic-initiated assess, treat, and refer (ATR) protocols. We determined patient decision-making and short-term outcomes after non-transport by EMS during the COVID-19 pandemic. This was a prospective, observational study of a random sample of patients evaluated and not transported by EMS from August 2020 to March 2021. From the EMS database, we randomly selected a daily sample of adult patients with disposition of ATR. We excluded patients dispositioned against medical advice (AMA) and those in police custody. Investigators contacted patients by phone to administer a standardized survey regarding decision-making, symptom progression, follow-up care, and satisfaction with non-transport decision. We also determined the proportion of patients who re-contacted 9-1-1 within 72 h, and unexpected deaths within 72 h using coroner data. Descriptive statistics were calculated. Of 4613 non-transported patients, 3330 (72%) patients for whom the disposition was ATR were included. Patients were 46% male with a median age of 49 (inter-quartile range (IQR) 31–67). Median vital signs measurements fell within the normal range. Investigators successfully contacted 584/3330 patients (18%). The most common reason for failure was lack of accurate phone number. The most common reasons patients reported for not going to the ED on initial encounter were: felt reassured after the paramedic assessment (151/584, 26%), medical complaint resolved (113/584, 19%), paramedic suggested transport was not required (73/584, 13%), concern for COVID-19 exposure (57/584, 10%), and initial concern was not medical (46/584, 8%). Ninety-five percent (552/584) were satisfied with the non-transport decision and 49% (284/584) had sought follow-up care. The majority (501/584, 86%) reported equal, improved, or resolved symptoms, while 80 patients (13%) reported worse symptoms, of whom (64/80, 80%) remained satisfied with the non-transport decision. Overall, there were 154 of 3330 (4.6%) 9-1-1 recontacts within 72 h. Based on coroner data, three unexpected deaths (0.09%) occurred within 72 h of the initial EMS calls. Paramedic disposition by ATR protocols resulted in a low rate of 9-1-1 recontact. Unexpected deaths were extremely rare. Patient satisfaction with the non-transport decision was high. [ABSTRACT FROM AUTHOR]

Introduction: Early detection of ST-segment elevation myocardial infarction (STEMI) on the prehospital electrocardiogram (ECG) improves patient outcomes. Current software algorithms optimize sensitivity but have a high false-positive rate. The authors propose an algorithm to improve the specificity of STEMI diagnosis in the prehospital setting. Methods: A dataset of prehospital ECGs with verified outcomes was used to validate an algorithm to identify true and false-positive software interpretations of STEMI. Four criteria implicated in prior research to differentiate STEMI true positives were applied: heart rate <130, QRS <100, verification of ST-segment elevation, and absence of artifact. The test characteristics were calculated and regression analysis was used to examine the association between the number of criteria included and test characteristics. Results: There were 44,611 cases available. Of these, 1,193 were identified as STEMI by the software interpretation. Applying all four criteria had the highest positive likelihood ratio of 353 (95% CI, 201-595) and specificity of 99.96% (95% CI, 99.93-99.98), but the lowest sensitivity (14%; 95% CI, 11-17) and worst negative likelihood ratio (0.86; 95% CI, 0.84-0.89). There was a strong correlation between increased positive likelihood ratio (r2 = 0.90) and specificity (r2 = 0.85) with increasing number of criteria. Conclusions: Prehospital ECGs with a high probability of true STEMI can be accurately identified using these four criteria: heart rate <130, QRS <100, verification of ST-segment elevation, and absence of artifact. Applying these criteria to prehospital ECGs with software interpretations of STEMI could decrease false-positive field activations, while also reducing the need to rely on transmission for physician over-read. This can have significant clinical and quality implications for Emergency Medical Services (EMS) systems. [ABSTRACT FROM AUTHOR]

Rearrest after successful resuscitation from out-of-hospital cardiac arrest (OHCA) is common and is associated with worse patient outcomes. However, little is known about the effect of interventions designed to prevent rearrest. We assessed the association between a prehospital care protocol for immediate management after return of spontaneous circulation (ROSC) and rates of field rearrest and survival to discharge in patients with prehospital ROSC. This was a retrospective study of adult patients with OHCA and field ROSC within a large EMS system before (April 2017–August 2018) and after (April 2019–February 2020) implementation of a structured prehospital post-ROSC care protocol. The protocol was introduced in September 2018 and provided on-scene stabilization direction including guidance on ventilation and blood pressure support. Field data and hospital outcomes were used to compare the frequency of field rearrest, hospital survival, and survival with good neurologic outcome before and after protocol implementation. Logistic regression was used to assess the association between the post-implementation period and these outcomes, and odds ratios were reported. The association between individual interventions on these outcomes was also explored. There were 2,706 patients with ROSC after OHCA in the pre-implementation period and 1,780 patients in the post-implementation period. The rate of prehospital rearrest was 43% pre-implementation vs 45% post-implementation (RD 2%, 95% CI −1, 4%). In the adjusted analysis, introduction of the protocol was not associated with decreased odds of rearrest (OR 0.87, 95% CI 0.73, 1.04), survival to hospital discharge (OR 1.01, 95% CI 0.81, 1.24), or survival with good neurologic outcome (OR 0.81, 95% CI 0.61, 1.06). Post-implementation, post-ROSC administration of saline and push-dose epinephrine increased from 11% to 25% (RD 14%, 95% CI 11, 17%) and from 3% to 12% (RD 9% 95% CI 7, 11%), respectively. In an exploratory analysis, push-dose epinephrine was associated with a decreased odds of rearrest (OR 0.68, 95% CI 0.50, 0.94). Introduction of a post-ROSC care protocol for patients with prehospital ROSC after OHCA was not associated with reduced odds of field rearrest. When elements of the care bundle were considered individually, push-dose epinephrine was associated with decreased odds of rearrest. [ABSTRACT FROM AUTHOR]

COVID-19 has had significant secondary effects on health care systems, including effects on emergency medical services (EMS) responses for time-sensitive emergencies. We evaluated the correlation between COVID-19 hospitalizations and EMS responses for time-sensitive emergencies in a large EMS system. This was a retrospective study using data from the Los Angeles County EMS Agency. We abstracted data on EMS encounters for stroke, ST-elevation myocardial infarction (STEMI), out-of-hospital cardiac arrest (OHCA), and trauma from April 5, 2020 to March 6, 2021 and for the same time period in the preceding year. We also abstracted daily hospital admissions and censuses (total and intensive care unit [ICU]) for COVID-19 patients. We designated November 29, 2020 to February 27, 2021 as the period of surge. We calculated Spearman's correlations between the weekly averages of daily hospital admissions and census and EMS responses overall and for stroke, STEMI, OHCA, and trauma. During the study period, there were 70,616 patients admitted for confirmed COVID-19, including 12,467 (17.7%) patients admitted to the ICU. EMS responded to 899,794 calls, including 9,944 (1.1%) responses for stroke, 3,325 (0.4%) for STEMI, 11,207 (1.2%) for OHCA, and 114,846 (12.8%) for trauma. There was a significant correlation between total hospital COVID-19 positive patient admissions and EMS responses for all time-sensitive emergencies, including a positive correlation with stroke (0.41), STEMI (0.37), OHCA (0.78), and overall EMS responses (0.37); and a negative correlation with EMS responses for trauma (-0.48). ICU COVID-19 positive patient admissions also correlated with increases in EMS responses for stroke (0.39), STEMI (0.39), and OHCA (0.81); and decreased for trauma (-0.53). Similar though slightly weaker correlations were found when evaluating inpatient census. During the period of surge, the correlation with overall EMS responses increased substantially (0.88) and was very strong with OHCA (0.95). We found significant correlation between COVID-19 hospitalizations and the frequency of EMS responses for time-sensitive emergencies in this regional EMS system. EMS systems should consider the potential effects of this and future pandemics on EMS responses and prepare to meet non-pandemic resource needs during periods of surge, particularly for time-sensitive conditions. [ABSTRACT FROM AUTHOR]

Subsequent to the Emergency Use Authorization (EUA) by the Food and Drug Administration, Gilead Sciences Inc. donated a supply of remdesivir to the United States government for immediate treatment of patients with COVID-19. The Los Angeles County Emergency Medical Services Agency (LAC-EMS) was tasked with the allocation. The objective of this study was to describe the process for allocation and the patients who were treated with the donated remdesivir in LAC. LAC-EMS developed a strategic plan to distribute federal allocations of remdesivir to LAC hospitals based on the proportion of patients admitted with COVID-19 at each hospital. Criteria for treatment and its duration were based on the EUA at local hospital discretion. Data were collected on patients treated from May to December 2020. Variables included characteristics (age, sex, race/ethnicity), hospital care (level of care and respiratory support at start of treatment, ventilator support, total ventilator days), and outcomes (length of intensive care (ICU) and hospital stay, survival to discharge, disposition). We compared demographics of treated patients to the overall population of hospitalized patients in LAC. LAC-EMS distributed 34,250 vials of remdesivir in 7 allocations, which treated 5,376 patients. The median age was 60 (IQR 48–70); 62% were male, 59% Hispanic, 17% White, 6% Asian, 5% Black. Prior to remdesivir, 96% of patients required respiratory support including 49% supplemental oxygen, 35% high-flow nasal cannula, 3% continuous or bilevel positive airway pressure and 9% mechanical ventilation, with one quarter of patients in the ICU. Overall, 26% of patients were mechanically ventilated during the hospitalization, median 11 days (IQR 8–23), while 41% required ICU care, median 10 days (IQR 5–19). Median length of stay for all patients was 10 days (IQR 7–18) with 4,218 patients (74%) surviving to discharge and 80% of survivors discharged home. Compared with overall hospitalized patients with COVID-19, treated patients more likely to be male and middle-aged, and less likely to be Black. LAC-EMS's strategic plan to distribute donated remdesivir to hospitals based on the number of inpatients with COVID-19 resulted in the treatment of 5,376 patients of whom 74% survived to hospital discharge. [ABSTRACT FROM AUTHOR]

Introduction: Rapid prehospital identification of patients with ST-elevation myocardial infarction (STEMI) is a critical step to reduce time to treatment. Broad screening with field 12-lead ECGs can lead to a high rate of false positive STEMI activations due to low prevalence. One strategy to reduce false positive STEMI interpretations is to limit acquisition of 12-lead ECGs to patients who have symptoms strongly suggestive of STEMI, but this may delay care in patients who present atypically and lead to disparities in populations with more atypical presentations. We sought to assess patient factors associated with atypical STEMI presentation. Methods: We retrospectively analyzed consecutive adult patients for whom Los Angeles Fire Department paramedics obtained a field 12-lead ECG from July 2011 through June 2012. The regional STEMI receiving center registry was used to identify patients with STEMI. Patients were designated as having typical symptoms if paramedics documented provider impressions of chest pain/discomfort, cardiac arrest, or cardiac symptoms, otherwise they were designated as having atypical symptoms. We utilized logistic regression to determine patient factors (age, sex, race) associated with atypical STEMI presentation. Results: Of the 586 patients who had STEMI, 70% were male, 43% White, 16% Black, 20% Hispanic, 5% Asian and 16% were other or unspecified race. Twenty percent of STEMI patients (n = 117) had atypical symptoms. Women who had STEMI were older than men (74 years [IQR 62–83] vs. 60 years [IQR 53–70], p < 0.001). Univariate predictors of atypical symptoms were older age and female sex (p < 0.0001), while in multivariable analysis older age [odd ratio (OR) 1.05 per year, [95%CI 1.04–1.07, p < 0.0001] and black race (OR vs White 2.18, [95%CI 1.20–3.97], p = 0.011) were associated with atypical presentation. Conclusion: Limiting prehospital acquisition of 12-lead ECGs to patients with typical STEMI symptoms would result in one in five patients with STEMI having delayed recognition, disproportionally impacting patients of older age, women, and Black patients. Age, not sex, may be a better predictor of atypical STEMI presentation. [ABSTRACT FROM AUTHOR]

Objective: Within Emergency Medical Systems (EMS) regional systems, there may be significant differences in the approach to patient care despite efforts to promote standardization. Identifying hospital-level factors that contribute to variations in care can provide opportunities to improve patient outcomes. The purpose of this analysis was to evaluate variation in post-cardiac arrest care within a large EMS system and explore the contribution of hospital-level factors. Methods: This was a retrospective analysis from a regional cardiac system serving over 10 million persons. Patients with out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) are transported to 36 cardiac arrest centers with 24/7 emergent coronary angiography (CAG) capabilities and targeted temperature management (TTM) policies based on regional guidelines. We included adult patients ≥18 years with non-traumatic OHCA from 2016-2018. Patients with a Do-Not-Resuscitate order and those who died in the emergency department (ED) were excluded. For the TTM analysis, we also excluded patients who were alert in the ED. The primary outcome was receiving CAG or TTM after cardiac arrest. The secondary outcome was neurologic recovery (dichotomized to define a "good" outcome as cerebral performance category (CPC) 1 or 2). We used generalized estimating equations including patient-level factors (age, sex, witnessed arrest, initial rhythm) and hospital-level factors (academic status, hospital size based on licensed beds, annual OHCA patient volume) to estimate the odds ratios associated with these variables. Results: There were 7831 patients with OHCA during the study period; 4694 were analyzed for CAG and 3903 for TTM. The median and range for treatment with CAG and TTM after OHCA was 23% (12-49%) and 58% (17-92%) respectively. Hospital size was associated with increased likelihood of CAG, adjusted odds ratio 1.71, 95% CI 1.05-2.86, p = 0.03. Academic status approached significance in its association with TTM, adjusted odds ratio 1.69, 95% CI 0.98-2.91, p = 0.06. Overall, 28% of patients survived with good neurologic outcome, ranging from 17 to 43% across hospitals. Conclusion: Within this regional cardiac system, there was significant variation in use of CAG and TTM after OHCA, which was not fully explained by patient-level factors. Hospital size was associated with increased CAG. [ABSTRACT FROM AUTHOR]