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Introduction: Emergency department unscheduled return visits within 72-h of discharge, called a "bounceback", have been used as a metric of quality of care. We hypothesize that specific demographics and dispositions may be associated with Emergency Medical Services (EMS) 72-h bouncebacks., Methods: For all patient encounters within one calendar year from a large, urban EMS agency, we recorded demographics (name, date of birth, race, gender), primary impression, disposition, and vital signs for EMS encounters. A bounceback was defined as a patient, identified by matching first name, last name and date of birth, with more than one EMS encounter within 72 h. We performed descriptive statistics for patients that did and did not have a subsequent bounceback using median (interquartile range) and Wilcoxon Rank Sum test for age and frequency (percent) and chi square test for gender, race and run disposition. For patients with a bounceback, we describe the frequency and percentage of EMS professional primary impressions on initial encounter., Results: 98,043 encounters from January 1, 2021 to December 31, 2021, were analyzed. The median age was 50 years (IQR 32-65); 49.4% (46,147) were female and 50.7% (47,376) were White patients. 3951 encounters had a subsequent bounceback, and compared to those without bouncebacks, they were more often male patients (58.7% versus 50.2%, p < 0.001) and more commonly not transported (22.3% versus 15.5%, p < 0.001). A multivariable logistic regression model estimated the odds of bounceback were lower for females [OR 0.64 (95% CI 0.61-0.68)], Asian and Latino patients compared to White patients [OR 0.33 (95% CI 0.21-0.53) and 0.42 (95% CI 0.34-0.51)], respectively, no significant difference for Black patients compared to White patients, and higher for non-transported patients [OR 1.25 (95% CI 1.16-1.34)]. The The most common EMS primary impression for initial and subsequent encounters was mental health [576 (14.7%) and 944 (17.0%), respectively]. For subsequent encounters, the primary impression was cardiac arrest or death in 67 (1.2%) of cases., Conclusion: Bouncebacks were common in this single year study of a high-volume urban EMS agency. Male and non-transported patients most often experienced bouncebacks. The most common primary impression for encounters with bounceback was mental health related. Out-of-hospital cardiac arrest occurred in 1 % of bounceback cases. Further study is necessary to understand the effect on patient-centered outcomes., (Copyright © 2022. Published by Elsevier Inc.)

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., Competing Interests: Declaration of Competing Interest None of the authors report any conflicts of interest., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Aim: We validated the NUE rule, using three criteria (Non-shockable initial rhythm, Unwitnessed arrest, Eighty years or older) to predict futile resuscitation of patients with out-of-hospital cardiac arrest (OHCA)., Methods: We performed a retrospective cohort analysis of all recorded OHCA in Marion County, Indiana, from January 1, 2014 to December 31, 2019. We described patient, arrest, and emergency medical services (EMS) response characteristics, and assessed the performance of the NUE rule in identifying patients unlikely to survive to hospital discharge., Results: From 2014 to 2019, EMS responded to 4370 patients who sustained OHCA. We excluded 329 (7.5%) patients with incomplete data. Median patient age was 62 years (IQR 49 - 73), 1599 (39.6%) patients were female, and 1728 (42.8%) arrests were witnessed. The NUE rule identified 290 (7.2%) arrests, of whom none survived to hospital discharge., Conclusion: In external validation, the NUE rule ( N on-shockable initial rhythm, U nwitnessed arrest, E ighty years or older) correctly identified 7.2% of OHCA patients unlikely to survive to hospital discharge. The NUE rule could be used in EMS protocols and policies to identify OHCA patients very unlikely to benefit from aggressive resuscitation.

Aim: Resuscitation of cardiac arrest involves invasive and traumatic interventions and places a large burden on limited EMS resources. Our aim was to identify prehospital cardiac arrests for which resuscitation is extremely unlikely to result in survival to hospital discharge., Methods: We performed a retrospective cohort analysis of all cardiac arrests in San Mateo County, California, for which paramedics were dispatched, from January 1, 2015 to December 31, 2018, using the Cardiac Arrest Registry to Enhance Survival (CARES) database. We described characteristics of patients, arrests, and EMS responses, and used recursive partitioning to develop decision rules to identify arrests unlikely to survive to hospital discharge, or to survive with good neurologic function., Results: From 2015-2018, 1750 patients received EMS dispatch for cardiac arrest in San Mateo County. We excluded 44 patients for whom resuscitation was terminated due to DNR directives. Median age was 69 years (IQR 57-81), 563 (33.0%) patients were female, 816 (47.8%) had witnessed arrests, 651 (38.2%) received bystander CPR, 421 (24.7%) had an initial shockable rhythm, and 1178 (69.1%) arrested at home. A simple rule (non-shockable initial rhythm, unwitnessed arrest, and age 80 or greater) excludes 223 (13.1%) arrests, of whom none survived to hospital discharge., Conclusion: A simple decision rule (non-shockable rhythm, unwitnessed arrest, age ≥ 80) identifies arrests for which resuscitation is futile. If validated, this rule could be applied by EMS policymakers to identify cardiac arrests for which the trauma and expense of resuscitation are extremely unlikely to result in survival., (Copyright © 2019 Elsevier B.V. All rights reserved.)