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Background: In the 2022-2023 global outbreak, the United States and state of Texas recorded a total of 31,277 and 3,085 confirmed monkeypox (Mpox) cases respectively as of November 2023. This study aims to investigate the demographic characteristics and risk factors of Mpox outbreak in Houston and document the epidemiologic control measures implemented with their outcomes. Methods: Houston Health Department received reports of suspected Mpox cases via electronic case reports and laboratory reports from healthcare providers within Houston. These were then investigated and reclassified as either positive or negative using DNA polymerase chain reaction tests. All the reported cases received between May 2022 and January 2023 were included in this study using convenient sampling methods. Descriptive statistics using frequency distribution was used to analyze the sociodemographic, clinical features and travel history of the cases. A two-sided Chi-squared test was used to determine association between Mpox test results and risk factors with significant level set at P < 0.05. Other infection control measures such as community engagement, health education, tracking and contact tracing, vaccination, referrals and laboratory sample logistics support were implemented by the health department. Results: Out of the total of 1,625 suspected persons investigated for Mpox, 724 (44.6%) tested positive. Among the 724 confirmed cases, male was 700 (96.7%), females 20 (2.8%), transgender male 1 (0.1%), transgender female 3 (0.4%). Age groups 30-39 years constituted 43.6%, 18-29 years 27.4%, 40-49 years 18.2%, 50-59 years was 8%. Race distribution of positive cases was Whites 43.4%, African American 38.7%, Asian 1.4%. Risk factors with P < 0.05 included male gender, age groups 30-39 years and 40-49 years, travel history to Mpox endemic areas, recent sexual contact with known or suspected Mpox cases, human immunodeficiency virus seropositivity. Identifying as gay and bisexual were also statistically significant risk factors for Mpox infection. Conclusion: The timely implementation of primary and secondary prevention measures targeted at the most at-risk populations was very effective at curtailing the spread of Mpox infection within the city of Houston. [ABSTRACT FROM AUTHOR]

Since the start of the COVID-19 pandemic, wastewater surveillance has emerged as a powerful tool used by public health authorities to track SARS-CoV-2 infections in communities. In May 2020, the Houston Health Department began working with a coalition of municipal and academic partners to develop a wastewater monitoring and reporting system for the city of Houston, Texas. Data collected from the system are integrated with other COVID-19 surveillance data and communicated through different channels to local authorities and the general public. This information is used to shape policies and inform actions to mitigate and prevent the spread of COVID-19 at municipal, institutional, and individual levels. Based on the success of this monitoring and reporting system to drive public health protection efforts, the wastewater surveillance program is likely to become a standard part of the public health toolkit for responding to infectious diseases and, potentially, other disease-causing outbreaks. [ABSTRACT FROM AUTHOR]

First responder (FR) cardiopulmonary resuscitation (CPR) is an important component of out-of-hospital cardiac arrest (OHCA) care. However, little is known about FR CPR disparities. We linked the 2014–2021 Texas Cardiac Arrest Registry to Enhance Survival (TX-CARES) database to census tract data. We included non-traumatic OHCAs that were not witnessed by 9-1-1 responders and did not receive bystander CPR. We defined census tracts as having >50% of a race/ethnicity: White, Black, or Hispanic/Latino. We also stratified patients into quartiles based on socioeconomic status (SES): household income, high school graduation, and unemployment. We also combined race/ethnicity and income to create a total of five mixed strata, comparing lower income and minority census tracts to high income White census tracts. We created mixed model logistic regression models, adjusting for confounders and modeling census tract as a random intercept. Using the models, we compared FR CPR rates for census race/ethnicity (Black and Hispanic/Latino compared to White), and SES quartiles (2nd, 3rd, and 4th quartiles compared to 1st quartiles). Secondarily, we evaluated the association between FR CPR and survival for all strata. We included 21,966 OHCAs, and 57.4% had FR CPR. Evaluating the association between census tract characteristic and FR CPR, majority Black (aOR 0.30, 95% CI 0.22–0.41) had a lower bystander CPR rate when compared to majority White. The lowest income quartile had a lower rate of bystander CPR (aOR 0.80, 95% CI 0.65–0.98). The worst unemployment quartile was also associated with a lower rate of FR CPR (aOR 0.75, 95% CI 0.61–0.92). Combining race/ethnicity and income, middle income majority Black (30.0%; aOR 0.27, 95% CI 0.17–0.46) and low income >80% Black (31.8%; aOR 0.27, 95% CI 0.10–0.68) had lower rates of FR CPR in comparison to high income majority White. There were no associations between Hispanic or lower high school graduation and lower rates of FR CPR. We found no association between FR CPR and survival for all three strata. While we identified disparities in FR CPR in low SES and majority Black census tracts, we identified no association between FR CPR and survival in Texas. [ABSTRACT FROM AUTHOR]

Background Mumps is a highly contagious disease spread by airborne droplets, making control especially difficult in congregate, crowded settings such as shelters and jails. A mumps outbreak in Honduras, starting in 2018 among adults who were unvaccinated, spread northward with Central Americans migrating to the United States. We describe 2 mumps outbreaks in Houston during 2019 among migrants at the Houston Contract Detention Facility (HCDF) and among inmates at the Harris County Jail (HCJ). Methods We investigated cases of acute onset parotitis. Three or more mumps cases in a facility was considered an outbreak. Confirmed cases had positive polymerase chain reactions (PCR). Probable cases were linked epidemiologically to a confirmed case in the same unit and a positive serology for serum anti-mumps immunoglobulin M (IgM) antibody. Outbreak control measures included enhanced surveillance, isolation of housing units, educational outreach, and immunization with Measles, Mumps, Rubella (MMR) vaccine. Results At HCDF, during a 10-month period, we investigated 42 possible cases. Of the possible cases, 28 were lab-confirmed with 9 probable, 4 ruled out, and 1 vaccine reaction. All were migrants. At HCJ, during a 3-month period, we investigated 60 suspect cases; 20 cases were lab-confirmed, 13 probable and 27 ruled out. All but 2 were inmates. Only about a third of those offered MMR vaccination accepted. Conclusions Successful outbreak resolution required close cooperation with HCDF and HCJ with ongoing surveillance, isolation of units with cases and MMR vaccination. Such facilities will have outbreaks; regular communications with local public health could improve response. [ABSTRACT FROM AUTHOR]

Background: Large and unacceptable variation exists in cardiac resuscitation care and outcomes across communities. Texas is the second most populous state in the US with wide variation in community and emergency response infrastructure. We utilized the Texas-CARES registry to perform the first Texas state analysis of out-of-hospital cardiac arrest (OHCA) in Texas, evaluating for variations in incidence, care, and outcomes. Methods: We analyzed the Texas-CARES registry, including all adult, non-traumatic OHCAs from 1/1/2014 through 12/31/2018. We analyzed the incidence and characteristics of OHCA care and outcome, overall and stratified by community. Utilizing mixed models accounting for clustering by community, we characterized variations in bystander CPR, bystander AED in public locations, and survival to hospital discharge across communities, adjusting for age, gender, race, location of arrest, and rate of witnessed arrest (bystander and 911 responder witnessed). Results: There were a total of 26,847 (5,369 per year) OHCAs from 13 communities; median 2,762 per community (IQR 444-2,767, min 136, max 9161). Texas care and outcome characteristics were: bystander CPR (43.3%), bystander AED use (9.1%), survival to discharge (9.1%), and survival with good neurological outcomes (4.0%). Bystander CPR rate ranged from 19.2% to 55.0%, and there were five communities above and five below the adjusted 95% confidence interval. Bystander AED use ranged from 0% to 19.5%, and there was one community below the adjusted 95% confidence interval. Survival to hospital discharge ranged from 6.7% to 14.0%, and there were three communities above and two below the adjusted 95% confidence interval. Conclusion: While overall OHCA care and outcomes were similar in Texas compared to national averages, bystander CPR, bystander AED use, and survival varied widely across communities in Texas. These variations signal opportunities to improve OHCA care and outcomes in Texas. [ABSTRACT FROM AUTHOR]

Fatalities from drug-induced overdoses in the United States have taken greater than 292,000 lives in the last five years, and nearly two-thirds of these are opioid-related. The burden on prehospital emergency medical services (EMS) to respond to these incidents is growing. The standard of care typically involves overdose reversal and rapid transport, although a few agencies have begun to use community paramedicine to more proactively follow-up, initiate treatment, and refer patients to addiction medicine providers. Methods: In this manuscript we share the details of an outreach case study to serve as a blueprint for other agencies and municipalities to adopt and refine. The University of Texas Health Science Center, in partnership with the Houston Fire Department and other local first responder agencies, developed a program in Houston, Texas based on rapid response to post-overdose survivors using available incident data from the primary municipal agencies. Results: The Houston Emergency Opioid Engagement System (HEROES) was created to more comprehensively address the opioid epidemic. By utilizing data extracted from the patient care record system, a team comprised of a peer recovery coach and a paramedic is dispatched to the home location of a recent overdose (OD) incident to provide outreach. Conclusions: Outreach dialog and motivational interviewing techniques are used to provide awareness of treatment options and to engage individuals into a treatment program. A case report of this program and recommendations for broader adoption are presented. [ABSTRACT FROM AUTHOR]

Purpose: Although trauma is the leading cause of death for the pediatric population, few studies have addressed the preventable/potentially preventable death rate (PPPDR) attributable to trauma.Methods: This is a retrospective study of trauma-related death records occurring in Harris County, Texas in 2014. Descriptive and Chi-squared tests were conducted for two groups, pediatric and adult trauma deaths in relation to demographic characteristics, mechanism of injury, death location and survival time.Results: There were 105 pediatric (age < 18 years) and 1738 adult patients. The PPPDR for the pediatric group was 21.0%, whereas the PPPDR for the adult group was 37.2% (p = 0.001). Analysis showed fewer preventable/potentially preventable (P/PP) deaths resulting from any blunt trauma mechanism in the pediatric population than in the adult population (19.6% vs. 48.4%, p < 0.001). Amongst the pediatric population, P/PP traumatic brain injury (TBI) were more common in the youngest age range (age 0-5) vs. the older (6-12 years) pediatric and adolescent (13-17 years) patients.Conclusion: Our results identify areas of opportunities for improving pediatric trauma care. Although the overall P/PP death rate is lower in the pediatric population than the adult, opportunities for improving initial acute care, particularly TBI, exist. [ABSTRACT FROM AUTHOR]

Introduction: Telehealth has been used nominally for trauma, neurological, and cardiovascular incidents in prehospital emergency medical services (EMS). Yet, much less is known about the use of telehealth for low-acuity primary care. We examine the development of one telehealth program and its impact on unnecessary ambulance transports. Objective: The objective of this study is to describe the development and impact of a large-scale telehealth program on ambulance transports. Methods: We describe the patient characteristics and results from a cohort of patients in Houston, Texas who received a prehospital telehealth consultation from an emergency medicine physician. Inclusion criteria were adults and pediatric patients with complaints considered to be non-urgent, primary care related. Data were analyzed for 36 months, from January 2015 through December 2017. Our primary dependent variable was the percentage of patients transported by ambulance. We used descriptive statistics to describe patient demographics, chi-square to examine differences between groups, and logistic regression to explore the effects with multivariate controls including age, gender, race, and chief complaint. Results: A total of 15,067 patients were enrolled (53% female; average age 44 years ± 19 years) over the three-year period. The 3 primary chief complaints were based on abdominal pains (13% of cases), nausea/vomiting/diarrhea (NVD) (9.4%), and back pain (9.3%). Ambulance transports represented 11.2% of all transports in the program, while alternative taxi transportation was used in 75.6%, and the remainder were self- or no-transports. Taxi transportation to an alternate, affiliated clinic (versus ED) was utilized in 5% of incidents. After multivariate controls, older age patients presenting with low-risk, non-acute chest pain, shortness of breath, and dizziness were much more likely to use ambulance transport. Race and gender were not significant predictors of ambulance transport. Conclusions: We found telehealth offers a technology strategy to address potentially unnecessary ambulance transports. Based on prior cost-effectiveness analyses, the reduction of unnecessary ambulance transports translates to an overall reduction in EMS agency costs. Telehealth programs offer a viable solution to support alternate destination and alternate transport programs. [ABSTRACT FROM AUTHOR]

Objective There has been very little use of telehealth in pre-hospital emergency medical services (EMS), yet the potential exists for this technology to transform the current delivery model. In this study, we explore the costs and benefits of one large telehealth EMS initiative. Methods Using a case-control study design and both micro- and gross-costing data from the Houston Fire Department EMS electronic patient care record system, we conducted a cost-benefit analysis (CBA) comparing costs with potential savings associated with patients treated through a telehealth-enabled intervention. The intervention consisted of telehealth-based consultation between the 911 patient and an EMS physician, to evaluate and triage the necessity for patient transport to a hospital emergency department (ED). Patients with non-urgent, primary care-related conditions were then scheduled and transported by alternative means to an affiliated primary care clinic. We measured CBA as both total cost savings and cost per ED visit averted, in US Dollars ($USD). Results In total, 5570 patients were treated over the first full 12 months with a telehealth-enabled care model. We found a 6.7% absolute reduction in potentially medically unnecessary ED visits, and a 44-minute reduction in total ambulance back-in-service times. The average cost for a telehealth patient was $167, which was a statistically significantly $103 less than the control group ( p < .0001). The programme produced a $928,000 annual cost savings from the societal perspective, or $2468 cost savings per ED visit averted (benefit). Conclusion Patient care enabled by telehealth in a pre-hospital environment, is a more cost effective alternative compared to the traditional EMS 'treat and transport to ED' model. [ABSTRACT FROM AUTHOR]

ABSTRACT BACKGROUND Rates of uncontrolled asthma vary by demographics, space, and time. This article uses data on ambulance-treated asthma attacks in children to analyze these variations so that school districts can improve their asthma management interventions. METHODS Incidence rates of 1826 ambulance-treated asthma attacks for children aged 5-18 years were calculated for school zones for elementary, middle, and high schools in the Houston (Texas) Independent School District (HISD). Zones with rates in the upper quartile were identified as the highest rate zones and were compared with other school zones in the district by demographics, location, and timing of attacks. RESULTS The ambulance-treated asthma rate was respectively 5, 3, and 2 times greater in the highest rate school zones compared with all other school zones for those school levels. Ambulance-treated asthma attacks in the high-rate school zones occurred most at midday and in the evening and high-rate zones were often geographically contiguous. Schools in the high-rate zones had a higher percent of socioeconomically disadvantaged students and were more often without a school nurse. CONCLUSION Spatial and temporal analysis of ambulance data can be valuable tools for schools to focus policy and program interventions for the students in need of improved asthma management. [ABSTRACT FROM AUTHOR]

Introduction: This study presents a framework for identifying "high-risk" days for asthma attacks associated with elevated concentrations of criteria pollutants using local information to warn citizens on days when the concentrations differ from Environmental Protection Agency Air Quality Index (AQI) warnings. Studies that consider the unique mixture of pollutants and the health data specific to a city provide additional information for asthma self-management. This framework is applied to air pollution and asthma data to identify supplemental warning days in Houston, Texas.Methods: A four-step framework was established to identify days with pollutant levels that pose meaningful increased risk for asthma attacks compared with baseline. Historical associations between 18,542 ambulance-treated asthma attacks and air pollutant concentrations in Houston, Texas (2004-2016; analyzed in 2018), were analyzed using a case-crossover study design with conditional logistic regression. Days with historically high associations between pollution and asthma attacks were identified as supplemental warning days.Results: Days with 8-hour maximum ozone >66.6 parts per billion for the 3 previous days and same-day 24-hour nitrogen dioxide >19.3 parts per billion pose an RR of 15% above baseline; concentrations above these levels pose an increased risk of 15% (RR=1.15, 95% CI=1.14, 1.16) and 30% (RR=1.30, 95% CI=1.29, 1.32), respectively. These warnings add an additional 12% days per year over the AQI warnings.Conclusions: Houston uses this framework to identify supplemental air quality warnings to improve asthma self-management. Supplemental days reflect risk lower than the National Ambient Air Quality Standards and consecutive poor air quality days, differing from the AQI. [ABSTRACT FROM AUTHOR]

Building on the success of initiatives put forth during the COVID-19 pandemic response, US health officials are expanding wastewater surveillance programs to track other target pathogens and diseases of public health interest. The Houston Health Department in Houston, Texas, USA, conducted a hypothesis-generating study whereby infectious disease subject matter experts suggested potential targets. This study addressed 2 criteria recommended by the National Academies of Sciences, Engineering, and Medicine for selecting wastewater targets. Results can be used as a basis of a questionnaire for a future population-based study to recommend targets of highest priority to include for expanded wastewater sampling.

Background: In contrast to studies that relied on volunteers or convenience sampling, there are few population-based severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroprevalence investigations and most were conducted early in the pandemic. The health department of the fourth largest US city recognized that sound estimates of viral impact were needed to inform decision making., Methods: Adapting standardized disaster research methodology, in September 2020 the city was divided into high and low strata based on reverse-transcriptase polymerase chain reaction (RT-PCR) positivity rates; census block groups within each stratum were randomly selected with probability proportional to size, followed by random selection of households within each group. Using 2 immunoassays, the proportion of infected individuals was estimated for the city, by positivity rate and sociodemographic and other characteristics. The degree of underascertainment of seroprevalence was estimated based on RT-PCR-positive cases., Results: Seroprevalence was estimated to be 14% with near 2-fold difference in areas with high (18%) versus low (10%) RT-PCR positivity rates and was 4 times higher compared to case-based surveillance data., Conclusions: Seroprevalence was higher than previously reported and greater than estimated from RT-PCR data. Results will be used to inform public health decisions about testing, outreach, and vaccine rollout., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America.)

Background: Opioid-related overdose deaths are the top accidental cause of death in the United States, and development of regional strategies to address this epidemic should begin with a better understanding of where and when overdoses are occurring., Methods and Findings: In this study, we relied on emergency medical services data to investigate the geographical and temporal patterns in opioid-suspected overdose incidents in one of the largest and most ethnically diverse metropolitan areas (Houston Texas). Using a cross sectional design and Bayesian spatiotemporal models, we identified zip code areas with excessive opioid-suspected incidents, and assessed how the incidence risks were associated with zip code level socioeconomic characteristics. Our analysis suggested that opioid-suspected overdose incidents were particularly high in multiple zip codes, primarily south and central within the city. Zip codes with high percentage of renters had higher overdose relative risk (RR = 1.03; 95% CI: [1.01, 1.04]), while crowded housing and larger proportion of white citizens had lower relative risks (RR = 0.9; 95% CI: [0.84, 0.96], RR = 0.97, 95% CI: [0.95, 0.99], respectively)., Conclusions: Our analysis illustrated the utility of Bayesian spatiotemporal models in assisting the development of targeted community strategies for local prevention and harm reduction efforts., Competing Interests: The authors have declared that no competing interests exist.

Background: Hemorrhage is the most common cause of potentially preventable trauma deaths, but no studies have focused on all civilian traumatic deaths from hemorrhage, so we describe a year of these deaths from a large county to identify opportunities for preventing hemorrhagic deaths., Methods: All trauma-related deaths in Harris County, Texas, in 2014 underwent examination by the medical examiner; patients were excluded if hemorrhage was not their primary reason for death. Deaths were then categorized as preventable/potentially preventable hemorrhage (PPH) or nonpreventable hemorrhage. These categories were compared across mechanism of injury, death location, and anatomic locations of hemorrhage to determine significant differences., Results: A total of 1,848 deaths were reviewed, and 305 were from uncontrolled hemorrhage. One hundred thirty-seven (44.9%) of these deaths were PPH. Of these PPH, 49 (35.8%) occurred prehospital and an additional 28 (20.4%) died within 1 hour of arriving at an acute care setting. Of the 83 PPH who arrived at a hospital, 21 (25.3%) died at a center not designated as level 1. Isolated truncal bleeding was the source of hemorrhage in 102 (74.5%) of the PPH. Of those who died with truncal PPH, the distribution was 22 chest (21.6%), 39 chest and abdomen (38.2%), 16 abdomen (15.7%), and 25 all other combinations (24.5%). When patients who died within 1 hour of arrival to a hospital were combined with the 168 deaths that occurred prehospital, 223 (74.3%) of 300 deaths occurred before spending 1 hour in a hospital and 77 (34.5%) of 223 of these deaths were PPH., Conclusion: In a well-developed, urban trauma system, 34.5% of patients died from PPH in the prehospital setting or within an hour of hospitalization. Earlier, more effective prehospital resuscitation and truncal hemorrhage control strategies are needed to decrease deaths from PPH., Level of Evidence: Therapeutic/Care management, level IV.

Introduction: Mobile Stroke Units (MSUs) deliver acute stroke treatment on-scene in coordination with Emergency Medical Services (EMS). One criticism of the MSU approach is the limited range of a single MSU. The Houston MSU is evaluating MSU implementation, and we developed a rendezvous approach as an innovative solution to expand the range and number of patients treated., Methods: In addition to direct 911 dispatch of our MSU to the scene within our 7-mile catchment area, we empowered more distant EMS units to activate the MSU. We also monitored EMS radio communications to identify possible patients. For these distant patients, the MSU met the EMS unit en route to the stroke center and treated the patient at that intermediate location. The distribution of the distance from MSU base station to site of stroke and time from 911 alert to tissue plasminogen activator (tPA) bolus were compared between patients treated on-scene and by rendezvous using Wilcoxon rank sum test., Results: Over 4 years, 338 acute ischemic stroke patients were treated with tPA on our MSU. Of these, 169 (50%) were treated on-scene after MSU dispatch at a median of 6.4 miles (IQR 6.4 miles) from MSU base station. 169 (50%) were treated by 'rendezvous' pathway with assessment and treatment of stroke a median of 12.4 miles from base (IQR 5.5 miles) (p< 0.0001). Time (min) from MSU alert to tPA bolus did not differ: 36.0 ± 10.0 for on-scene vs 37.0 ± 10.0 with rendezvous (p=0.65). 13% of patients alerted via direct 911 dispatch were treated vs 44% of rendezvous patients., Conclusion: Adding a rendezvous approach to an MSU dispatch pathway doubles the range of operations and the number of patients treated by an MSU in an urban area, without incurring delay., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr Grotta and Ms Parker receiving consulting fees from Frazer Ltd, a manufacturer or Mobile Stroke Units. Dr Grotta receives research support from the Patient Centered Outcomes Research Institute, Genentech, and CSL Behring, (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To establish a trauma preventable/potentially preventable death rate (PPPDR) within a heavily populated county in Texas., Summary: The National Academies of Sciences estimated the trauma preventable death rate in the United States to be 20%, issued a call for zero preventable deaths, while acknowledging that an accurate preventable death rate was lacking. In this absence, effective strategies to improve quality of care across trauma systems will remain difficult., Methods: A retrospective review of death-related records that occurred during 2014 in Harris County, TX, a diverse population of 4.4 million. Patient demographics, mechanism of injury, cause, timing, and location of deaths were assessed. Deaths were categorized using uniform criteria and recorded as preventable, potentially preventable or nonpreventable., Results: Of 1848 deaths, 85% had an autopsy and 99.7% were assigned a level of preventability, resulting in a trauma PPPDR of 36.2%. Sex, age, and race/ethnicity varied across preventability categories (P < 0.01). Of 847 prehospital deaths, 758 (89.5%) were nonpreventable. Among 89 prehospital preventable/potentially preventable (P/PP) deaths, hemorrhage accounted for 55.1%. Of the 657 initial acute care setting deaths, 292 (44.4%) were P/PP; of these, hemorrhage, sepsis, and traumatic brain injury accounted for 73.3%. Of 339 deaths occurring after initial hospitalization, 287 (84.7%) were P/PP, of these 117 resulted from sepsis and 31 from pulmonary thromboembolism, accounted for 51.6%., Conclusions: The trauma PPPDR was almost double that estimated by the National Academies of Sciences. Data regarding P/PP deaths offers opportunity to target research, prevention, intervention, and treatment corresponding to all phases of the trauma system.

Context: Houston policy is to dual dispatch medically trained firefighters, in addition to emergency medical services (EMS) units to out-of-hospital cardiac arrest (OHCA) cases. While believed to improve public health outcomes, no research exists supporting the policy that when firefighters respond before a better-equipped EMS unit, they increase the probability of survival., Objective: To inform EMS policy decisions regarding the effectiveness of dual dispatch by determining the impact of medically trained firefighter dispatch on return of spontaneous circulation (ROSC), a measure of survivability, in OHCA 911 calls while controlling for the subsequent arrival of an EMS unit., Design: This retrospective study uses logistic regression to determine the association between ROSC and response time for fire apparatus first responders controlling for arrival of the EMS unit., Setting: Out-of-hospital cardiac arrest cases in Houston between May 2008 and April 2013 when dual dispatch was used., Participants: A total of 6961 OHCA cases with the complete data needed for the analysis., Main Outcome Measures: Logistic regression of the dependence of OHCA survival using the indicator ROSC, as related to the fire first responder response times controlling for subsequent arrival of the EMS., Results: Fire apparatus arrived first in 46.7% of cases, a median value of 1.5 minutes before an EMS unit. Controlling for subsequent arrival time of EMS has no effect on ROSC achieved by the fire first responder. If the firefighters had not responded, the resulting 1.5-minute increase in response time equates to a decrease in probability of attaining ROSC of 20.1% for cases regardless of presenting heart rhythm and a 47.7% decrease for ventricular fibrillation cases in which bystander cardiopulmonary resuscitation was initiated., Conclusions: The firefighter first responder not only improved response time but also greatly increased survivability independent of the arrival time of the better-equipped EMS unit, validating the public health benefit of the dual dispatch policy in Houston.

Background: Despite evidence to suggest significant spatial variation in out-of-hospital cardiac arrest (OHCA) and bystander cardiopulmonary resuscitation (BCPR) rates, geographic information systems (GIS) and spatial analysis have not been widely used to understand the reasons behind this variation. This study employs spatial statistics to identify the location and extent of clusters of bystander CPR in Houston and Travis County, TX., Methods: Data were extracted from the Cardiac Arrest Registry to Enhance Survival for two U.S. sites - Austin-Travis County EMS and the Houston Fire Department - between October 1, 2006 and December 31, 2009. Hierarchical logistic regression models were used to assess the relationship between income and racial/ethnic composition of a neighborhood and BCPR for OHCA and to adjust expected counts of BCPR for spatial cluster analysis. The spatial scan statistic was used to find the geographic extent of clusters of high and low BCPR., Results: Results indicate spatial clusters of lower than expected BCPR rates in Houston. Compared to BCPR rates in the rest of the community, there was a circular area of 4.2km radius where BCPR rates were lower than expected (RR=0.62; p<0.0001 and RR=0.55; p=0.037) which persist when adjusted for individual-level patient characteristics (RR=0.34; p=0.027) and neighborhood-level race (RR=0.34; p=0.034) and household income (RR=0.34; p=0.046). We also find a spatial cluster of higher than expected BCPR in Austin. Compared to the rest of the community, there was a 23.8km radius area where BCPR rates were higher than expected (RR=1.75; p=0.07) which disappears after controlling for individual-level characteristics., Conclusions: A geographically targeted CPR training strategy which is tailored to individual and neighborhood population characteristics may be effective in reducing existing disparities in the provision of bystander CPR for out-of-hospital cardiac arrest., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background: Evidence of an association between the exposure to air pollution and overall cardiovascular morbidity and mortality is increasingly found in the literature. However, results from studies of the association between acute air pollution exposure and risk of out-of-hospital cardiac arrest (OHCA) are inconsistent for fine particulate matter, and, although pathophysiological evidence indicates a plausible link between OHCA and ozone, none has been reported. Approximately 300 000 persons in the United States experience an OHCA each year, of which >90% die. Understanding the association provides important information to protect public health., Methods and Results: The association between OHCA and air pollution concentrations hours and days before onset was assessed by using a time-stratified case-crossover design using 11 677 emergency medical service-logged OHCA events between 2004 and 2011 in Houston, Texas. Air pollution concentrations were obtained from an extensive area monitor network. An average increase of 6 µg/m(3) in fine particulate matter 2 days before onset was associated with an increased risk of OHCA (1.046; 95% confidence interval, 1.012-1.082). A 20-ppb ozone increase for the 8-hour average daily maximum was associated with an increased risk of OHCA on the day of the event (1.039; 95% confidence interval, 1.005-1.073). Each 20-ppb increase in ozone in the previous 1 to 3 hours was associated with an increased risk of OHCA (1.044; 95% confidence interval, 1.004-1.085). Relative risk estimates were higher for men, blacks, or those aged >65 years., Conclusions: The findings confirm the link between OHCA and fine particulate matter and introduce evidence of a similar link with ozone.

Introduction: Little is known about the capacity and activity of emergency medical services (EMS) during large-scale disasters. This article provides a case study of the role of EMS in one large urban city during a major hurricane., Methods: The authors analyzed changes in call volume data from the City of Houston Fire Department's EMS during Hurricane Ike. Descriptive and statistical analyses are used to explain surges and statistical differences in volumes., Results: Demand for EMS care can increase approximately 40 percent during surges in the disaster cycle, placing extreme burdens on system capacity and workload. The largest increase in demand came from respiratory problems, falls, and chest pains, with the largest decrease in calls from motor vehicle accidents., Conclusions: A strategy for managing surges in prehospital care from major disasters is a requirement for modern EMS.

After Hurricane Katrina hit the Gulf Coast on August 29, 2005, thousands of ill and injured evacuees were transported to Houston, TX. Houston's regional disaster plan was quickly implemented, leading to the activation of the Regional Hospital Preparedness Council's Catastrophic Medical Operations Center and the rapid construction of a 65-examination-room medical facility within the Reliant Center. A plan for triage of arriving evacuees was quickly developed and the Astrodome/Reliant Center Complex mega-shelter was created. Herein, we discuss major elements of the regional disaster response, including regional coordination, triage and emergency medical service transfers into the region's medical centers, medical care in population shelters, and community health challenges.

After Hurricane Katrina hit the Gulf Coast on August 29, 2005, thousands of ill and injured evacuees were transported to Houston, TX. Houston's regional disaster plan was quickly implemented, leading to the activation of the Regional Hospital Preparedness Council's Catastrophic Medical Operations Center and the rapid construction of a 65-examination-room medical facility within the Reliant Center. A plan for triage of arriving evacuees was quickly developed and the Astrodome/Reliant Center Complex mega-shelter was created. Herein, we discuss major elements of the regional disaster response, including regional coordination, triage and emergency medical service transfers into the region's medical centers, medical care in population shelters, and community health challenges.

Background and Purpose: Establishment of stroke centers, combined with accurate paramedic diagnosis and rapid transport, is essential to deliver acute stroke therapy. We wanted to measure and improve paramedic and hospital performance through implementation of the Brain Attack Coalition and American Stroke Association guidelines., Methods: Pre-intervention and active-intervention phases with parallel data measurement points were used. The study involved six hospitals comprising the majority of acute-stroke admissions in Houston, Tex. Hospital, paramedic, and patient data were collected prospectively pre-intervention and during the active-intervention phase on all suspected acute-stroke patients admitted by Houston Fire Department-Emergency Medical Services. A multilevel educational intervention included paramedic, hospital, and community education. Paramedic diagnostic accuracy, hospital-performance efficiency, and thrombolytic treatment rates were the main outcome measures of the study., Results: Four hundred forty-six patients (74 per month) were transported in the pre-intervention phase to participating hospitals (59.8% of all suspected stroke patients transported city wide by Houston Fire Department-Emergency Medical Services), compared with 1072 patients (89 per month, or 68.7%) transported in the active-intervention phase (P<0.001). Accuracy of paramedic diagnosis of stroke increased from 61% to 79%. Admission within 2 hours of symptom onset increased from 58% to 62% (P=0.002). Thrombolysis rates increased in 4 of 6 centers, with 1 post- tissue plasminogen activator hemorrhage (3.7%) reported., Conclusions: A multilevel educational program improves rapid hospitalization and paramedic diagnostic accuracy and increases the number of patients presenting for evaluation within the 3-hour tissue plasminogen activator window. Stroke center development supports safe thrombolytic practice in community settings.

Objectives: The purpose of this study was to determine if emergency medical services (EMS) customer satisfaction could be assessed using telephone-survey methods. The process by which customer satisfaction with the EMS service in a large, fire department-based EMS system is reported, and five month results are presented., Methods: Ten percent of all patients transported during the period of October 15, 2001, through March 15, 2002, were selected for study. In addition, during the same period, all EMS incidents in which a patient was not transported were identified for contact. Customer-service representatives contacted patients via telephone and surveyed them from prepared scripts., Results: A total of 88,528 EMS incidents occurred during the study period. Of these, 53,649 resulted in patient transports and 34,879 did not. Ten percent of patients transported (5,098) were selected for study participation, of which 2,498 were successfully contacted; of these, 2,368 (94.8%) reported overall satisfaction with the service provided. Of the 34,879 incidents without transport, only 5,859 involved patients who were seen but not transported. All of these patients were selected for study. Of these, 2,975 were successfully contacted, with 2,865 (96.3%) reporting overall satisfaction. The most common reason given for nonsatisfaction in both groups was the perception of a long response time., Conclusions: It is possible to conduct a survey of EMS customer satisfaction using telephone-survey methods. Although difficulties exist in contacting patients, useful information is made available with this method. Such surveys should be an integral part of any EMS system's quality-improvement efforts. In this survey, the overwhelming majority of patients, both transported and not transported, were satisfied with their encounter with EMS.

Objective: To examine the effect of a paramedic educational program and quality improvement feedback loop on paramedic-initiated nontransport of patients 65 years of age and older., Methods: Prospective observational study. Patients 65 years of age and older who were evaluated but not transported by paramedics were contacted by telephone within two weeks of emergency medical services (EMS) contact and asked: 1) whether the patient sought medical help within 24 hours after contact; 2) whether the patient was admitted to a hospital and, if so, what was the diagnosis; 3) who was responsible for the nontransport decision (patient, paramedic, or mutual); and 4) how satisfied the patient was with the EMS service. After six weeks of data collection, the results were presented in a nonjudgmental fashion to the paramedics. After this intervention, the data collection continued for another five weeks without the paramedics' knowledge., Results: After the intervention, the overall nontransport rate remained constant (11.5% vs. 10.7%). The percentage of patients seeking further medical attention within 24 hours also remained constant (37.1% vs. 33.9%). The percentage of patients who required hospitalization within 24 hours of the nontransport declined from 12.6% to 6.4%. The percentage of patients who refused ambulance transportation by paramedics declined from 9.3% to 3.7%. Overall satisfaction level rose from 94.7% to 100%., Conclusion: When paramedics were provided with objective feedback regarding outcome of patients not transported, the paramedic-initiated nontransportation and delayed hospitalization rates decreased, and the patient satisfaction level rose to 100%.