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1. Prehospital hypoxemia, measured by pulse oximetry, predicts hospital outcomes during the New York City COVID‐19 pandemic

Author

Elizabeth A. Lancet, Dario Gonzalez, Nikolaos A. Alexandrou, Benjamin Zabar, Pamela H. Lai, Charles B. Hall, James Braun, Rachel Zeig‐Owens, Douglas Isaacs, David Ben‐Eli, Nathan Reisman, Bradley Kaufman, Glenn Asaeda, Michael D. Weiden, Anna Nolan, Hugo Teo, Eric Wei, Shaw Natsui, Christopher Philippou, and David J. Prezant

Subjects
Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Abstract Objective To determine if oxygen saturation (out‐of‐hospital SpO2), measured by New York City (NYC) 9‐1‐1 Emergency Medical Services (EMS), was an independent predictor of coronavirus disease 2019 (COVID‐19) in‐hospital mortality and length of stay, after controlling for the competing risk of death. If so, out‐of‐hospital SpO2 could be useful for initial triage. Methods A population‐based longitudinal study of adult patients transported by EMS to emergency departments (ED) between March 5 and April 30, 2020 (the NYC COVID‐19 peak period). Inclusion required EMS prehospital SpO2 measurement while breathing room air, transport to emergency department, and a positive severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) reverse transcription polymerase chain reaction test. Multivariable logistic regression modeled mortality as a function of prehospital SpO2, controlling for covariates (age, sex, race/ethnicity, and comorbidities). A competing risk model also was performed to estimate the absolute risks of out‐of‐hospital SpO2 on the cumulative incidence of being discharged from the hospital alive. Results In 1673 patients, out‐of‐hospital SpO2 and age were independent predictors of in‐hospital mortality and length of stay, after controlling for the competing risk of death. Among patients ≥66 years old, the probability of death was 26% with an out‐of‐hospital SpO2 >90% versus 54% with an out‐of‐hospital SpO2 ≤90%. Among patients 90% versus 31% with an out‐of‐hospital SpO2 ≤ 90%. An out‐of‐hospital SpO2 level ≤90% was associated with over 50% decreased likelihood of being discharged alive, regardless of age. Conclusions Out‐of‐hospital SpO2 and age predicted in‐hospital mortality and length of stay: An out‐of‐hospital SpO2 ≤90% strongly supports a triage decision for immediate hospital admission. For out‐of‐hospital SpO2 >90%, the decision to admit depends on multiple factors, including age, resource availability (outpatient vs inpatient), and the potential impact of new treatments.

Published
2021
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2. Abstract WP243: Identification of Common Confounders in the Prehospital Identification of Stroke in Urban, Underserved Minorities

Author

Ethan S Brandler, Mohit Sharma, Priyank Khandelwal, David Kinraich, John P Freese, James Braun, David Ben-Eli, Toby Gropen, Bradley Kaufman, and Steven R Levine

Subjects
Advanced and Specialized Nursing, Neurology (clinical), Cardiology and Cardiovascular Medicine
Abstract

Background: Pre-hospital providers report positive predictive values (PPV) of 40-85% for the diagnosis of stroke, typically using the Cincinnati Pre-hospital Stroke Scale. In New York City 911, both emergency medical technicians [Basic Life Support (BLS)] and paramedics [Advanced Life Support (ALS)] care for/transport stroke patients. Hypotheses: (1) In an urban, underserved, minority population, ALS would have greater PPV than BLS for the confirmed diagnosis of stroke, and (2) Hypoglycemia and seizures would be frequent confounders, particularly for BLS providers. Methods: After IRB approval, medical records were reviewed of patients (85% Carribean Blacks) transported by EMS to participating Brooklyn facilities from 1/1/10-12/31/11. We compared EMS impressions of the presenting problem with AHA/ASA “Get with the Guidelines” (GWTG) databases - serving as the gold standard for diagnosis of stroke/TIA. Medical records of patients thought to have stroke by EMS but without a GWTG stroke diagnosis were queried for confounders (e.g. hypoglycemia, seizures). Patients who were not transported by EMS were excluded. Differences in confounders between ALS and BLS were analyzed using chi squared and Fisher’s exact test. Results: Of 671 patients suspected of having stroke by EMS, 628 patients (94%) had complete records (n=445 BLS, 183 ALS) available for review; 392 were confirmed strokes (275 ischemic, 46 TIA, 66 ICH, 5 SAH). There was no difference in PPV between ALS 59% (95% CI, 52% to 66%) and BLS 64% (95% CI, 59% to 68%) (P=0.277). Of the remaining 236 who did not have confirmed strokes, seizure was the greatest single confounder (n=72, 31%) followed in frequency by syncope (n=24, 10%), infections (n=23, 10%) and hypoglycemia (n=18, 8%). ALS more frequency diagnosed confounders than BLS (chi squared 8.64, df=3, p = 0.034), driven by seizure (2 tailed p < 0.0001). Conclusions: Our data suggest EMS called seizures a stroke more commonly than the other 3 leading confounders (hypoglycemia, syncope, and infection) combined and this was true more frequent for ALS than BLS, suggesting an area for focused EMS education. There was no difference between ALS and BLS in PPV. Further study is planned to determine the accuracy of ALS vs. BLS providers for the diagnosis of stroke.

Published
2013

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