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BackgroundAnticipating an increased utilization of healthcare facilities during the COVID-19 surge, the San Francisco Department of Public Health developed a plan to deploy neighborhood-based Field Care Clinics (FCCs) that would decompress emergency departments by serving patients with low acuity complaints. These clinics would receive patients directly from the Emergency Medical Services (EMS) system. Transports were initiated by a paramedic-driven protocol, originally by EMS crews and later by the Centralized Ambulance Destination Determination (CADDiE) System. In this study, we evaluated the outcomes of EMS patients who were transported to the FCC, specifically as to whether they required subsequent transfer to the emergency department.MethodsWe performed a retrospective study of all patients transported to the Bayview-Hunters Point (BHP) neighborhood FCC by EMS between April 11th, 2020, and December 16th, 2020. Descriptive statistics and Chi-Square Tests were used to analyze patient data.ResultsIn total, 35 patients (20 men, 15 women, average age of 50.9 years) were transported to the FCC. Of these, 16 were Black/African American, 7 were White, 3 were Asian, with 9 identifying as of other races and 9 of Hispanic ethnicity. Twenty-three of these transports resulted from a CADDiE recommendation. Approximately half (n=20) of calls originated within the BHP neighborhood. The most frequent patient complaint was "Pain." Of patients transported to the FCC, 23 were treated and discharged. The 12 remaining patients required hospital transfer, with 3 being discharged after receiving treatment in the emergency department and 9 requiring hospital admission, psychiatric, or sobering services. The likelihood of hospital transfer did not significantly vary by sex (p=0.41), 9-1-1 call origination relative to BHP neighborhood (p=0.92), or CADDiE recommendation (p=0.51).ConclusionThree-fourths of patients who required subsequent hospital transfer were admitted or required specialized services, suggesting that the FCC was viable for managing low acuity conditions. However, the underutilization of the FCC by EMS as a transport destination and a high hospital transfer rate indicates training and protocol refinement opportunities. Despite the small cohort size, this study demonstrates that an FCC alternative care site can act as a viable source for urgent and emergency care during a pandemic.

This article draws on existing literature, a large, multi-institutional dataset, and several case studies to explore two empirical questions: Do students of color (SOC) differ from white students in statistically significant ways in respect to the global learning goal of cultural humility? And what interactive effects do students and faculty from diverse backgrounds, diversity and inclusion advocacy, and diverse community contexts have on one another? We draw on existing literature and quantitative data to demonstrate that SOC tend to bring strengths to global learning experiences. We share several case studies to demonstrate how those strengths may lead to specific alliances regarding justice work in host communities, complicating any conception of students as visitors unattached to local justice struggles. Throughout the article, we draw on current literature and practice to present several questions at the intersections of education abroad, diversity, equity, inclusion, community-based global learning, and critical global citizenship.

Introduction: In response to the ongoing opioid overdose crisis, US officials urged the expansion of access to naloxone for opioid overdose reversal. Since then, emergency medical services’ (EMS) dispensing of naloxone kits has become an emerging harm reduction strategy.  Methods: We created a naloxone training and low-barrier distribution program in San Francisco: Project FRIEND (First Responder Increased Education and Naloxone Distribution). The team assembled an advisory committee of stakeholders and subject-matter experts, worked with local and state EMS agencies to augment existing protocols, created training curricula, and developed a naloxone-distribution data collection system. Naloxone kits were labeled for registration and data tracking. Emergency medical technicians and paramedics were asked to distribute naloxone kits to any individuals (patient or bystander) they deemed at risk of experiencing or witnessing an opioid overdose, and to voluntarily register those kits.  Results: Training modalities included a video module (distributed to over 700 EMS personnel) and voluntary, in-person training sessions, attended by 224 EMS personnel. From September 25, 2019–September 24, 2020, 1,200 naloxone kits were distributed to EMS companies. Of these, 232 kits (19%) were registered by EMS personnel. Among registered kits, 146 (63%) were distributed during encounters for suspected overdose, and 103 (44%) were distributed to patients themselves. Most patients were male (n = 153, 66%) and of White race (n = 124, 53%); median age was 37.5 years (interquartile range 31-47). Conclusion: We describe a successful implementation and highlight the feasibility of a low-threshold, leave-behind naloxone program. Collaboration with multiple entities was a key component of the program’s success.

This study examines parental participation in children's schooling. Using a survey of parents of children attending a majority Hispanic school district, we employ exploratory factor analysis and determine that standard forms of participation align along two dimensions: Involvement and Engagement. Analysis reveals a third dimension: Parental Community. The data suggest that income but not educational attainment influence Involvement, whereas family circumstances correlate best with Engagement. Households with the closest proximity to a Spanish-language/immigrant culture feel the strongest sense of Parental Community. The findings may inform the design of programming to help involve parents more fully in their children's schooling.

BackgroundThe assessment and treatment of pediatric patients in the out-of-hospital environment often presents unique difficulties and stress for EMS practitioners.ObjectiveUse a mixed-methods approach to assess the current experience of EMS practitioners caring for critically ill and injured children, and the potential role of a simulation-based curriculum to improve pediatric prehospital skills.MethodsData were obtained from three sources in a single, urban EMS system: a retrospective review of local pediatric EMS encounters over one year; survey data of EMS practitioners' comfort with pediatric skills using a 7-point Likert scale; and qualitative data from focus groups with EMS practitioners assessing their experiences with pediatric patients and their preferred training modalities.Results2.1% of pediatric prehospital encounters were considered "critical," the highest acuity level. A total of 136 of approximately 858 prehospital providers responded to the quantitative survey; 34.4% of all respondents either somewhat disagree (16.4%), disagree (10.2%), or strongly disagree (7.8%) with the statement: "I feel comfortable taking care of a critically ill pediatric patient." Forty-seven providers participated in focus groups that resulted in twelve major themes under three domains. Specific themes included challenges in medication dosing, communication, and airway management. Participants expressed a desire for more repetition and reinforcement of these skills, and they were receptive to the use of high-fidelity simulation as a training modality.ConclusionsCritically ill pediatric prehospital encounters are rare. Over one third of EMS practitioners expressed a low comfort level in managing critically ill children. High-fidelity simulation may be an effective means to improve the comfort and skills of prehospital providers.

Abstract Background Dental caries incidence in adults is similar to that in children and adolescents, but few caries preventive agents have been evaluated for effectiveness in adults populations. In addition, dentists direct fewer preventive services to their adult patients. Xylitol, an over-the-counter sweetener, has shown some potential as a caries preventive agent, but the evidence for its effectiveness is not yet conclusive and is based largely on studies in child populations. Methods/Design X-ACT is a three-year, multi-center, placebo controlled, double-blind, randomized clinical trial that tests the effects of daily use of xylitol lozenges versus placebo lozenges on the prevention of adult caries. The trial has randomized 691 participants (ages 21-80) to the two arms. The primary outcome is the increment of cavitated lesions. Discussion This trial should help resolve the overall issue of the effectiveness of xylitol in preventing caries by contributing evidence with a low risk of bias. Just as importantly, the trial will provide much-needed information about the effectiveness of a promising caries prevention agent in adults. An effective xylitol-based caries prevention intervention would represent an easily disseminated method to extend caries prevention to individuals not receiving caries preventive treatment in the dental office. Trial Registration ClinicalTrials.Gov NCT00393055

Introduction: Emergency medical services (EMS) systems can become impacted by sudden surges that can occur throughout the day, as well as by natural disasters and the current pandemic. Because of this, emergency department crowding and ambulance “bunching,” or surges in ambulance-transported patients at receiving hospitals, can have a detrimental effect on patient care and financial implications for an EMS system. The Centralized Ambulance Destination Determination (CAD-D) project was initially created as a pilot project to look at the impact of an active, online base hospital physician and paramedic supervisor to direct patient destination and distribution, as a way to improve ambulance distribution, decrease surges at hospitals, and decrease diversion status.  Methods: The project was initiated March 17, 2020, with a six-week baseline period; it had three additional study phases where the CAD-D was recommended (Phase 1), mandatory (Phase 2), and modified (Phase 3), respectively. We used coefficients of variation (CV) statistical analysis to measure the relative variability between datasets (eg, CAD-D phases), with a lower variation showing better and more even distribution across the different hospitals. We used analysis of co-variability for the CV to determine whether level loading was improved systemwide across the three phases against the baseline period. The primary outcomes of this study were the following: to determine the impact of ambulance distribution across a geographical area by using the CV; to determine whether there was a decrease in surge rates at the busiest hospital in this area; and the effects on diversion. Results: We calculated the CV of all ratios and used them as a measure of EMS patient distribution among hospitals. Mean CV was lower in Phase 2 as compared to baseline (1.56 vs 0.80 P < 0.05), and to baseline and Phase 3 (1.56 vs. 0.93, P

This paper discusses adapting Churches' approach to large-scale teacher/researcher conceptual replications of major "science of learning" findings, to increase teachers' engagement with empirical research on, and building research networks for, gathering data on the science of learning. The project here demonstrated the feasibility of teacher-led randomised controlled trials for conceptually replicating the effects of cognitive science on learning, as specified by researchers. It also indicated high levels of interest by teachers in applying more science of learning in their practice. The approach gave freedom to teachers to design interventions, choose research methods, and measure outcomes, even though such freedom would be in tension with some scientific research which relies on constraining the sources of variation. This paper discusses how a balance can be struck between the objectives of teachers and researchers engaged in replicating cognitive science findings, and promoting teacher engagement in conceptual replication research.

Introduction: We developed evidence-based recommendations for prehospital evaluation and treatment of adult patients with respiratory distress. These recommendations are compared with current protocols used by the 33 local emergency medical services agencies (LEMSA) in California.Methods: We performed a review of the evidence in the prehospital treatment of adult patients with respiratory distress. The quality of evidence was rated and used to form guidelines. We then compared the respiratory distress protocols of each of the 33 LEMSAs for consistency with these recommendations.Results: PICO (population/problem, intervention, control group, outcome) questions investigated were treatment with oxygen, albuterol, ipratropium, steroids, nitroglycerin, furosemide, and non-invasive ventilation. Literature review revealed that oxygen titration to no more than 94-96% for most acutely ill medical patients and to 88-92% in patients with acute chronic obstructive pulmonary disease (COPD) exacerbation is associated with decreased mortality. In patients with bronchospastic disease, the data shows improved symptoms and peak flow rates after the administration of albuterol. There is limited data regarding prehospital use of ipratropium, and the benefit is less clear. The literature supports the use of systemic steroids in those with asthma and COPD to improve symptoms and decrease hospital admissions. There is weak evidence to support the use of nitrates in critically ill, hypertensive patients with acute pulmonary edema (APE) and moderate evidence that furosemide may be harmful if administered prehospital to patients with suspected APE. Non-invasive positive pressure ventilation (NIPPV) is shown in the literature to be safe and effective in the treatment of respiratory distress due to acute pulmonary edema, bronchospasm, and other conditions. It decreases both mortality and the need for intubation. Albuterol, nitroglycerin, and NIPPV were found in the protocols of every LEMSA. Ipratropium, furosemide, and oxygen titration were found in a proportion of the protocols, and steroids were not prescribed in any LEMSA protocol.Conclusion: Prehospital treatment of adult patients with respiratory distress varies widely across California. We present evidence-based recommendations for the prehospital treatment of undifferentiated adult patients with respiratory distress that will assist with standardizing management and may be useful for EMS medical directors when creating and revising protocols.

Nearly half of medical care in the United States is managed through the emergency department, a large portion of which could be managed by "lateral" health services provided by public health facilities like human immunodeficiency virus (HIV) prophylaxis, alcohol and drug treatment programs, emergency psychiatric resources, and medical respite or rehabilitation centers. These options may be underutilized due to lack of knowledge of their services and demographics by patients and health care workers alike. We aimed to educate all levels of emergency medicine trainees and staff to citywide services via bike tour. Participants reported an improved understanding of health services as well as a sense of "camaraderie" toward lateral health services and other providers on the rides.

Genetic improvement through breeding is one of the key approaches to increasing biomass supply. This paper documents the breeding progress to date for four perennial biomass crops (PBCs) that have high output-input energy ratios: namely Panicum virgatum (switchgrass), species of the genera Miscanthus (miscanthus), Salix (willow) and Populus (poplar). For each crop, we report on the size of germplasm collections, the efforts to date to phenotype and genotype, the diversity available for breeding and on the scale of breeding work as indicated by number of attempted crosses. We also report on the development of faster and more precise breeding using molecular breeding techniques. Poplar is the model tree for genetic studies and is furthest ahead in terms of biological knowledge and genetic resources. Linkage maps, transgenesis and genome editing methods are now being used in commercially focused poplar breeding. These are in development in switchgrass, miscanthus and willow generating large genetic and phenotypic data sets requiring concomitant efforts in informatics to create summaries that can be accessed and used by practical breeders. Cultivars of switchgrass and miscanthus can be seed-based synthetic populations, semihybrids or clones. Willow and poplar cultivars are commercially deployed as clones. At local and regional level, the most advanced cultivars in each crop are at technology readiness levels which could be scaled to planting rates of thousands of hectares per year in about 5 years with existing commercial developers. Investment in further development of better cultivars is subject to current market failure and the long breeding cycles. We conclude that sustained public investment in breeding plays a key role in delivering future mass-scale deployment of PBCs.

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.

Genetic improvement through breeding is one of the key approaches to increasing biomass supply. This paper documents the breeding progress to date for four perennial biomass crops (PBCs) that have high output-input energy ratios: namely Panicum virgatum (switchgrass), species of the genera Miscanthus (miscanthus), Salix (willow) and Populus (poplar). For each crop, we report on the size of germplasm collections, the efforts to date to phenotype and genotype, the diversity available for breeding and on the scale of breeding work as indicated by number of attempted crosses. We also report on the development of faster and more precise breeding using molecular breeding techniques. Poplar is the model tree for genetic studies and is furthest ahead in terms of biological knowledge and genetic resources. Linkage maps, transgenesis and genome editing methods are now being used in commercially focused poplar breeding. These are in development in switchgrass, miscanthus and willow generating large genetic and phenotypic data sets requiring concomitant efforts in informatics to create summaries that can be accessed and used by practical breeders. Cultivars of switchgrass and miscanthus can be seed-based synthetic populations, semihybrids or clones. Willow and poplar cultivars are commercially deployed as clones. At local and regional level, the most advanced cultivars in each crop are at technology readiness levels which could be scaled to planting rates of thousands of hectares per year in about 5 years with existing commercial developers. Investment in further development of better cultivars is subject to current market failure and the long breeding cycles. We conclude that sustained public investment in breeding plays a key role in delivering future mass-scale deployment of PBCs.

Introduction: In the United States emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with an acute change in mental status and to compare these recommendations against the current protocols used by the 33 EMS agencies in the State of California.Methods: We performed a literature review of the current evidence in the prehospital treatment of a patient with altered mental status (AMS) and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the AMS protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were patient assessment, point-of-care tests, supplemental oxygen, use of standardized scoring, evaluating for causes of AMS, blood glucose evaluation, toxicological treatment, and pediatric evaluation and management.  Results: Protocols across 33 EMS agencies in California varied widely. All protocols call for a blood glucose check, 21 (64%) suggest treating adults at

Introduction: California has led successful regionalized efforts for several time-critical medicalconditions, including ST-segment elevation myocardial infarction (STEMI), but no specific mandatedprotocols exist to define regionalization of care. We aimed to study the trends in regionalizationof care for STEMI patients in the state of California and to examine the differences in patientdemographic, hospital, and county trends.Methods: Using survey responses collected from all California emergency medical services (EMS)agencies, we developed four categories – no, partial, substantial, and complete regionalization– to capture prehospital and inter-hospital components of regionalization in each EMS agency’sjurisdiction between 2005-2014. We linked the survey responses to 2006 California non-publichospital discharge data to study the patient distribution at baseline.Results: STEMI regionalization-of-care networks steadily developed across California. Only 14%of counties were regionalized in 2006, accounting for 42% of California’s STEMI patient population,but over half of these counties, representing 86% of California’s STEMI patient population, reachedcomplete regionalization in 2014. We did not find any dramatic differences in underlying patientcharacteristics based on regionalization status; however, differences in hospital characteristics wererelatively substantial.Conclusion: Potential barriers to achieving regionalization included competition, hospital ownership,population density, and financial challenges. Minimal differences in patient characteristics canestablish that patient differences unlikely played any role in influencing earlier or later regionalizationand can provide a framework for future analyses evaluating the impact of regionalization on patientoutcomes.

Introduction: We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of adult and pediatric patients with a seizure and to compare these recommendations against the current protocol utilized by the 33 EMS agencies in California.Methods: We performed a review of the evidence in the prehospital treatment of a patients with a seizure. We compared the seizure protocols of each of the 33 EMS agencies for consistency with these recommendations.  We analyzed the type and route of medication administered, number of additional rescue doses permitted, and requirements for glucose testing prior to medication. The treatment for eclampsia and seizures in pediatric patients were analyzed separately.Results: Protocols across EMS Agencies in California varied widely.  Multiple drugs, dosages, routes of administration, re-dosing instructions, and requirement for blood glucose testing prior to medication delivery were identified. Blood glucose testing prior to benzodiazepine administratin is required by 61% (20/33) of agencies for adult patients and 76% (25/33) for pediatric patients. All agencies have protocols for giving intramuscular benzodiazepines and 76% (25/33) have protocols for intranasal benzodiazepines. Intramuscular midazolam dosages ranged from 2 to 10 mg per single adult dose, 2 to 8 mg per single pediatric dose, and 0.1 to 0.2 mg/kg as a weight-based dose. Intranasal midazolam dosages ranged from 2 to 10 mg pr single adult or pediatric dose, and 0.1 to 0.2 mg/kg as a weight-based dose. Intravenous/intrasosseous midazolam dosages ranged from 1 to 6 mg per single adult dose, 1 to 5 mg per single pediatric dose, and 0.05 to 0.1 mg/kg as a weight-based dose. Eclampsia is specifically addressed by 85% (28/33) of agencies.  Forty-two percent (14/33) have a protocol for adminstering magnesium sulfate, with intravenous dosages ranging from 2 to 6 mg, and 58% (19/33) allow benzodiazepines to be administered.Conclusion: Protocols for a patient with a seizure, including eclampsia, and febrile seizures, vary widely across California. These recommendations for the prehospital diagnosis and treatment of seizures may be useful for EMS Medical Directors tasked with creating and revising these protocols.

Proficiency with instrumental analysis via GC-MS is an important skill for chemistry students. The application of analytical techniques and fundamental theoretical principles to real-world problems can be valuable learning exercises for undergraduates which can also improve their analytical thinking skills. Xylitol is generally considered safe for human consumption and is frequently used in sugar-free gum; however, it is extremely toxic to dogs. In this laboratory experiment, upper-level undergraduate chemistry students extract xylitol from both fresh and chewed gum sticks followed by direct aqueous injection GC-MS analysis. Students learn the proper steps and techniques required for sample extraction and preparation and GC--MS analysis, and they determine concentrations of xylitol present in gum samples. Identification and quantification of the chemical components in gum extract occurs via GC-MS analysis; however, other GC detectors could be used. Students also compare external and internal standard calibration methods for xylitol quantification. Upon quantification of xylitol in chewed and unchewed gum samples, students are able to calculate the level of hazard for dogs upon ingestion.

This document provides a detailed account of the construction of the Eads Bridge in St. Louis, which was the first steel bridge in the world. The bridge was designed by James Eads, a steamboat man without formal engineering training, and financed by Junius and Pierpont Morgan. The construction faced numerous challenges, including a tornado, material procurement difficulties, and financial setbacks due to the Panic of 1873. The bridge struggled initially but eventually prospered after being foreclosed and reorganized under the Morgan banks. The document also explores the role of monopolies and the influence of figures like Pierpont Morgan in shaping the bridge's history. [Extracted from the article]

Introduction: In the United States, Emergency Medical Services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with a suspected stroke and to compare these recommendations against the current protocols utilized by the 33 EMS agencies in the State of California.Methods: We performed a literature review of the current evidence in the prehospital treatment of a patient with a suspected stroke and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the stroke protocols of each of the 33 EMS agencies for consistency with these recommendations.  The specific protocol components that we analyzed were the use of a stroke scale, blood glucose evaluation, use of supplemental oxygen, patient positioning, 12 lead ECG and cardiac monitoring, fluid assessment and intravenous access, and stroke regionalization. Results: Protocols across EMS agencies in California varied widely.  Most used some sort of stroke scale with the majority using the Cincinnati Prehospital Stroke Scale (CPSS).  All recommended the evaluation of blood glucose with the level for action ranging from 60 to 80mg/dL.  Cardiac monitoring was recommended in 58% and 33% recommended an ECG. More than half required the direct transport to a primary stroke center and 88% recommended hospital notification. Conclusion: Protocols for a patient with a suspected stroke vary widely across the State of California.  The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.

Introduction: In the United States, emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of chest pain of suspected cardiac origin and to compare these recommendations against the current protocols used by the 33 EMS agencies in the state of California.Methods: We performed a literature review of the current evidence in the prehospital treatment of chest pain and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the chest pain protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were use of supplemental oxygen, aspirin, nitrates, opiates, 12-lead electrocardiogram (ECG), ST segment elevation myocardial infarction (STEMI) regionalization systems, prehospital fibrinolysis and β-blockers. Results: The protocols varied widely in terms of medication and dosing choices, as well as listed contraindications to treatments. Every agency uses oxygen with 54% recommending titrated dosing. All agencies use aspirin (64% recommending 325mg, 24% recommending 162mg and 15% recommending either), as well as nitroglycerin and opiates (58% choosing morphine). Prehospital 12-Lead ECGs are used in 97% of agencies, and all but one agency has some form of regionalized care for their STEMI patients. No agency is currently employing prehospital fibrinolysis or β-blocker use. Conclusion: Protocols for chest pain of suspected cardiac origin vary widely across California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.

Abstract Objective. Emergency medical services (EMS) "superusers" -those who use EMS services at extremely high rates -have not been well characterized. Recent interest in the small group of individuals who account for a disproportionate share of health-care expenditures has led to research on frequent users of emergency departments and other health services, but little research has been done regarding those who use EMS services. To inform policy and intervention implementation, we undertook a descriptive analysis of EMS superusers in a large urban community. In this paper we compare EMS superusers to low, moderate, and high users to characterize factors contributing to EMS use. We also estimate the financial impact of EMS superusers. Methods. We conducted a retrospective cross-sectional study based on 1 year of data from an urban EMS system. Data for all EMS encounters with patients age ≥18 years were extracted from electronic records generated on scene by paramedics. We identified demographic and clinical variables associated with levels of EMS use. EMS users were characterized by the annual number of EMS encounters: low (1), moderate (2-4), high (5-14), and superusers (≥15). In addition, we performed a financial analysis using San Francisco Fire Department (SFFD) 2009 charge and reimbursement data. Results. A total of 31,462 adults generated 43,559 EMS ambulance encounters, which resulted in 39,107 transports (a 90% transport rate). Encounters for general medical reasons were common among moderate and high users and less frequent among superusers and low users, while alcohol use was exponentially correlated with encounter frequency. Superusers were significantly younger than moderate EMS users, and more likely to be male. The superuser group created a significantly higher financial burden/person than any other group, comprising 0.3% of the study population, but over 6% of annual EMS charges and reimbursements. Conclusions. In this retrospective study, adult EMS "superusers" emerged as a distinct, predominantly male population and their EMS encounters were associated with alcohol use. Continued analysis of this unique, high-cost, and frequently transported population will likely illuminate specific intervention strategies.

BackgroundThe Medical Priority Dispatch System (MPDS) is a commonly used computer-based emergency medical dispatch (EMD) system that is widely used to prioritize 9-1-1 calls and optimize resource allocation. There are five major priority classes used to dispatch 9-1-1 calls in the San Francisco System; Alpha codes are the lowest priority (lowest expected acuity) and Echo are the highest priority.ObjectiveWe sought to determine which MPDS dispatch codes are associated with high prehospital nontransport rates (NTRs).MethodsAll unique MPDS call categories from 2009 in a highly urbanized, two-tier advanced life support (ALS) system were sorted according to highest NTRs. There are many reasons for nontransport, such as "gone on arrival," and "patient denied transport." Those categories with greater than 100 annual calls were further evaluated. MPDS groups that included multiple categories with NTRs exceeding 25% were then identified and each category was analyzed. Results. EMS responded to a total of 81,437 calls in 2009, of which 18,851 were not transported by EMS. The majority of the NTRs were found among "cardiac/ respiratory arrest/death," "assault/sexual assaults," "unknown problem/man down," "traffic/transportation accidents," and "unconscious/fainting." "Cardiac or respiratory arrest/death -obvious death" (9B1) had the highest overall nontransport rate, 99.25% (1/134), most likely due to declaration of death. "Unknown problem -man down -medical alert notification" had the second highest NTR, 67.22% (138/421). However, Echo priority codes had the highest overall nontransport rates (45.45%) and Charlie had the lowest (13.84%).ConclusionsThe nontransport rates of individual MPDS categories vary considerably and should be considered in any system design. We identified 52 unique call categories to have a 25% or greater NTR, 18 of which exceeded 40%. The majority of NTRs occurred among the "cardiac/respiratory arrest/death," "assault/sexual assaults," "unknown problem/man down," "traffic/transportation accidents," and "unconscious/fainting" categories. The higher the priority code within each subset (AB vs. CDE), the less likely the patient was to be transported. Charlie priority codes had a lower NTR than Delta, and Delta was lower than Echo. Charlie codes were therefore the strongest predictors of hospital transport, while Echo codes (highest priority) were those with the highest nontransport rates and were the worst predictors of hospital transport in the emergent subset.