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The purpose was to measure faculty members': (1) knowledge of quality improvement and patient safety (QIPS), (2) attitudes and beliefs about their own QI skills, and (3) self-efficacy toward participating in, leading, and teaching QIPS. Faculty completed an online survey. Questions assessed demographic and academic characteristics, knowledge, attitudes/beliefs, and self-efficacy. Knowledge was measured using the Quality Improvement Knowledge Assessment Tool-Revised (QIKAT-R). Participants provided free-text responses to questions about clinical scenarios. Almost half of participants (n = 236) self-reported that they were moderately or extremely comfortable with QIPS skills. Few were very (20%) or most (15%) comfortable teaching QIPS. Ninety-one participants attempted the QIKAT-R, and 78 participants completed it. The mean score was 16.6 (SD = 5.6). Despite positive attitudes and beliefs about their own QIPS skills, study results demonstrate a general lack of knowledge among surveyed faculty members. Faculty development efforts are needed to improve proficiency in participating, leading, and teaching QIPS projects.

Objective We evaluated the effect of chest compression fraction (CCF) on survival to hospital discharge and return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) patients with non-shockable rhythms. Methods This is a retrospective analysis (completed in 2016) of a prospective cohort study which included OHCA patients from ten U.S. and Canadian sites (Resuscitation Outcomes Consortium Epistry and PRIMED study (2007–2011)). We included all OHCA victims of presumed cardiac aetiology, not witnessed by emergency medical services (EMS), without automated external defibrillator shock prior to EMS arrival, receiving > 1 min of CPR with CPR process measures available, and initial non-shockable rhythm. We measured CCF using the first 5 min of electronic CPR records. Results Demographics of 12,928 adult patients were: mean age 68; male 59.9%; public location 8.5%; bystander witnessed 35.2%; bystander CPR 39.3%; median interval from 911 to defibrillator turned on 10 min:04 s; initial rhythm asystole 64.8%, PEA 26.0%, other non-shockable 9.2%; compression rate 80−120/min (69.1%); median CCF 74%; ROSC 25.6%; survival to hospital discharge 2.4%. Adjusted odds ratio (OR); 95% confidence intervals (95%CI) of survival for each CCF category were: 0−40% (2.00; 1.16, 3.32); 41−60% (0.83; 0.54, 1.24); 61−80% (1.02; 0.77, 1.35); and 81−100% (reference group). Adjusted (OR; 95%CI) of ROSC for each CCF category were: 0−40% (1.02; 0.79, 1.30); 41−60% (0.83; 0.72, 0.95); 61−80% (0.85; 0.77, 0.94); and 81−100% (reference group). Conclusions We observed an incremental benefit from higher CCF on the incidence of ROSC, but not survival, among non-shockable OHCA patients with CCF higher than 40%.

Purpose: Emergency medical services (EMS) responders are a group of medically skilled professionals who perform a wide range of essential medical services within a community including emergency response, patient transport, and mobile integrated healthcare. The proper functioning of the EMS system is paramount to the well-being of the medical system and public health. The intent of this paper is to review current EMS standards and practice to determine the danger a high consequence infectious disease (HCID) may pose to these healthcare workers and the community.Areas Addressed: Through the review of EMS practice several areas were identified as vulnerabilities to the EMS network. These vulnerabilities consisted of the lack of standardized licensing practice, inconsistent medical direction, and the inability to properly implement the use of personal protective equipment (PPE). The compounding of these vulnerabilities allows for HCIDs to pose a serious threat to EMS personnel with the possibility of devastating and crippling the EMS infrastructure within the US.Discussion: The vulnerabilities identified must be addressed both to protect EMS providers and to enhance the resilience of the US healthcare system. Ways to address the identified vulnerabilities should focus on improving the EMS curriculum and increasing minimum levels of education for first responders. Targeting minimum education and training standards could be the most effect method of reducing the dangers of HCIDs to EMS systems.

Objective: The aim of this study was to assess variations in presentation and outcomes of coronavirus disease 2019 (COVID-19) across race/ethnicity at a large Texas metroplex hospital. Methods: A retrospective cohort study was performed. Results: Although COVID-19 patients demonstrated significant socioeconomic disparities, race/ethnicity was not a significant predictor of intensive care unit (ICU) admission (P = 0.067) or case fatality (P = 0.078). Hospital admission varied by month, with incidence among Black/African-American and Hispanic/Latino patients peaking earlier in the pandemic timeline (P < 0.001). Patients reporting Spanish as their primary language were significantly more likely to be admitted to the ICU (odds ratio, 1.75; P = 0.007). Conclusions: COVID-19 patients do not demonstrate significant racial/ethnic disparities in case fatality, suggesting that state-wide disparities in mortality rate are rooted in infection risk rather than hospital course. Variations in admission rates by race/ethnicity across the timeline and increased ICU admission among Spanish-speaking patients demonstrate the need to pursue tailored interventions on both a community and structural level to mitigate further health disparities throughout the pandemic and after.

Objectives: Combined with devices that enhance venous return out of the brain and into the thorax, preclinical outcomes are improved significantly using a synergistic bundled approach involving mild elevation of the head and chest during cardiopulmonary resuscitation. The objective here was to confirm clinical safety/feasibility of this bundled approach including use of mechanical cardiopulmonary resuscitation provided at a head-up angle. Design: Quarterly tracking of the frequency of successful resuscitation before, during, and after the clinical introduction of a bundled head-up/torso-up cardiopulmonary resuscitation strategy. Setting: 9-1-1 response system for a culturally diverse, geographically expansive, populous jurisdiction. Patients: All 2,322 consecutive out-of-hospital cardiac arrest cases (all presenting cardiac rhythms) were followed over 3.5 years (January 1, 2014, to June 30, 2017). Interventions: In 2014, 9-1-1 crews used LUCAS (Physio-Control Corporation, Redmond, WA) mechanical cardiopulmonary resuscitation and impedance threshold devices for out-of-hospital cardiac arrest. After April 2015, they also 1) applied oxygen but deferred positive pressure ventilation several minutes, 2) solidified a pit-crew approach for rapid LUCAS placement, and 3) subsequently placed the patient in a reverse Trendelenburg position (~20°). Measurements and Main Results: No problems were observed with head-up/torso-up positioning (n = 1,489), but resuscitation rates rose significantly during the transition period (April to June 2015) with an ensuing sustained doubling of those rates over the next 2 years (mean, 34.22%; range, 29.76–39.42%; n = 1,356 vs 17.87%; range, 14.81–20.13%, for 806 patients treated prior to the transition; p < 0.0001). Outcomes improved across all subgroups. Response intervals, clinical presentations and indications for attempting resuscitation remained unchanged. Resuscitation rates in 2015–2017 remained proportional to neurologically intact survival (~35–40%) wherever tracked. Conclusions: The head-up/torso-up cardiopulmonary resuscitation bundle was feasible and associated with an immediate, steady rise in resuscitation rates during implementation followed by a sustained doubling of the number of out-of-hospital cardiac arrest patients being resuscitated. These findings make a compelling case that this bundled technique will improve out-of-hospital cardiac arrest outcomes significantly in other clinical evaluations.

The coronavirus disease 2019 (COVID-19) has greatly impacted health-care systems worldwide, leading to an unprecedented rise in demand for health-care resources. In anticipation of an acute strain on established medical facilities in Dallas, Texas, federal officials worked in conjunction with local medical personnel to convert a convention center into a Federal Medical Station capable of caring for patients affected by COVID-19. A 200,000 square foot event space was designated as a direct patient care area, with surrounding spaces repurposed to house ancillary services. Given the highly transmissible nature of the novel coronavirus, the donning and doffing of personal protective equipment (PPE) was of particular importance for personnel staffing the facility. Furthermore, nationwide shortages in the availability of PPE necessitated the reuse of certain protective materials. This article seeks to delineate the procedures implemented regarding PPE in the setting of a COVID-19 disaster response shelter, including workspace flow, donning and doffing procedures, PPE conservation, and exposure event protocols.

It is known that women with ST-segment elevation myocardial infarction (STEMI) have higher mortality in comparison to men. While the reasons for this sex-based difference are not completely understood, biologic differences and disparities in care have been implicated. Whether these differences persist within an urban, regional STEMI system of care with defined protocols is unclear. Our objective was to explore sex-related effects in outcomes in a large regional system of care.Data were drawn from a regional subset of the National Cardiovascular Data Registry for 33 hospitals in and around Dallas County, Texas from 2010 to 2015. We explored adjusted differences between women and men for discharge disposition, door to balloon (D2B), total ischemic time (TIS), length of stay, and in-hospital mortality rates.Multivariate regressions to control for confounding factors, including age, D2B, and TIS, were significantly prolonged in women compared to men (D2B 58 vs. 54 minutes; TIS 206 vs. 178 minutes; both p 0.001). Length of stay was 0.45 median days longer. Women were also much less likely to survive at discharge than men [odds ratio (OR): 0.63; 95% confidence interval (CI): 0.52-0.76]. Most notably, they were much less likely to be discharged to home than men (88% vs. 92%, p 0.001).In this study, we found that sex-based disparities persist for both cardiovascular outcomes and discharge disposition, even in a modern regionalized system of care.

Objective: A few studies report comparable analgesic efficacy between low-dose ketamine and opioids such as morphine or fentanyl; however, limited research has explored the safety and effectiveness...

To discuss the evolution of the technique of cardiopulmonary resuscitation (CPR), including presenting important research that has made substantial improvements in patient outcome.The last half century has seen the arising of guidelines for performing CPR increasingly based on good scientific evidence. Improvements in the technique, including teaching citizens 'compressions only CPR', have simplified the process of rescue while improving survival.Numerous scientific studies and the better understanding of physiology have contributed to enhanced outcomes while creating community-based systems of care.

Introduction: A registry for out-of-hospital cardiac arrests facilitates cardiac arrest research, and emergency medical services (EMS) and community health quality improvement programs. Maintaining a cardiac arrest registry is labor intensive and costly, both of which could be reduced through automation. Objective: To determine the feasibility of automating data population of a cardiac arrest registry and to identify the components needed for and barriers to automation. Methods: This is a prospective feasibility study at the Dallas Fort-Worth (DFW) Center for Resuscitation Research. Our cardiac arrest registry was part of the multi-center Resuscitation Outcomes Consortium (ROC) Epistry from 2006 to 2016. Since 2016, we modified and maintained it separately from the ROC and over 20,000 cases have been enrolled. We identified the following critical elements necessary for automated data population of the registry: Create a registry dataset; create Business Associate Agreements with EMS agencies and hospitals; identify EMS and hospital electronic health record programs; develop a search strategy; search for appropriate cases in city servers where EMS patient care reports (PCRs) are stored and download data; move EMS data through our institutional firewall to a secure server; perform the same steps for hospital medical records; match EMS cases with hospital medical records, and automatically populate the registry with EMS and hospital data on a regular basis. Results: At the DFW site, EMS agencies use five different PCR programs and hospitals use two different electronic health record programs. A combination of 13 search terms captured 90% to 100% of appropriate cardiac arrest cases across six EMS agencies. Two different strategies can be used for streaming data across our firewall: A proprietary program entitled “Move-It” or a university generated file transfer protocol. We used a probabilistic logical approach for matching EMS cases with hospital cases. Conclusions: Automating a cardiac arrest registry is feasible. A cardiac arrest registry has many elements that must be considered to accomplish automation. The authors found that the most time consuming element is establishing Business Associate Agreements with all parties that provide data.

Introduction: An automated registry for out-of-hospital cardiac arrest can facilitate cardiac arrest research and emergency medical services (EMS) and community health quality improvement programs. A key element of a cardiac arrest registry is outcome, especially survival to hospital discharge, which is usually obtained from the hospital medical record. A crucial step in capturing survival data automatically is being able to reliably match EMS patient care reports with hospital medical records. Objective: To determine the accuracy of a probabilistic record-linkage approach to match EMS and hospital encounters and identify barriers of automation. Methods: This is a prospective feasibility study from the Dallas Fort-Worth Center for Resuscitation Research. Our cardiac arrest registry was part of the Resuscitation Outcomes Consortium (ROC) Epistry from 2006 to 2016. Since 2016, we maintained it separately from the ROC and have since enrolled over 20,000 cases. Record linkage was performed using demographic data of encounters from a single EMS agency within the registry and a community hospital in Dallas where these were transported from January 2017 to May 2018. An expectation maximization algorithm to aid in discerning matches and nonmatches was performed using the R package RecordLinkage identifying record pairs as a match, non-match, or possible match based on a pre-determined threshold. Match and Possible Match pairs were manually reviewed to assess the algorithm’s accuracy. Results: The EMS and hospital data sets had 67 and 6,050 unique encounters, respectively. The record linkage algorithm identified 40 EMS encounters as having a match (60%), 12 with a possible match (18%), and 15 with no identified match (22%). After manual review, the algorithm had a positive predictive value (PPV) of 100% (40/40) for the match group with a sensitivity of 60%. Conclusions: Applying probabilistic linkage to aid in automating a cardiac arrest registry was successful in linking over half of the EMS encounters with a PPV of 100%. When reviewing the unmatched encounters, many were adjacent to each other when sorted by time suggesting the poor sensitivity is more likely a reflection of the hospital’s data collection method as opposed to the linkage methodology.

Background The U.S. and worldwide death toll from opioids and other drugs has accelerated, rivaling all other causes of premature death. Emergency medical services (EMS) now has an evolving role in providing solutions. Methods EMS medical directors from the majority of the largest U.S. cities and global counterparts met to share/compile an inventory of best practices derived from their respective high-volume experiences in jurisdictions with >114 million residents combined. In turn, they created a consensus guideline document for the purposes of information-sharing among themselves and other interested parties. Results The group concluded that EMS personnel have evolving training needs with respect to new medical care challenges, but they also recommended that agencies have a special place within the collective of those hoping to provide solutions to the public health crisis of addiction and drug-related epidemics. In addition to intervening in real-time overdose events, it was recommended that they partner with other key stakeholders to develop mechanisms to end the repetitive cycle of emergency rescue followed by an almost immediate return to addictive behaviors. EMS providers should be trained to optimally communicate, refer, and direct the affected individuals to appropriate resources that will provide viable and evidence-based pathways directed toward long-term recovery. Conclusions Beyond a need to update acute medical rescue practices and improved assessment techniques, EMS providers should also learn to optimally communicate, encourage, and even participate in facilitating management continuity for the affected individuals by identifying and using the appropriate resources that will provide viable, evidence-based pathways toward sustained recovery.

Objective Ischemic postconditioning (PC) using three intentional pauses at the start of cardiopulmonary resuscitation (CPR) improves outcomes after cardiac arrest in pigs when epinephrine (epi) is used before defibrillation. We hypothesized PC, performed during basic life support (BLS) in the absence of epinephrine, would reduce reperfusion injury and enhance 24h functional recovery. Design Prospective animal investigation. Setting Animal laboratory Subjects Female farm pigs ( n =46, 39±1kg). Interventions Protocol A: After 12min of ventricular fibrillation (VF), 28 pigs were randomized to four groups: (A) Standard CPR (SCPR), (B) active compression-decompression CPR with an impedance threshold device (ACD-ITD), (C) SCPR+PC (SCPR+PC) and (D) ACD-ITD CPR+PC. Protocol B: After 15min of VF, 18 pigs were randomized to ACD-ITD CPR or ACD-ITD+PC. The BLS duration was 2.75min in Protocol A and 5min in Protocol B. Following BLS, up to three shocks were delivered. Without return of spontaneous circulation (ROSC), CPR was resumed and epi (0.5mg) and defibrillation delivered. The primary end point was survival without major adverse events. Hemodynamic parameters and left ventricular ejection fraction (LVEF) were also measured. Data are presented as mean±SEM. Measurements and Main Results Protocol A: ACD-ITD+PC (group D) improved coronary perfusion pressure after 3min of BLS versus the three other groups (28±6, 35±7, 23±5 and 47±7 for groups A, B, C, D respectively, p =0.05). There were no significant differences in 24h survival between groups. Protocol B LVEF 4h post ROSC was significantly higher with ACD-ITD+PC vs ACD-ITD alone (52.5±3% vs. 37.5±6.6%, p =0.045). Survival rates were significantly higher with ACD-ITD+PC vs. ACD-ITD alone ( p =0.027). Conclusions BLS using ACD-ITD+PC reduced post resuscitation cardiac dysfunction and improved functional recovery after prolonged untreated VF in pigs. Protocol number 12-11.

It is known that women generally have worse mortality outcomes than men with regards to ST-segment elevation myocardial infarction. However, less is known about contemporary gender differences in non-STEMI acute coronary syndrome, particularly those presenting to emergency departments within a regionalized system of care with standardized protocols.Retrospective registry data from 2010 to 2016 were examined from the North Texas Mission: Lifeline system of care, representing 33 hospitals around the Dallas Texas metropolitan area. We explored gender-based differences using multivariate logistic regression model, controlling for patient's age, baseline condition, and hospital factors.There were 16,861 patients who presented directly to emergency departments with NSTEMI, and 6513 (38.6%) were women. At baseline, women were older (68.04 vs. 63.7 years, p 0.001) and presented with history of prior cardiovascular disease more often than men. Women had higher unadjusted in-hospital mortality rates than men (4.8% vs. 3.9%, p 0.001), which persisted after controlling for patient age, comorbidities, and hospital factors. Women also had 23 min longer ED lengths of stay (p 0.001) and were much less likely to receive an early invasive strategy (diagnostic coronary angiography within 24 h of arrival) than men (47.0% vs 54.4%, p 0.001).Emergency department NSTEMI protocols should consider potential gender disparities that exist for women. Overall, women had worse outcomes, which persist even in an urban system of care with standardized protocols.

Introduction:After Hurricane Harvey and the flooding that ensued, 3,829 displaced persons were transported from their homes and sheltered in the Dallas Convention Center. This large general population sheltering operation was medically supported by the onsite Mega-Shelter Medical Clinic (MMC). In an altered standard of care environment, a number of multi-disciplinary medical services were provided including emergent management, acute pediatric and adult care, psychiatric/behavioral services, onsite pharmaceutical, and durable medical equipment distribution, epidemiologic surveillance, and select laboratory services.Aim:To describe how onsite medical care in the adapted environment of a large population shelter can provide comparable services and limit the direct impact on the local medical community.Methods:A retrospective chart review of medical records was generated for all clinical encounters at the MMC. Data were sorted by daily census, disease surveillance, medical decision making, treatment, and transport destinations.Results:40.7% of registered evacuees utilized the MMC accounting for a total of 2,654 clinic visits by 1,560 unique patients representing all age groups. During the sustained MMC operations, 8% of patients required emergency transport and 500 additional patient transports were arranged for clinic appointments. No deaths occurred and no iatrogenic morbidity was reported.Discussion:Medical care was provided for a large number of evacuees which mitigated the potential impact on the local medical infrastructure. The provision of medical services in a large population shelter may necessitate adaptation to the standard of care. However, despite the nontraditional clinical setting, care delivery was not compromised.

Introduction: Differences in after-hours capability or performance of ST-elevation myocardial infarction (STEMI) centers has the potential to impact outcomes of patients presenting outside of regular hours. Methods: Using a prospective observational study, we analyzed all 1,247 non-transfer STEMI patients treated in 15 percutaneous coronary intervention (PCI) facilities in Dallas, Texas, during a 24-month period (2010-2012). Controlling for confounding factors through a variety of statistical techniques, we explored differences in door-to-balloon (D2B) and in-hospital mortality for those presenting on weekends vs. weekdays and business vs. after hours. Results: Patients who arrived at the hospital on weekends had larger D2B times compared to weekdays (75 vs. 65 minutes; KW=48.9; p16 minutes longer than those who arrived during business hours and a higher likelihood of mortality (OR 2.23, CI [1.15-4.32], p

On August 25, 2017, Hurricane Harvey made landfall near Corpus Christi, Texas. The ensuing unprecedented flooding throughout the Texas coastal region affected millions of individuals.1 The statewide response in Texas included the sheltering of thousands of individuals at considerable distances from their homes. The Dallas area established large-scale general population sheltering as the number of evacuees to the area began to amass. Historically, the Dallas area is one familiar with “mega-sheltering,” beginning with the response to Hurricane Katrina in 2005.2 Through continued efforts and development, the Dallas area had been readying a plan for the largest general population shelter in Texas. (Disaster Med Public Health Preparedness. 2019;13:33–37)

Background With increasing rates of obesity and its link with cardiovascular disease, there is a need for better understanding of the obesity‐outcome relationship. This study explores the association between categories of obesity with treatment times and mortality for patients experiencing ST‐segment elevation myocardial infarction. Methods and Results We examined 8725 patients with ST‐segment elevation myocardial infarction who underwent primary percutaneous coronary intervention and used regression models to analyze the relationship between 6 categories of body mass index with key door‐to‐balloon time, total ischemic time, and in‐hospital mortality. We relied on data from the Mission: Lifeline North Texas program, consisting of 33 percutaneous coronary intervention–capable hospitals in 6 counties surrounding Dallas, Texas. Data were extracted from the National Cardiovascular Data Registry for each participating hospital. Of the samples, 76% were overweight or obese. Comparing the univariate differences between the normal‐weight group and the pooled sample, we observed a U‐shaped association between body mass index and both mortality and door‐to‐balloon times. The most underweight and severely obese had the highest mortality and median door‐to‐balloon time, respectively. These differences persisted after multivariate adjustments for door‐to‐balloon time, but not for mortality. Conclusions Extremely obese patients have longer treatment time delays than other body mass index categories. However, this did not extend to significant differences in mortality in the multivariate models. We conclude that clinicians should incorporate body mass assessments into their diagnosis and treatment plans to mitigate observed disparities.

Background: It is known that women with ST-elevation myocardial infarction (STEMI) have higher mortality in comparison to men. While the reasons for this sex-based difference are not completely understood, older age, higher prevalence of risk factors and co-morbid disease and longer time to reperfusion have been implicated. To determine whether the difference in outcomes persist even with an increase in the regional breadth of STEMI systems of care, we evaluated discharge disposition patterns and medications in a mature, multi-hospital cardiovascular network. Methods and Results: Data were drawn from a regional subset of the National Cardiovascular Data Registry for 33 hospitals in and around Dallas County, Texas from 2010 to 2015 (8,725 STEMI patients). We explored the difference between men and women in discharge dispositions (to home or other facility), to cardiac rehabilitation programs, to dietary counseling, as well as prescribed discharge medications. After multivariate controls for confounding factors including age, we found that men were 1.277 times more likely be discharged home than women (92% versus 86%), while women were more likely to be sent to an additional transitional care unit, nursing facility, or other facility. Women were also less likely to be offered dietary modification counseling (71% vs. 67%). Importantly, women were also much less likely to be prescribed Class I medications at discharge, including aspirin, beta blockers, statins, GP IIb/IIA and ACE inhibitors (all p Conclusions: Women treated for STEMI have notable differences in discharge dispositions patterns following percutaneous coronary intervention discharge. The post-discharge medications and services that women are prescribed needs to be carefully considered to reduce the significant differences in discharge disposition, although more research is needed in order to fully understand the impact of these differences.

Background: Guidelines and Class I AHA/ACCF recommendations suggest that high volume percutaneous coronary interventions (PCI) centers produce better patient outcomes than lower-volume centers. Although limited research suggests that volume matters, most of this research is not current, and was not conducted using hospitals from a fully developed regionalized system of care. Objective: To assess the relationship between hospital PCI volumes and two key patient outcomes: door-to-balloon (D2B) and mortality. Methods: We examined 9,674 STEMI patients who underwent primary percutaneous intervention and 18,539 non-STEMI patients. We relied on data from a developed regional system of care in Dallas County, which has been organized for the last five year and represents 33 PCI-capable hospitals. We used data extracted from the National Cardiovascular Data Registry Action Registry from the 2010-2015. Center volume was divided into three groups: low (400 PCIs /year) volumes. We analyzed the data using general linear regression model and logistics regressions. We incorporated institutional covariates as controls, including hospital size (number of beds), teaching status, geographic location (suburban, urban), and percent of managed care. Further, we controlled for patient-level differences by incorporating type of transportation (self, EMS), patient age and gender, and patient’s condition on presentation (shock, heart failure). Results: Mortality and door-to-balloon time were examined for each group. Unadjusted mortality rate and door-to-balloon time were significantly higher in low-volume hospitals compared with high-volume hospitals (6.2% versus 4.2%, p Conclusions: The higher-volume PCI hospitals have significantly reduced treatment times. This analysis of contemporary PCI suggests that volume persists as a significant influence on outcomes for STEMI, even in amidst growth of sophisticated, regional systems of care.

Background Reducing delays in time to treatment is a key goal of ST-elevation myocardial infarction (STEMI) emergency care. Emergency medical services (EMS) are a critical component of the STEMI chain of survival. Study Objective We sought to assess the impact of the careful integration of EMS as a strategy for improving systemic treatment times for STEMI. Methods We conducted a study of all 747 nontransfer STEMI patients who underwent primary percutaneous coronary intervention (PCI) in Dallas County, Texas from October 1, 2010 through December 31, 2011. EMS leaders from 24 agencies and 15 major PCI receiving hospitals collected and shared common, de-identified patient data. We used 15 months of data to develop a generalized linear regression to assess the impact of EMS on two treatment metrics—hospital door to balloon (D2B) time, and symptom onset to arterial reperfusion (SOAR) time, a new metric we developed to assess total treatment times. Results We found statistically significant reductions in median D2B (11.1-min reduction) and SOAR (63.5-min reduction) treatment times when EMS transported patients to the receiving facility, compared to self-transport. In addition, when trained EMS paramedics field-activated the cardiac catheterization laboratory using predefined specified protocols, D2B times were reduced by 38% (43 min) after controlling for confounding variables, and field activation was associated with a 21.9% reduction (73 min) in the mean SOAR time (both with p Conclusion Active EMS engagement in STEMI treatment was associated with significantly lower D2B and total coronary reperfusion times.

Introduction:The Dallas Convention Center received over 3800 evacuees because of the unprecedented flooding caused by Hurricane Harvey. A multidisciplinary medical clinic was established onsite to address evacuee needs for medical evaluations, emergency care, chronic disease management, pharmaceuticals, durable medical equipment, and local health services integration. To operate efficiently, the Dallas Mega-Shelter Emergency Operations Center (EOC) worked with the Mega-Shelter Medical Clinic (MMC) under a fluid incident command (IC) structure that was National Incident Management System (NIMS) compliant. Iterations of MMC IC demonstrated maturations in organizational structure while supporting MMC operations that varied from rigid NIMS doctrine.Aim:To explore the use of a fluid IC structure at a large evacuation medical shelter after Hurricane Harvey.Methods:We observed evolutions of IC organizational charts and operational impacts.Results:Modifications through just-in-time iterations of the IC organizational chart were posted and reviewed with MMC IC and EOC sector chiefs. Changes in the organizational chart were noted to improve identification of logistical needs, supply delivery, coordinate with other agencies, and to make decisions for resource typing and personnel utilization. Adaptations also improved communication, which led to timely situational awareness and reporting accuracy.Discussion:MMC medical services were improved by allowing modifications and adaptations to NIMS compliant MMC IC organizational roles and duty assignments. The fluidity of IC structure with ability for just-in-time modifications directly impacted the provision of disaster medical services. Unique situational awareness, coordination of care pathways within the local innate health infrastructure, compliance with health service regulations, and personnel resource typing all contributed to and benefitted from these IC modifications. MMC and EOC IC collaboration facilitated effective communication and maintained an appropriate span of control and efficient activity reporting.

Introduction:Residency education delivery in the United States has migrated from conventional lectures to alternative educational models that include mini-lectures, small group, and learner lead discussions. As training programs struggle with mandated hours of content, prehospital (EMS) and disaster medicine are given limited focus. While the need for prehospital and disaster medicine education in emergency training is understood, no standard curriculum delivery has been proposed and little research has been done to evaluate the effectiveness of any particular model.Aim:To demonstrate a four-hour multi-modal curriculum that includes lecture based discussions and small group exercises, culminating in an interactive multidisciplinary competition that integrates the previously taught information.Methods:EMS and disaster faculty were surveyed on the previous disaster and prehospital educational day experiences to evaluate course content, level of engagement, and participation by faculty. Based on this feedback, the EMS/Disaster divisions developed a schedule for the four hour EMS and Disaster Day that incorporated vital concepts while addressing the pitfalls previously identified. Sessions included traditional lectures, question and answer sessions, small group exercises, and a tabletop competition. Structured similarly to a strategy board game, the tabletop exercise challenged residents to take into account both medical and ethical considerations during a traditional triage exercise.Results:Compared to past reviews by emergency medical faculty, residents, and medical students, there was a precipitous increase in satisfaction scores on the part of all participants.Discussion:This curriculum deviates from the conventional education model and has been successfully implemented at our 3-year residency program of 66 residents. This EMS and Disaster Day promotes active learning, resident and faculty participation, and retention of important concepts while also fostering relationships between disaster managers and the Department of Emergency Medicine.

Introduction:Hurricane Harvey made landfall in southeast Texas in August 2017, causing unprecedented flooding throughout the Texas coastal region. Residents of affected regions were forced to evacuate to nearby unaffected areas, including Dallas, TX, where a large shelter operation was opened for 23 days to care for those evacuees. Retrospective evaluation of pharmaceutical prescribing patterns for the evacuees who self-presented to the Megashelter Medical Clinic (MMC) established in the shelter contributes to developing evidence-based planning strategies for healthcare delivery in the post-disaster setting.Aim:To describe the pharmacy needs of a displaced population following a large-scale evacuation after a hurricaneMethods:De-identified prescription records written and filled at a shelter pharmacy were reviewed, looking at both cost and category of medications dispensed over time.Results:Approximately 41% of evacuees with a total of 2,654 visits utilized the MMC clinic, resulting in 1,590 prescriptions filled with an associated cost of $78,039. The most commonly prescribed drug categories were cardiovascular (21.2%), neuropsychotropic (15.6%), infectious disease (12.5%), and endocrine (9.6%). While the most commonly dispensed were antihypertensives, diabetes treatment-related prescriptions, antibacterials, antidepressants, and NSAIDs, the costliest individual prescriptions were antiretrovirals and antipsychotics.Discussion:Prescribing patterns for the MMC differed from normal prescribing patterns of a general population. Of the prescriptions dispensed at the MMC, pharmaceutical prescription patterns suggest the immediate needs of evacuees differ from later needs. There is a greater need for chronic disease management in the early phase of shelter operations, and an increasing need for neuropsychotropic and infectious disease prescriptions over time. Understanding overall patterns of drug utilization over the duration of the shelter provides valuable insight on post-disaster medical resource utilization in evacuee populations.

Introduction:In the United States, over 50% of people have at least one chronic medical condition, access, or functional limitation. In 2017 during Hurricane Harvey, the establishment of a comprehensive multidisciplinary onsite medical clinic provided health and medical services to over 3,800 evacuees at the Dallas Mega Shelter, providing large-scale general population sheltering support to all evacuees and prioritizing family unit integrity by meeting physical, sensory, and cognitive limitations, and chronic medical conditions. The effectiveness of the Dallas Mega Shelter onsite medical operations supporting this aim is reviewed.Aim:To utilize onsite health and medical resources to meet access and functional needs of evacuees seeking general population mass sheltering in Dallas, Texas during Hurricane Harvey.Methods:Observational.Results:Over 3,800 evacuees were evaluated for functional needs support services (FNSS) resulting in over 2,500 evacuee patient encounters during 21 continuous days of onsite health and medical clinic operations.1 A comprehensive array of services were available at no cost to the evacuees and were in accordance with the Federal Emergency Management Association (FEMA) published Guidance on Planning for Integration of Functional Needs Support Service in General Population Shelters.2 The goal to maintain nearly all evacuees choosing to stay in the Mega Shelter was achieved. The challenges, limitations, and risks identified are reviewed.Discussion:FNSS guidelines require all persons, regardless of limitations, when evacuated from home be provided all services necessary to allow them to remain in general population sheltering.2 This prioritization of personal choice, functional independence, and family integrity for those with comprehensive FNSS requirements presented notable challenges, including public health and safety risks impacting the wellbeing of others. Meeting these expectations must be balanced with maintaining shelter integrity.

The American Heart Association Caruth Initiative (AHACI) is a multiyear project to increase the speed of coronary reperfusion and create an integrated system of care for patients with ST-elevation myocardial infarction (STEMI) in Dallas County, TX. The purpose of this study was to determine if the AHACI improved key performance metrics, that is, door-to-balloon (D2B) and symptom-onset-to-balloon times, for nontransfer patients with STEMI.Hospital patient data were obtained through the National Cardiovascular Data Registry Action Registry-Get With The Guidelines, and prehospital data came from emergency medical services (EMS) agencies through their electronic Patient Care Record systems. Initial D2B and symptom-onset-to-balloon times for nontransfer primary percutaneous coronary intervention (PCI) STEMI care were explored using descriptive statistics, generalized linear models, and logistic regression.Data were collected by 15 PCI-capable Dallas hospitals and 24 EMS agencies. In the first 18 months, there were 3,853 cases of myocardial infarction, of which 926 (24%) were nontransfer patients with STEMI undergoing primary PCI. D2B time decreased significantly (P.001), from a median time of 74 to 64 minutes. Symptom-onset-to-balloon time decreased significantly (P.001), from a median time of 195 to 162 minutes.The AHACI has improved the system of STEMI care for one of the largest counties in the United States, and it demonstrates the benefits of integrating EMS and hospital data, implementing standardized training and protocols, and providing benchmarking data to hospitals and EMS agencies.

BACKGROUND Interorganizational collaboration management theory contends that cooperation between distinct but related organizations can yield innovation and competitive advantage to the participating organization. Yet, it is unclear if a multi-institutional collaborative can improve quality outcomes across communities. METHODS We developed a large regional collaborative network of 15 hospitals and 24 emergency medical service agencies surrounding Dallas, Texas, and collected patient-level data on treatment times for acute myocardial infarctions. Using a pre-/posttest research design, we applied median tests of differences to explore outcome changes between groups and over the 6-year period, using data extracted from participating hospital electronic health records. RESULTS We analyzed temporal trends and changes in treatment times for 2302 patients with ST-elevation myocardial infarction between the pre- and posttest groups. We found a statistically significant 19-minute median reduction in the key outcome metric (total ischemic time, the time difference between the patient's first reported symptoms and the definitive opening of the artery). This represents a 10.8% community-wide improvement over time. CONCLUSIONS Interorganizational collaboration focused on quality improvement can impact population health across a community. This study provides a basis for broader understanding and participation by health care organizations in multi-institutional community change efforts.

Recent randomized clinical trials1–5 established the superiority of endovascular recanalization techniques, specifically mechanical embolectomy, compared with best medical therapy alone for the treatment of patients with emergent large vessel occlusion (ELVO) stroke. ELVO stroke is defined as a stroke secondary to anterior circulation large vessel occlusion (LVO) of the internal carotid, middle cerebral (M1 segments) arteries documented by imaging, without large completed infarct and presenting within 6 hours of symptom onset.6 Given the overwhelming clinical evidence provided by these trials, recent American Heart Association (AHA) guidelines concluded that “embolectomy needs to be performed as rapidly as possible for the greatest clinical benefit, and is best when performed within 6 h from onset of symptoms” (AHA class I, level of evidence A).6 In addition, cost modeling derived from trial outcomes data and claims databases in the USA strongly suggests that cost-effectiveness and an overall societal benefit is associated with investment in access to these endovascular techniques.7 Rapid access to endovascular services depends upon optimization of prehospital stroke care and transport within stroke systems of care, focusing on the unique needs of patients with ELVO through their diagnostic investigation and treatment pathway. The Society of NeuroInterventional Surgery (SNIS) proposed process time metrics for ELVO stroke treatment, including door to IV tissue plasminogen activator (t-PA) of

a b s t r a c t Objective: To simplify airway management and minimize cardiopulmonary resuscitation (CPR) chest com- pression interruptions, some emergency medical services (EMS) practitioners utilize supraglottic airway (SGA) devices instead of endotracheal intubation (ETI) as the primary airway adjunct in out-of-hospital cardiac arrest (OHCA). We compared the outcomes of patients receiving ETI with those receiving SGA following OHCA. Methods: We performed a secondary analysis of data from the multicenter Resuscitation Outcomes Con- sortium (ROC) PRIMED trial. We studied adult non-traumatic OHCA receiving successful SGA insertion (King Laryngeal Tube, Combitube, and Laryngeal Mask Airway) or successful ETI. The primary outcome was survival to hospital discharge with satisfactory functional status (Modified Rankin Scale ≤3). Sec- ondary outcomes included return of spontaneous circulation (ROSC), 24-h survival, major airway or pulmonary complications (pulmonary edema, internal thoracic or abdominal injuries, acute lung injury, sepsis, and pneumonia). Using multivariable logistic regression, we studied the association between out- of-hospital airway management method (ETI vs. SGA) and OHCA outcomes, adjusting for confounders. Results: Of 10,455 adult OHCA, 8487 (81.2%) received ETI and 1968 (18.8%) received SGA. Survival to hospital discharge with satisfactory functional status was: ETI 4.7%, SGA 3.9%. Compared with successful SGA, successful ETI was associated with increased survival to hospital discharge (adjusted OR 1.40; 95% CI: 1.04, 1.89), ROSC (adjusted OR 1.78; 95% CI: 1.54, 2.04) and 24-h survival (adjusted OR 1.74; 95% CI: 1.49, 2.04). ETI was not associated with secondary airway or pulmonary complications (adjusted OR 0.84; 95% CI: 0.61, 1.16). Conclusions: In this secondary analysis of data from the multicenter ROC PRIMED trial, ETI was associated with improved outcomes over SGA insertion after OHCA.

Background Low compliance to randomized nondrug interventions can affect treatment estimates of clinical trials. Cluster-randomized crossover may be appropriate for increasing compliance in the out-of-hospital cardiac arrest setting. Purpose The purpose was to determine whether the elapsed time from start of a nonblinded treatment period to episode enrollment date in a cluster-randomized crossover trial is associated with compliance to either a period of brief cardiopulmonary resuscitation (CPR) with electrocardiogram (ECG) rhythm analysis or a period of longer CPR with a delayed ECG rhythm analysis in patients with out-of-hospital cardiac arrest. Methods The Resuscitation Outcomes Consortium PRIMED Analyze Late (AL) versus Analyze Early (AE) trial was a cluster-randomized crossover trial at 10 North American regional sites. Clusters were created based on local service preference with treatment periods varying from 3 to 12 months depending on the expected enrollment rate of each randomizing unit. Episodes on the AL arm had a target of 180 s from CPR start to shock assessment and were deemed compliant if total time was between 150 and 210 s. Episodes on the AE arm had a target of Results We had 8769 episodes in our analysis population. Overall compliance to the randomized arm was 63.5%. After adjusting for treatment arm and treatment period length, the odds of compliance for episodes occurring >300 days from treatment period start were 33% lower (odds ratio (OR): 0.67; 95% confidence interval (CI): 0.52, 0.86) than for those Limitations A major challenge was the lack of synchronicity between training cycles and agency crossover dates. Conclusion We found a significant decrease in compliance to the AL versus AE cardiac arrest intervention as the elapsed time from start of treatment period increased. We did not find a difference in compliance immediately before and after a crossover. While these results suggest that future cluster with crossover trials in the out-of-hospital setting be designed with short treatment periods and frequent crossovers, provider logistical concerns must also be considered.

Methods: An effective disaster response requires competent responders and leaders. The purpose of this study was to ask experts to identify attributes that distinguish effective from ineffective responders and leaders in a disaster. In this qualitative study, focus groups were held with jurisdictional medical directors for the 9-1-1 emergency medical services systems of the majority of the nation's largest cities. These sessions were recorded with audio equipment and later transcribed.Results: The researchers identified themes within the transcriptions, created categories, and coded passages into these categories. Overall interrater reliability was excellent (κ = .8). The focus group transcripts yielded 138 codable passages. Ten categories were developed from analysis of the content: Incident Command System/Disaster Training/Experience, General Training/Experience, Teamwork/Interpersonal, Communication, Cognition, Problem Solving/Decision Making, Adaptable/Flexible, Calm/Cool, Character, and Performs Role. The contents of these categories included knowledge, skills, attitudes, behaviors, and personal characteristics.Conclusions: Experts in focus groups identified a variety of competencies for disaster responders and leaders. These competencies will require validation through further research that involves input from the disaster response community at large.(Disaster Med Public Health Preparedness. 2010;4:332-338)

PURPOSE OF REVIEW Management of ischemic stroke is challenging. No prehospital treatment option exists, and the only approved pharmacologic therapy, that is, systemic thrombolysis, requires brain imaging and initiation of therapy within a narrow therapeutic window. This review provides an overview of recent efforts to optimize management of suspected stroke patients by reducing the interval from symptom onset to reperfusion therapy. RECENT FINDINGS There is clear evidence that stroke patients have a favorable outcome when treated with thrombolysis in specialized stroke centers. Data from the European Cooperative Acute Stroke Study-III trial, coupled with improved patient selection by advanced imaging technologies will expand future therapeutic options. However, major obstacles remain in consistently translating scientific advances into clinical practice with only a small percentage of potentially eligible patients receiving thrombolysis. Integrated systems of prehospital management and clinical pathways are necessary to reduce this treatment gap. SUMMARY The dogma 'time is brain' is as relevant now as it was at the inauguration of recombinant tissue plasminogen activator for acute stroke treatment in 1996. Knowledge of stroke symptoms and treatment options by the public and first responders, along with integrated stroke systems of care are crucial to ensure rapid access to stroke expertise and treatment.

Hospital surge capacity has been advocated to accommodate large increases in demand for healthcare; however, existing urban trauma centers and emergency departments (TC/EDs) face barriers to providing timely care even at baseline patient volumes. The purpose of this study is to describe how alternate-site medical surge capacity absorbed large patient volumes while minimizing impact on routine TC/ED operations immediately after Hurricane Katrina.From September 1 to 16, 2005, an alternate site for medical care was established. Using an off-site space, the Dallas Convention Center Medical Unit (DCCMU) was established to meet the increased demand for care. Data were collected and compared with TC/ED patient volumes to assess impact on existing facilities.During the study period, 23,231 persons displaced by Hurricane Katrina were registered to receive evacuee services in the City of Dallas, Texas. From those displaced, 10,367 visits for emergent or urgent healthcare were seen at the DCCMU. The mean number of daily visits (mean +/- SD) to the DCCMU was 619 +/- 301 visits with a peak on day 3 (n = 1,125). No patients died, 3.2% (n = 257) were observed in the DCCMU, and only 2.9% (n = 236) required transport to a TC/ED. During the same period, the mean number of TC/ED visits at the region's primary provider of indigent care (Hospital 1) was 346 +/- 36 visits. Using historical data from Hospital 1 during the same period of time (341 +/- 41), there was no significant difference in the mean number of TC/ED visits from the previous year (p = 0.26).Alternate-site medical surge capacity provides for safe and effective delivery of care to a large influx of patients seeking urgent and emergent care. This protects the integrity of existing public hospital TC/ED infrastructure and ongoing operations.

Thousands of critically ill emergency patients are treated in the out-of-hospital setting in the United States every year. In many patients intravenous (IV) therapy cannot be initiated because of inadequate access to peripheral veins. In some cases, this lack of vascular access may limit benefit of medications because of late administration.[1] Both speed and overall success of vascular access are important when evaluating potential methodologies for their use in the out-of-hospital environment. Insertion of an IV cannula has been reported to require substantial time in the prehospital environment, with a recent study reporting an average successful intravenous line placement time of 4.4+/-2.8 minutes.[2] In critically ill pediatric patients, vascular access may present substantial difficulties to the provide.[3] Intraosseous access may provide a significant time saving which may benefit many critically ill patients, both by decreasing the time to achieve access and by decreasing the time to administration of indicated medications.[4] Achieving rapid administration of medications may facilitate the care of critically ill patients.[1] Devices are now available that permit rapid, accurate access to the intraosseous space. Recent changes in the American Heart Association's resuscitation guidelines state that the intraosseous route should be the first alternative to difficult or delayed intravenous access.[5] With these considerations, the role of intraosseous vascular access in the out-of-hospital environment should be reemphasized.

The optimal Emergency Medical Services (EMS) system characteristics have not been defined, resulting in substantial variability across systems. The Resuscitation Outcomes Consortium (ROC) is a United States-Canada research network that organized EMS agencies from 11 different systems to perform controlled trials in cardiac arrest and life-threatening trauma resuscitation.To describe EMS systems participating in ROC using a novel framework.Standardized surveys were created by ROC investigators and distributed to each site for completion. These included separate questions for individual hospitals, EMS agencies, and dispatch centers. Results were collated and analyzed by using descriptive statistics.A total of 264 EMS agencies, 287 hospitals, and 154 dispatch centers were included. Agencies were described with respect to the type (fire-based, non-fire governmental, private), transport status (transport/non-transport), and training level (BLS/ALS). Hospitals were described with regard to their trauma designation and the presence of electrophysiology and cardiac catheterization laboratories. Dispatch center characteristics, including primary versus secondary public safety answering point (PSAP) status and the use of prearrival instructions, were also described. Differences in EMS system characteristics between ROC sites were observed with multiple intriguing patterns. Rural areas and fire-based agencies had more EMS units and providers per capita. This may reflect longer response and transport distances in rural areas and the additional duties of most fire-based providers. In addition, hospitals in the United States typically had catheterization laboratories, whereas Canadian hospitals generally did not. The vast majority of both primary and secondary PSAPs use computer-aided dispatch.Similarities and differences among EMS systems participating in the ROC network were described. The framework used in this analysis may serve as a template for future EMS research.

Numerous studies addressing airway management in OHCA have shown a strong association between improved survival with treatment using BVM alone rather than with advanced airways. This BVM effect appears to persist despite variations in geographical region, patient population, and CPR quality. The underlying cause of this phenomenon remains to be determined. Of note, the survival benefit with BVM alone vs. advanced airways doesn't appear in the pediatric population in the papers reviewed by the authors. The authors recommend that a prospective randomized study be conducted in order to explore this finding and to attempt to determine its causation.

Large numbers of evacuees arrived in Dallas, Texas, from Hurricanes Katrina and Rita just 3 weeks apart in 2005 and from Hurricanes Gustav and Ike just 3 weeks apart again in 2008. The Dallas community needed to locate, organize, and manage the response to provide shelter and health care with locally available resources. With each successive hurricane, disaster response leaders applied many lessons learned from prior operations to become more efficient and effective in the provision of services. Mental health services proved to be an essential component. From these experiences, a set of operating guidelines for large evacuee shelter mental health services in Dallas was developed, with involvement of key stakeholders. A generic description of the processes and procedures used in Dallas that highlights the important concepts, key considerations, and organizational steps was then created for potential adaptation by other communities. (Disaster Med Public Health Preparedness. 2015;9:423–429)

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2015 and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/annualupdate2015. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.