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Introduction: Since the development of an Accreditation Council of Graduate Medical Education (ACGME)-accredited emergency medical services (EMS) fellowship, there has been little published literature on effective methods of content delivery or training modalities. Here we explore a variety of innovative approaches to the development and revision of the EMS fellowship curriculum.Methods: Three academic, university-based ACGME-accredited EMS fellowship programs each implemented an innovative change to their existing training curricula. These changes included the following: a novel didactic curriculum delivery modality and evaluation; implementation of a distance education program to improve EMS fellows’ rural EMS experiences; and modification of an existing EMS fellowship curriculum to train a non-emergency medicine physician.Results: Changes made to each of the above EMS fellowship programs addressed unique challenges, demonstrating areas of success and promise for more generalized implementation of these curricula. Obstacles remain in tailoring the described curricula to the needs of each unique institution and system.Conclusion: Three separate curricula and program changes were implemented to overcome specific challenges and achieve educational goals. It is our hope that our shared experiences will enable others in addressing common barriers to teaching the EMS fellowship core content and share similar innovative approaches to educational challenges.

Inequities have been described in areas of prehospital care ranging from pain medication administration and scene time, to stroke and cardiac arrest management. Though a critical element in understanding inequity, race and ethnicity information are often missing from the prehospital patient care report. This study aimed to characterize and understand demographic trends among records with missing race and ethnicity information. This before-and-after retrospective review compared patient care reports prior to and after an intervention that mandated the recording of patient race and ethnicity. Records with incomplete race and ethnicity information in the before group were evaluated to understand demographic patterns associated with this incomplete documentation. Among 98,725 patient care reports, race/ethnicity in the before period as compared to the after period was less likely to be documented in nonwhite patients (p < 0.001), younger patients (p < 0.001), male patients (p < 0.001), and non-emergent transports (p < 0.001). When compared to data after the implementation of mandated race and ethnicity fields, missing race and ethnicity data were found to be more common in patients of color, younger patients, males, and those transported non-emergently. Inconsistent completion of race and ethnicity documentation may lead to a poor understanding of equity issues within a system, suggesting a need for mandatory race and ethnicity fields. [ABSTRACT FROM AUTHOR]

This study describes differences in medicolegal death investigators' written descriptions for people who died by homicide, suicide, or accident. We evaluated 17 years of death descriptions from a midsized metropolitan midwestern county in the United States to assess how death investigators psychologically respond to different manners of death (N = 10,408 cases). Automated text analyses suggest investigators describe accidental deaths with more immediacy relative to homicides, while they also described suicidal deaths in less emotional terms than homicides as well. These data suggest medicolegal death investigators have different psychological reactions to circumstances and manners of death as indicated by their professional writing. Future research may surface context-specific psychological reactions to vicarious trauma that could inform the design or personalization of workplace-coping interventions. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has highlighted racial and ethnic disparities, most recently in vaccine administration. The EVE (Evaluating Vulnerability and Equity) Model combines a community's vulnerability with vaccination rates to enhance the equity of vaccine distribution in an intentional, targeted manner. When applied to Milwaukee County, Wisconsin, two extreme categories of vaccination status were identified to aid in resource allocation and messaging: populations with high vulnerability and low vaccination levels, and, conversely, those with low vulnerability and high vaccinations levels. (Am J Public Health. 2022;112(2):220–222. https://doi.org/10.2105/AJPH.2021.306585) [ABSTRACT FROM AUTHOR]

Objective: Various continuous quality improvement (CQI) approaches have been used to improve quality of cardiopulmonary resuscitation (CPR) delivered at the scene of out-of-hospital cardiac arrest. We evaluated a post-event, self-assessment, CQI feedback form to determine its impact on delivery of CPR quality metrics. Methods: This before/after retrospective review evaluated data from a CQI program in a midsized urban emergency medical services (EMS) system using CPR quality metrics captured by Zoll Medical Inc. X-series defibrillator ECG files in adult patients (≥18 years old) with non-traumatic out-of-hospital cardiac arrest. Two 9-month periods, one before and one after implementation of the feedback form on December 31, 2013 were evaluated. Metrics included the mean and percentage of goal achievement for chest compression depth (goal: >5 centimeters [cm]; >90%/episode), rate (goal: 100-120 compressions/minute [min]), chest compression fraction (goal: ≥75%), and preshock pause (goal: <10 seconds [sec]). The feedback form was distributed to all EMS providers involved in the resuscitation within 72 hours for self-review. Results: A total of 439 encounters before and 621 encounters after were evaluated including basic life support (BLS) and advanced life support (ALS) providers. The Before Group consisted of 408 patients with an average age of 61 ± 17 years, 61.8% male. The After Group consisted of 556 patients with an average age of 61 ± 17 years, 58.3% male. Overall, combining BLS and ALS encounters, the mean CPR metric values before and after were: chest compression depth (5.0 cm vs. 5.5 cm; p < 0.001), rate (109.6/min vs 114.8/min; p < 0.001), fraction (79.2% vs. 86.4%; p < 0.001), and preshock pause (18.8 sec vs. 11.8 sec; p < 0.001), respectively. Overall, the percent goal achievement before and after were: chest compression depth (48.5% vs. 66.6%; p < 0.001), rate (71.8% vs. 71.7%, p = 0.78), fraction (68.1% vs. 91.0%; p < 0.001), and preshock pause (24.1% vs. 59.5%; p < 0.001), respectively. The BLS encounters and ALS encounters had similar statistically significant improvements seen in all metrics. Conclusion: This post-event, self-assessment CQI feedback form was associated with significant improvement in delivery of out-of-hospital CPR depth, fraction and preshock pause time. [ABSTRACT FROM AUTHOR]

Introduction: Reducing time between stroke onset and hospital intervention is crucial for positive outcomes in stroke patients. While EMS utilization decreases time to intervention, many US regions are not within timely proximity to an advanced-care-capable stroke center (ASC), defined as a comprehensive or thrombectomy-capable center. This study aims to utilize geographic methodology to identify regions in Wisconsin with both high stroke mortality and low physical accessibility to certified stroke centers (SCs), particularly ASCs., Methods: Geocoded mortality records for stroke death between 2015 and 2020 were accessed from the Wisconsin Department of Health Services. Indirectly age-standardized mortality ratios (SMRs) were estimated continuously across Wisconsin using adaptive spatial filtering and mortality records at the census block group level; the surface was then averaged by census tract for tract level SMRs. Addresses for SC locations within Wisconsin and bordering states were collected, and drive times from Wisconsin census tract centroids to the nearest SC subtypes were estimated. Drive times and mortality ratios were evaluated at the tract level alongside Rural-Urban Commuting Area (RUCA) codes. Spatial error regression modeling was used to determine RUCA classifications with the highest stroke risk independent of accessibility to stroke centers., Results: Approximately 50%, 68%, and 78% of Wisconsin residents resided within 30, 45, and 60 minutes of an ASC, respectively. Median drive time from census tract centroids to the nearest ASC were highest for rural tracts (M=90 minutes, IQR=68-115) compared to small-town (M=82 minutes, IQR=49-113), micropolitan (M=53 minutes, IQR=43-77), and metropolitan tracts (M=19 minutes, IQR=11-35; p<0.001). Clusters of high stroke SMRs were found in urban centers as well as rural areas irrespective of county declinations. Spatial regression modeling suggested small-town census tracts had the highest SMR irrespective of physical accessibility to care and spatial correlation. In small-town census tracts >45 minutes from the nearest ASC, the median stroke SMR was 1.12 (IQR=0.94-1.40) with 226,000 residents and 150 stroke deaths per year., Conclusion: Small-town areas are associated with both long drive distance to ASC locations and high stroke mortality. Geographical analyses reveal apparent stroke care deserts and may inform strategic allocation of emergency medicine resources and coverage., Competing Interests: Declaration of competing interest The authors report there are no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Tiered trauma team activation (TTA) allows systems to optimally allocate resources to an injured patient. Target undertriage and overtriage rates of <5% and <35% are difficult for centers to achieve, and performance variability exists. The objective of this study was to optimize and externally validate a previously developed hospital trauma triage prediction model to predict the need for emergent intervention in 6 hours (NEI-6), an indicator of need for a full TTA., Methods: The model was previously developed and internally validated using data from 31 US trauma centers. Data were collected prospectively at five sites using a mobile application which hosted the NEI-6 model. A weighted multiple logistic regression model was used to retrain and optimize the model using the original data set and a portion of data from one of the prospective sites. The remaining data from the five sites were designated for external validation. The area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC) were used to assess the validation cohort. Subanalyses were performed for age, race, and mechanism of injury., Results: 14 421 patients were included in the training data set and 2476 patients in the external validation data set across five sites. On validation, the model had an overall undertriage rate of 9.1% and overtriage rate of 53.7%, with an AUROC of 0.80 and an AUPRC of 0.63. Blunt injury had an undertriage rate of 8.8%, whereas penetrating injury had 31.2%. For those aged ≥65, the undertriage rate was 8.4%, and for Black or African American patients the undertriage rate was 7.7%., Conclusion: The optimized and externally validated NEI-6 model approaches the recommended undertriage and overtriage rates while significantly reducing variability of TTA across centers for blunt trauma patients. The model performs well for populations that traditionally have high rates of undertriage., Level of Evidence: 2., Competing Interests: Competing interests: RM and CT have a patent for the NEI-6 predictive model. RM and CT are founders of Advanced Trauma Analytics. MH receives support from Blue Cross Blue Shield of Michigan and grant funding from the Michigan Department of Health and Human Services for administration of the Michigan Trauma Quality Improvement Program., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)