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Objectives: To identify variation in patient, event, and scene characteristics of out-of-hospital cardiac arrest (OOHCA) patients assessed by emergency medical services (EMS), and to investigate variation in transport practices in relation to documented prehospital return of spontaneous circulation (ROSC) within eight regional clinical centers participating in the Resuscitation Outcomes Consortium (ROC) Epistry-Cardiac Arrest.Methods: OOHCA patient, event, and scene characteristics were compared to identify variation in treatment and transport practices across sites. Findings were adjusted for site and standard Utstein covariates. Using logistic regression, these covariates were modeled to identify factors related to the initiation of transport without documented prehospital ROSC as well as survival in these patients.Setting: Eight US and Canadian sites participating in the ROC Epistry-Cardiac Arrest.Population: Persons ≥ 20 years with OOHCA who (a) received compressions or shock by EMS providers and/or received bystander AED shock or (b) were pulseless but received no EMS compressions or shock between December 2005 and May 2007.Results: 23,233 OOHCA cases were assessed by EMS in the defined period. Resuscitation (treatment) was initiated by EMS in 13,518 cases (58%, site range: 36-69%, p < 0.0001). Of treated cases, 59% were transported (site range: 49-88%, p < 0.0001). Transport was initiated in the absence of documented ROSC for 58% of transported cases (site range: 14-95%, p < 0.0001). Of these transported cases, 8% achieved ROSC before hospital arrival (site range: 5-21%, p < 0.0001) and 4% survived to hospital discharge (site range: 1-21%, p < 0.0001). In cases with transport from the scene initiated after documented ROSC, 28% survived to hospital discharge (site range: 18-44%, p < 0.0001).Conclusion: Initiation of resuscitation and transport of OOHCA and the reporting of ROSC prior to transport markedly varies among ROC sites. This variation may help clarify reported differences in survival rates among sites and provide a target for identifying EMS practices most likely to enhance survival from OOHCA. [ABSTRACT FROM AUTHOR]

Background: Advance care planning documents, including Physician Orders for Life-Sustaining Treatment (POLST), are intended to guide care near end of life, particularly in emergency situations. Yet, research on POLST during emergency care is sparse. Methods: A total of 7,055 injured patients age ≥ 65 years were transported by 8 emergency medical services (EMS) agencies to 23 hospitals in Oregon. We linked multiple data sources to EMS records, including: the Oregon POLST Registry, Medicare claims data, Oregon Trauma Registry, Oregon statewide inpatient data, and Oregon vital statistics records. We describe patient and event characteristics by POLST status at time of 9-1-1 contact, subsequent changes in POLST forms, and mortality to 12 months. Results: Of 7,055 injured older adults, 1,412 (20.0%) had a registered POLST form at the time of 911 contact. Among the 1,412 POLST forms, 390 (27.6%) specified full orders, 585 (41.4%) limited interventions, and 437 (30.9%) comfort measures only. By one year, 2,471 (35%) patients had completed POLST forms. Among the 4 groups (no POLST, POLST-full orders, POLST-limited intervention, POLST-comfort measures), Injury Severity Scores were similar. Mortality differences were present by 30 days (5.0%, 4.6%, 8.0%, and 13.3%, p < 0.01) and were greater by one year (19.5%, 23.9%, 35.4%, and 46.2%, p < 0.01). Conclusions: Among injured older adults transported by ambulance in Oregon, one in 5 had an active POLST form at the time of 9-1-1 contact, the prevalence of which increased over the following year. Mortality differences by POLST status were evident at 30 days and large by one year. This information could help emergency, trauma, surgical, inpatient, and outpatient clinicians understand how to guide patients through acute injury episodes of care and post-injury follow up.

Study Objective: Physician Orders for Life-Sustaining Treatment (POLST) forms are intended to help prevent the provision of unwanted medical interventions among patients with advanced illness or frailty who are approaching the end of life. We seek to evaluate how POLST form completion, treatment limitations, or both influence intensity of treatment among patients who present to the emergency department (ED)., Methods: This was a retrospective cohort study of adults who presented to the ED at an academic medical center in Oregon between April 2015 and October 2016. POLST form completion and treatment limitations were the main exposures. Primary outcome was hospital admission; secondary outcomes included ICU admission and a composite measure of aggressive treatment., Results: A total of 26,128 patients were included; 1,769 (6.8%) had completed POLST forms. Among patients with POLST, 52.1% had full treatment orders, and 6.4% had their forms accessed before admission. POLST form completion was not associated with hospital admission (adjusted odds ratio [aOR]=0.97; 95% confidence interval [CI] 0.84 to 1.12), ICU admission (aOR=0.82; 95% CI 0.55 to 1.22), or aggressive treatment (aOR=1.06; 95% CI 0.75 to 1.51). Compared with POLST forms with full treatment orders, those with treatment limitations were not associated with hospital admission (aOR=1.12; 95% CI 0.92 to 1.37) or aggressive treatment (aOR=0.87; 95% CI 0.5 to 1.52), but were associated with lower odds of ICU admission (aOR=0.31; 95% CI 0.16 to 0.61)., Conclusion: Among patients presenting to the ED with POLST, the majority of POLST forms had orders for full treatment and were not accessed by emergency providers. These findings may partially explain why we found no association of POLST with treatment intensity. However, treatment limitations on POLST forms were associated with reduced odds of ICU admission. Implementation and accessibility of POLST forms are crucial when considering their effect on the provision of treatment consistent with patients' preferences., (Copyright © 2019 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Introduction: The Oregon Physicians Orders for Life-Sustaining Treatment (POLST) Program allows patients with advanced illness to document end-of-life (EOL) care preferences. We examined the characteristics and associated EOL care among Veterans with and without a registered POLST., Methods: Retrospective, cohort study of advanced-stage (IIIB and IV) patients with lung cancer who were diagnosed between 2008 and 2013 as recorded in the VA Central Cancer Registry. We examined a subgroup of 346 Oregon residents. We obtained clinical and sociodemographic variables from the VA Corporate Data Warehouse and EOL preferences from the Oregon POLST Registry. We compared hospice enrollment and place of death between those with and without a registered POLST., Results: Twenty-two (n = 77) percent of our cohort had registered POLST forms. Compared to those without a registered POLST, Veterans with a POLST had a higher income ($51 456 vs $48 882) and longer time between diagnosis and death (223 days vs 119 days). Those with a registered POLST were more likely to be enrolled in hospice (adjusted odds ratio [aOR] = 2.37, 95% confidence interval [CI]: 1.01-5.54) and less likely to die in a VA facility (aOR = 0.27, 95% CI: 0.12-0.59)., Conclusion: There was low submission to the POLST Registry among Veterans who received care in Veterans' Health Administration. Veterans who had a registered POLST were more likely to be enrolled in hospice and less likely to die in a VA care setting. The POLST may improve metrics of high-quality EOL care; however, opportunities for improvement in submission and implementation within the VA exist.

Introduction/objective: Little is known about the long-term outcomes of injured older adults cared for in trauma systems. We sought to describe mortality and causes of death over time, and the independent association of injury severity, comorbidities, and other factors on 12-month mortality among injured older adults transported by emergency medical services (EMS)., Materials and Methods: This was a population-based cohort study of injured adults ≥ 65 years in the United States transported by 44 EMS agencies to 51 hospitals from January 1, 2011 to December 31, 2011, with 12-month follow-up through December 31, 2012. The primary outcomes were time to death and causes of death. We used descriptive statistics and Cox proportional hazards models to generate adjusted hazard ratios (HR)., Results: 15,649 injured older adults were transported by EMS, frequently after a fall (84.5%). Serious injuries (Injury Severity Score [ISS] ≥ 16) occurred in 3.5%, with serious extremity injury (Abbreviated Injury Scale score ≥ 3) being most common (17.8%). Mortality rates were: 1.6% in-hospital, 5.1% at 30 days, 9.4% at 90 days and 20.3% at 1 year. The adjusted HR for patients in the highest comorbidity quartile was 2.20 (versus lowest quartile, 95% CI 1.97-2.46, p <  .001), while the HR for ISS ≥ 25 was 2.69 (versus ISS 0-8, 95% CI 1.60-4.51, p =  .001). Cardiovascular etiologies (53.3%) and dementia (32.7%) were the most common causes of death, with injury listed in 12.8% of death certificates., Conclusions: Injury requiring EMS transport is a sentinel event among older adults, with death typically occurring months later, often due to cardiovascular causes and dementia. A heavy comorbidity burden had an adjusted mortality risk comparable to severe injury., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Comorbid conditions and anticoagulants have been considered as field triage criteria to raise the sensitivity for identifying seriously injured older adults, but research is sparse. We evaluated the utility of comorbidities, anticoagulant use, and geriatric-specific physiologic measures to improve the sensitivity of the field triage guidelines for high-risk older adults in the out-of-hospital setting., Methods: This was a cohort study of injured adults 65 years or older transported by 44 emergency medical services agencies to 51 trauma and nontrauma hospitals in seven Oregon and Washington counties from January 1, 2011, to December 31, 2011. Out-of-hospital predictors included current field triage criteria, 13 comorbidities, preinjury anticoagulant use, and previously developed geriatric specific physiologic measures. The primary outcome (high-risk patients) was Injury Severity Score of 16 or greater or need for major nonorthopedic surgical intervention. We used binary recursive partitioning to develop a clinical decision rule with a target sensitivity of 95% or greater., Results: There were 5,021 older adults, of which 320 (6.4%) had Injury Severity Score of 16 or greater or required major nonorthopedic surgery. Of the 2,639 patients with preinjury medication history available, 400 (15.2%) were taking an anticoagulant. Current field triage practices were 36.6% sensitive (95% confidence interval [CI], 31.2%-42.0%) and 90.1% specific (95% CI, 89.2%-91.0%) for high-risk patients. Recursive partitioning identified (in order): any current field triage criteria, Glasgow Coma Scale score of 14 or less, geriatric-specific vital signs, and comorbidity count of 2 or more. Anticoagulant use was not identified as a predictor variable. The new criteria were 90.3% sensitive (95% CI, 86.8%-93.7%) and 17.0% specific (95% CI, 15.8%-18.1%)., Conclusions: The current field triage guidelines have poor sensitivity for high-risk older adults. Adding comorbidity information and geriatric-specific physiologic measures improved sensitivity, with a decrement in specificity., Level of Evidence: Prognostic/Epidemiologic, level II.

Background: Exception from infor med consent (EFIC) is allowed using federal regulations 21 CFR 50.24 and facilitates research on patients with critical conditions such as cardiac arrest. Little is known regarding the differences in the application of EFIC requirements such as community consultation (CC), public disclosure (PD) and patient notification. We sought to characterize variations in the fulfillment of EFIC requirements in a national multicenter clinical trial in the United States., Methods: We determined the strategies for fulfillment of EFIC requirements at five regional coordinating centers of the Pragmatic Airway Resuscitation Trial (PART), a cluster-crossover randomized trial comparing airway devices in out-of-hospital cardiac arrest. We collected information from the including site demographics, how CC and PD were implemented, methods undertaken by the site investigative team to meet the local IRB's interpretation, and patient notification timing (post-enrollment). We analyzed the data using descriptive statistics., Results: Sites had multiple approaches to CC, including social media advertising, random digit dialing surveys, working with city officials, and websites with embedded surveys. All sites used more than one approach for conducting CC. Public Disclosure activities included press releases through various means, website documentation, and letters to community members and local officials. Time from CC to study approval ranged from 42 days to 253 days., Conclusion: EFIC implementation varies across sites and highlight community and regional variation. Different EFIC approaches may be needed to effectively accomplish the goals of community consultation, public disclosure, and patient notification., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: The objective was to describe and validate construction of a population-based, longitudinal cohort of injured older adults from 9-1-1 call to 1-year follow-up using existing data sources, probabilistic linkage, and multiple imputation., Methods: This was a descriptive cohort study conducted in seven counties in Oregon and Washington from January 1, 2011, through December 31, 2011, with follow-up through December 31, 2012. The primary cohort included all injured adults ≥ 65 years served by 44 emergency medical services (EMS) agencies. We used nine existing databases to assemble the cohort, including EMS data, two state trauma registries, two state discharge databases, two state vital statistics databases, the Oregon Physician Order for Life-Sustaining Treatment registry, and Medicare claims data. We matched data files using probabilistic linkage and handled missing values with multiple imputation. We independently validated data processes using 1,350 randomly sampled records for probabilistic linkage and 3,140 randomly sampled records for variables created from existing data sources., Results: There were 15,649 injured older adults in the primary cohort, with 13,661 (87.3%) total matched records and 9,337 (59.7%) matches to the index ED/hospital visit. The sensitivity of linkage was 99.9% (95% confidence interval [CI] = 99.3%-100%) for any match and 98.3% (95% CI = 96.2%-99.4%) for index event matches. The specificity of linkage was 95.7% (95% CI = 93.7%-97.2%) for any match and 100% (95% CI = 99.2%-100%) for index event matches. Name, date of birth, home zip code, age, and hospital had the highest yield for linkage. Patients with matched records tended to be higher acuity than unmatched patients, suggesting selection bias if unmatched patients were excluded. Compared to hand-abstracted values, the sensitivity of electronically derived variables ranged from 18.2% (abdominal-pelvic Abbreviated Injury Scale score ≥ 3) to 97.4% (in-hospital mortality), with specificity of 88.0% to 99.8%., Conclusions: A population-based emergency care cohort with long-term outcomes can be constructed from existing data sources with high accuracy and reasonable validity of resulting variables., (© 2018 by the Society for Academic Emergency Medicine.)

Background: The Resuscitation Outcomes Consortium (ROC)epidemiological registry (Epistry) provides opportunities to assess trends in out-of-hospital cardiac arrest treatment and outcomes., Methods: Patient, event, system, treatment, and outcome data from adult (≥18 years) out-of-hospital cardiac arrest (OHCA) from 10 geographically diverse North American ROC sites over four 12-month epochs, from July 1, 2011 to June 30, 2015, were assessed. Descriptive statistics were used to characterize the sample and logistic regression assessed the association of study epoch and key covariates on survival., Results: Overall, 85,553 patients were assessed by Emergency Medical Services (EMS) and 45,516 (53.2%, site range 30.4%-69.9%) had resuscitation attempted by EMS. Patient and event characteristics were consistent except for increases in bystander CPR (41.3%-44.9%) and bystander AED application (3.9%-5.2%). EMS CPR depth and compression fraction increased while pre-shock pause interval decreased. Targeted temperature management was performed in 51.1% of admitted patients and early coronary angiography in 30.2%. Survival to hospital discharge improved (from 10.9% to 11.3% across epochs) with epoch significantly associated with survival (p < 0.001) showing an increasing trend in survival over time. (p = 0.02). Marked site variation in survival persisted within and across epochs (overall site range: 4.2%-19.8%). Patients with an initially shockable rhythm (VT/VF) had an overall survival of 32.2% (site range: 11.9%-47.1%) while survival in bystander witnessed VT/VF was 35.8% (site range: 12.9%-53.1%)., Conclusions: Survival from adult OHCA in multiple large geographically-separate sites improved over the study period. Marked site differences in survival persist and addressing this variation is essential to improve outcomes from OHCA across North America., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Conducting out-of-hospital research is unique and challenging and requires tracking patients across multiple phases of care, using multiple sources of patient records and multiple hospitals. The logistics and strategies used for out-of-hospital research are distinct from other forms of clinical research. The increasing use of electronic health records (EHRs) by hospitals and emergency medical services (EMS) agencies presents a large opportunity for accelerating out-of-hospital research, as well as particular challenges. In this study, we describe seven key aspects of designing and implementing out-of-hospital research in the era of EHRs: (1) selection of research sites, (2) defining the patient population, (3) patient sampling and sample size calculations, (4) EMS data, (5) hospital selection, (6) handling missing data, and (7) statistical analysis. We use examples from a recent prospective out-of-hospital cohort study to illustrate these topics, including lessons learned.

Background: During cardiopulmonary resuscitation (CPR), there is a high incidence of capnograms distorted by chest compression artifact. This phenomenon adversely affects the reliability of automated ventilation detection based on the analysis of the capnography waveform. This study explored the feasibility of several filtering techniques for suppressing the artifact to improve the accuracy of ventilation detection., Materials and Methods: We gathered a database of 232 out-of-hospital cardiac arrest defibrillator recordings containing concurrent capnograms, compression depth and transthoracic impedance signals. Capnograms were classified as non-distorted or distorted by chest compression artifact. All chest compression and ventilation instances were also annotated. Three filtering techniques were explored: a fixed-coefficient (FC) filter, an open-loop (OL) adaptive filter, and a closed-loop (CL) adaptive filter. The improvement in ventilation detection was assessed by comparing the performance of a capnogram-based ventilation detection algorithm with original and filtered capnograms., Results: Sensitivity and positive predictive value of the ventilation algorithm improved from 91.9%/89.5% to 97.7%/96.5% (FC filter), 97.6%/96.7% (OL), and 97.0%/97.1% (CL) for the distorted capnograms (42% of the whole set). The highest improvement was obtained for the artifact named type III, for which performance improved from 77.8%/74.5% to values above 95.5%/94.5%. In addition, errors in the measurement of ventilation rate decreased and accuracy in the detection of over-ventilation increased with filtered capnograms., Conclusions: Capnogram-based ventilation detection during CPR was enhanced after suppressing the artifact caused by chest compressions. All filtering approaches performed similarly, so the simplicity of fixed-coefficient filters would take advantage for a practical implementation., Competing Interests: The authors have declared that no competing interests exist.

Background: Intra-resuscitation antiarrhythmic drugs may improve resuscitation outcomes, in part by avoiding rearrest, a condition associated with poor out-of-hospital cardiac arrest (OHCA) outcomes. However, antiarrhythmics may also alter defibrillation threshold. The objective of this study was to investigate the relationship between rearrest and intra-resuscitation antiarrhythmic drugs in the context of the Resuscitation Outcomes Consortium (ROC) amiodarone, lidocaine, and placebo (ALPS) trial., Hypothesis: Rearrest rates would be lower in cases treated with amiodarone or lidocaine, versus saline placebo, prior to first return of spontaneous circulation (ROSC). We also hypothesized antiarrhythmic effects would be quantifiable through analysis of the prehospital electrocardiogram., Methods: We conducted a secondary analysis of the ROC ALPS trial. Cases that first achieved prehospital ROSC after randomized administration of study drug were included in the analysis. Rearrest, defined as loss of pulses following ROSC, was ascertained from emergency medical services records. Rearrest rate was calculated overall, as well as by ALPS treatment group. Multivariable logistic regression models were constructed to assess the association between treatment group and rearrest, as well as rearrest and both survival to hospital discharge and survival with neurologic function. Amplitude spectrum area, median slope, and centroid frequency of the ventricular fibrillation (VF) ECG were calculated and compared across treatment groups., Results: A total of 1144 (40.4%) cases with study drug prior to first ROSC were included. Rearrest rate was 44.0% overall; 42.9% for placebo, 45.7% for lidocaine, and 43.0% for amiodarone. In multivariable logistic regression models, ALPS treatment group was not associated with rearrest, though rearrest was associated with poor survival and neurologic outcomes. AMSA and median slope measures of the first available VF were associated with rearrest case status, while median slope and centroid frequency were associated with ALPS treatment group., Conclusion: Rearrest rates did not differ between antiarrhythmic and placebo treatment groups. ECG waveform characteristics were correlated with treatment group and rearrest. Rearrest was inversely associated with survival and neurologic outcomes., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Capnography has been proposed as a method for monitoring the ventilation rate during cardiopulmonary resuscitation (CPR). A high incidence (above 70%) of capnograms distorted by chest compression induced oscillations has been previously reported in out-of-hospital (OOH) CPR. The aim of the study was to better characterize the chest compression artefact and to evaluate its influence on the performance of a capnogram-based ventilation detector during OOH CPR., Methods: Data from the MRx monitor-defibrillator were extracted from OOH cardiac arrest episodes. For each episode, presence of chest compression artefact was annotated in the capnogram. Concurrent compression depth and transthoracic impedance signals were used to identify chest compressions and to annotate ventilations, respectively. We designed a capnogram-based ventilation detection algorithm and tested its performance with clean and distorted episodes., Results: Data were collected from 232 episodes comprising 52 654 ventilations, with a mean (±SD) of 227 (±118) per episode. Overall, 42% of the capnograms were distorted. Presence of chest compression artefact degraded algorithm performance in terms of ventilation detection, estimation of ventilation rate, and the ability to detect hyperventilation., Conclusion: Capnogram-based ventilation detection during CPR using our algorithm was compromised by the presence of chest compression artefact. In particular, artefact spanning from the plateau to the baseline strongly degraded ventilation detection, and caused a high number of false hyperventilation alarms. Further research is needed to reduce the impact of chest compression artefact on capnographic ventilation monitoring., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: To compare odds of survival to hospital discharge among pediatric out-of-hospital cardiac arrest (OHCA) patients receiving either bag-valve-mask ventilation (BVM), supraglottic airway (SGA) or endotracheal intubation (ETI), after adjusting for the propensity to receive a given airway intervention., Methods: Retrospective cohort study using the Cardiac Arrest Registry to Enhance Survival (CARES) database from January 1 201-December 31, 2015. The CARES registry includes data on cardiac arrests from 17 statewide registries and approximately 55 additional US cities. We included patients less than18 years of age who suffered a non-traumatic OHCA and received a resuscitation attempt by Emergency Medical Services (EMS). The key exposure was the airway management strategy (BVM, ETI, or SGA). The primary outcome was survival to hospital discharge., Results: Of the 3793 OHCA cases included from 405 EMS agencies, 1724 cases were analyzed after limiting the analysis to EMS agencies that used all 3 devices. Of the 1724, 781 (45.3%) were treated with BVM only, 727 (42.2%) ETI, and 215 (12.5%) SGA. Overall, 20.7% had ROSC and 10.9% survived to hospital discharge. After using a propensity score analysis, the odds ratio for survival to hospital discharge for ETI compared to BVM was 0.39 (95%CI 0.26-0.59) and for SGA compared to BVM was 0.32 (95% CI 0.12-0.84). These relationships were robust to the sensitivity analyses including complete case, EMS-agency matched, and age-stratified., Conclusions: BVM was associated with higher survival to hospital discharge compared to ETI and SGA. A large randomized clinical trial is needed to confirm these findings., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: To compare the sensitivity of current field triage practices for identifying high-risk trauma patients to strict guideline adherence, including changes in triage specificity, ambulance transport patterns, and trauma center volumes., Methods: This was a pre-planned secondary analysis of an out-of-hospital prospective cohort of injured children and adults transported by 44 EMS agencies to 28 trauma and non-trauma hospitals in 7 Northwest U.S. counties from January 1, 2011 through December 31, 2011. Outcomes included Injury Severity Score (ISS) ≥16 (primary) and early critical resource use. Strict adherence of the triage guidelines was based on evidence in the EMS chart for patients meeting any current field triage criteria, calculated with and without strict interpretation of the age criterion (<15 or >55 years). Due to the probability sampling nature of the cohort, strata and weights were included in all analyses., Results: 17,633 injured patients were transported by EMS (weighted to represent 53,487 transported patients), including 3.1% with ISS ≥16 and 1.7% requiring early critical resources. Field triage sensitivity for identifying patients with ISS ≥16 increased from the current 66.2% (95% CI 60.2-71.7%) to 87.3% (95% CI 81.9-91.2%) for strict adherence without age and to 91.0% (95% CI 86.4-94.2%) for strict adherence with age. Specificity decreased with increasing adherence, from 87.8% (current) to 47.6% (strict adherence without age) and 35.8% (strict adherence with age). Areas under the curve (AUC) were 0.78, 0.73, and 0.72, respectively. Results were similar for patients requiring early critical resources. We estimate the number of triage-positive patients transported each year by EMS to an individual major trauma center (on average) to increase from 1,331 (current) to 5,139 (strict adherence without age) and to 6,256 (strict adherence with age)., Conclusions: The low sensitivity of current triage practices would be expected to improve with strict adherence to current triage guidelines, with a commensurate decrease in triage specificity and an increase in the number of triage-positive patients transported to major trauma centers.

Background: Some patients with out-of-hospital cardiac arrest (OHCA) assessed by emergency medical services (EMS) do not receive attempts at resuscitation on the basis of perceived futility., Aims: 1) To measure variability in the initiation of resuscitation attempts in EMS-assessed OHCA patients across EMS agencies, 2) to evaluate the association between selected EMS agency characteristics and the proportion of patients receiving resuscitation attempts, and 3) to evaluate the association between proportion receiving resuscitation attempts and survival., Methods: A retrospective cohort study using data from 129 EMS agencies participating in the Resuscitation Outcomes Consortium (ROC) epidemiologic registry (EPISTRY) - Cardiac Arrest from 12/01/2005 to 12/31/2010. We included non-traumatic OHCA patients assessed by EMS., Results: We included 86,912 OHCA patients. Overall, 54.8% had resuscitation attempted by EMS providers, varying from 23.9% to 100% (p=<0.001) across EMS agencies. The proportion of patients receiving a resuscitation attempt was 7.87% less (95% CI 3.73-12.0) among agencies with longer average response intervals (≥6min) compared with shorter average response intervals (<6min) and 16.9% less (95% CI 11.9-21.9) among agencies with higher levels of advanced life support (ALS) availability (≥50% of available units) compared with lower levels of ALS availability (<50% of available units). There was a moderate positive correlation between the proportion of patients with resuscitation attempts and survival to hospital discharge (r=0.54, p<0.001)., Conclusions: The proportion of patients with OHCA who receive resuscitation attempts is variable across EMS agencies and is associated with EMS response interval, ALS unit availability and geographic region. On average, survival was higher among EMS agencies more likely to initiate resuscitation., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Previous work has demonstrated that when out-of-hospital cardiac arrest (OHCA) patients achieve return of spontaneous circulation (ROSC), but subsequently have another cardiac arrest prior to hospital arrival (rearrest), the probability of survival to hospital discharge is significantly decreased. Additionally, few modifiable factors for rearrest are known. We sought to examine the association between rearrest and compression-to-ventilation ratio during cardiopulmonary resuscitation (CPR) and to confirm the association between rearrest and outcomes., Hypothesis: Rearrest incidence would be similar between cases treated with 30:2 or continuous chest compression (CCC) CPR, but inversely related to survival and good neurological outcome., Methods: We conducted a secondary analysis of a large randomized-controlled trial of CCC versus 30:2 CPR for the treatment of OHCA between 2011 and 2015 among 8 sites of the Resuscitation OUTCOMES: Consortium (ROC). Patients were randomized through an emergency medical services (EMS) agency-level cluster randomization design to receive either 30:2 or CCC CPR. Case data were derived from prehospital patient care reports, digital defibrillator files, and hospital records. The primary analysis was an as-treated comparison of the proportion of patients with a rearrest for patients who received 30:2 versus those who received CCC. In addition, we assessed the association between rearrest and both survival to hospital discharge and favorable neurological outcome (Modified Rankin Score≤3) in patients with and without ROSC upon ED arrival using multivariable logistic regression adjusting for age, sex, initial rhythm and measures of CPR quality., Results: There were 14,109 analyzable cases that were determined to have definitively received either CCC or 30:2 CPR. Of these, 4713 had prehospital ROSC and 2040 (43.2%) had at least one rearrest. Incidence of rearrest was not significantly different between patients receiving CCC and 30:2 (44.1% vs 41.8%; adjusted OR: 1.01; 95% CI: 0.88, 1.16). Rearrest was significantly associated with lower survival (23.3% vs 36.9%; adjusted OR: 0.46; 95%CI: 0.36-0.51) and worse neurological outcome (19.4% vs 30.2%; adjusted OR: 0.46; 95%CI: 0.38, 0.55)., Conclusion: Rearrest occurrence was not significantly different between patients receiving CCC and 30:2, and was inversely associated with survival to hospital discharge and MRS., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm records advance care planning for patients with advanced illness or frailty as actionable medical records. The National POLST Paradigm Task Force recommends that physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs) be permitted to execute POLST forms., Objective: To investigate the percentage of Oregon POLST forms signed by APRNs, and examine the obstacles faced by states attempting to allow APRNs to sign POLST forms., Design: Cross-sectional., Setting/subjects: 226,101 Oregon POLST Registry forms from 2010 to 2015., Measurements: POLST forms in the Oregon Registry were matched with signer type (MD, DO, APRN, PA)., Results: 226,101 POLST forms have been added to the Oregon POLST Registry from 2010 to 2015: 85.3% of forms were signed by a physician, 10.9% of forms were signed by an APRN, and 3.8% of forms were signed by a PA. From 2010 to 2015, the overall percentage of POLST forms signed by an APRN has increased from 9.0% in 2010 to 11.9% in 2015. Physicians are authorized signers in all 19 states with endorsed POLST Paradigm programs; 16 of these states also authorize APRN signature, and 3 states (LA, NY, and GA) allow only physicians to sign., Conclusions: More than 10% of Oregon POLST forms are signed by APRNs. Given the need for timely POLST form completion, ideally by a member of the interdisciplinary team who knows the patient's preferences best, these data support authorizing APRNs to complete POLST forms.

Background: The national field trauma triage guidelines have been widely implemented in US trauma systems, but never prospectively validated. We sought to prospectively validate the guidelines, as applied by out-of-hospital providers, for identifying high-risk trauma patients., Study Design: This was an out-of-hospital prospective cohort study from January 1, 2011 through December 31, 2011 with 44 Emergency Medical Services agencies in 7 counties in 2 states. We enrolled injured patients transported to 28 acute care hospitals, including 7 major trauma centers (Level I and II trauma hospitals) and 21 nontrauma hospitals. The primary exposure term was Emergency Medical Services' use of one or more field triage criteria in the national field triage guidelines. Outcomes included Injured Severity Score ≥16 (primary) and critical resource use within 24 hours of emergency department arrival (secondary)., Results: We enrolled 53,487 injured children and adults transported by Emergency Medical Services to an acute care hospital, 17,633 of which were sampled for the primary analysis; 13.9% met field triage guidelines, 3.1% had Injury Severity Score ≥16, and 1.7% required early critical resources. The sensitivity and specificity of the field triage guidelines were 66.2% (95% CI, 60.2-71.7%) and 87.8% (95% CI, 87.7-88.0%) for Injury Severity Score ≥16 and 80.1% (95% CI, 65.8-89.4%) and 87.3% (95% CI 87.1-87.4%) for early critical resource use. Triage guideline sensitivity decreased with age, from 87.4% in children to 51.8% in older adults., Conclusions: The national field triage guidelines are relatively insensitive for identifying seriously injured patients and patients requiring early critical interventions, particularly among older adults., (Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

The study attempts to determine the prevalence of organisms associated with urethritis in men in rural southwestern Haiti and to determine the association with demographic, clinical and laboratory variables. A standardised verbal interview was conducted; genital examinations were done; urethral swabs were collected for nucleic acid amplification testing, and first void urine was obtained for urinalysis. The mean participant age was 54; 88.8% lived in a rural area. Swabs were positive for Trichomonas vaginalis in 13.7% (28/205), Mycoplasma genitalium in 6.3% (13/205), Chlamydia trachomatis in 4.4% (9/205) and Neisseria gonorrhoeae in 0% (0/205). Subjects who never reported using condoms were nearly 3.5 times more likely to have any positive swab result (OR: 3.46, 95% CI 1.31-9.14). Subjects who reported their partners had other sexual partners or were unsure were more than three times likely to have any positive swab result (OR: 3.44, 95% CI 1.33-8.92). Infections with Trichomonas vaginalis and Mycoplasma genitalium were the most common., (© The Author(s) 2014.)

Background: Survival varies among those resuscitated from out-of-hospital cardiac arrest (OHCA). Evidence-based performance measures have been used to describe hospital quality of care in conditions such as acute coronary syndrome and major trauma. It remains unclear if adherence to performance measures is associated with better outcome in patients hospitalized after OHCA., Objectives: To assess whether a composite performance score based on evidence-based guidelines for care of patients resuscitated from OHCA was independently associated with clinical outcomes., Methods: Included were 3252 patients with OHCA who received care at 111 U.S. and Canadian hospitals participating in the Resuscitation Outcomes Consortium (ROC-PRIMED) study between June 2007 and October 2009. We calculated composite performance scores for all patients, aggregated these at the hospital level, then associated them with patient mortality and favorable neurological status at discharge., Results: Composite performance scores varied widely (median [IQR] scores from lowest to highest hospital quartiles, 21% [20%, 25%] vs. 59% [55%, 64%]. Adjusted survival to discharge increased with each quartile of performance score (from lowest to highest: 16.2%, 20.8%, 28.5%, 34.8%, P<0.01), with similar findings for adjusted rates of good neurologic status. Hospital score was significantly associated with outcome after risk adjustment for established baseline factors (highest vs. lowest adherence quartile: adjusted OR of survival 1.64; 95% CI 1.13, 2.38)., Conclusions: Greater survival and favorable neurologic status at discharge were associated with greater adherence to recommended hospital based post-resuscitative care guidelines. Consideration should be given to measuring, reporting and improving hospital adherence to guideline-based performance measures, which could improve outcomes following OHCA., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: Cardiopulmonary resuscitation (CPR) guidelines recommend the administration of chest compressions (CC) at a standardized rate and depth without guidance from patient physiologic output. The relationship between CC performance and actual CPR-generated blood flow is poorly understood, limiting the ability to define "optimal" CPR delivery. End-tidal carbon dioxide (ETCO2) has been proposed as a surrogate measure of blood flow during CPR, and has been suggested as a tool to guide CPR despite a paucity of clinical data. We sought to quantify the relationship between ETCO2 and CPR characteristics during clinical resuscitation care., Methods: Multicenter cohort study of 583 in- and out-of-hospital cardiac arrests with time-synchronized ETCO2 and CPR performance data captured between 4/2006 and 5/2013. ETCO2, ventilation rate, CC rate and depth were averaged over 15-s epochs. A total of 29,028 epochs were processed for analysis using mixed-effects regression techniques., Results: CC depth was a significant predictor of increased ETCO2. For every 10mm increase in depth, ETCO2 was elevated by 1.4mmHg (p<.001). For every 10 breaths/min increase in ventilation rate, ETCO2 was lowered by 3.0mmHg (p<.001). CC rate was not a predictor of ETCO2 over the dynamic range of actual CC delivery. Case-averaged ETCO2 values in patients with return of spontaneous circulation were higher compared to those who did not have a pulse restored (34.5±4.5 vs 23.1±12.9mmHg, p<.001)., Conclusions: ETCO2 values generated during CPR were statistically associated with CC depth and ventilation rate. Further studies are needed to assess ETCO2 as a potential tool to guide care., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objectives: To examine the relationship between Physician Orders for Life-Sustaining Treatment (POLST) for Scope of Treatment and setting of care at time of death., Design: Cross-sectional., Setting: Oregon in 2010 and 2011., Participants: People who died of natural causes., Measurements: Oregon death records containing cause and location of death were matched with POLST orders for people with a POLST form in the Oregon POLST registry. Logistic regression was used to measure the association between POLST orders and location of death., Results: Of 58,000 decedents, 17,902 (30.9%) had a POLST form in the registry. Their orders for Scope of Treatment were comfort measure only, 11,836 (66.1%); limited interventions, 4,787 (26.7%); and full treatment, 1,153 (6.4%). Comfort measures only (CMO) orders advise avoiding hospitalization unless comfort cannot be achieved in the current setting; 6.4% of participants with POLST CMO orders died in the hospital, compared with 44.2% of those with orders for full treatment and 34.2% for those with no POLST form in the registry. In the logistic regression, the odds of dying in the hospital of those with an order for limited interventions was 3.97 times as great (95% CI = 3.59-4.39) as of those with a CMO order, and the odds of those with an order for full treatment was 9.66 times as great (95% CI = 8.39-11.13)., Conclusions: The association with numbers of deaths in the hospital suggests that end-of-life preferences of people who wish to avoid hospitalization as documented in POLST orders are honored., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

Study Objective: Resuscitation measures should be guided by previous patient choices about end-of-life care, when they exist; however, documentation of these choices can be unclear or difficult to access. We evaluate the concordance of a statewide registry of actionable resuscitation orders unique to Oregon with out-of-hospital and emergency department (ED) care provided for patients found by emergency medical services (EMS) in out-of-hospital cardiac arrest., Methods: This was a retrospective cohort study of patients found by EMS providers in out-of-hospital cardiac arrest in 5 counties in 2010. We used probabilistic linkage to match patients found in out-of-hospital cardiac arrest with previously signed documentation of end-of-life decisions in the Oregon Physician Orders for Life-Sustaining Treatment (POLST) registry. We evaluated resuscitation interventions in the field and ED., Results: There were 1,577 patients found in out-of-hospital cardiac arrest, of whom 82 had a previously signed POLST form. Patients with POLST do-not-resuscitate orders for whom EMS was called had resuscitation withheld or ceased before hospital admission in 94% of cases (95% confidence interval [CI] 83% to 99%). Compared with patients with no POLST or known do-not-resuscitate orders, more patients with attempt resuscitation POLST orders had field resuscitation attempted (84% versus 60%; difference 25%; 95% CI 12% to 37%) and were admitted to hospitals (38% versus 17%; difference 20%; 95% CI 3% to 37%), with no documented misinterpretations of the form once CPR was initiated., Conclusion: In this sample of patients in out-of-hospital cardiac arrest, out-of-hospital and ED care was generally concordant with previously documented end-of-life orders in the setting of critical illness. Further research is needed to compare the effectiveness of Oregon's POLST system to other methods of end-of-life order documentation., (Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Background: Physician Orders for Life-Sustaining Treatment (POLST) has become a common means of documenting patient treatment preferences. In addition to orders either for Attempt Resuscitation or Do Not Attempt Resuscitation, for patients not in cardiopulmonary arrest, POLST provides three levels of treatment: Full Treatment, Limited Interventions, and Comfort Measures Only. Oregon has an electronic registry for POLST forms completed in the state. We used registry data to examine the different combinations of treatment orders., Methods and Results: We analyzed data from forms signed and entered into the Oregon POLST Registry in 2012. The analysis included 31,294 POLST forms. The mean Registrant age was 76.7 years. 21,396 (68.4%) had Do Not Attempt Resuscitation (DNR) orders and 9900 (31.6%) had orders for "Attempt Resuscitation". The 6 order combinations were: Do Not Resuscitate (DNR)/Comfort Measures Only 10,769 (34.4%), DNR/Limited Interventions 9306 (29.7%), DNR/Full Treatment 1211 (3.9%), Attempt Cardiopulmonary Resuscitation (CPR)/Comfort Measures Only 11 (0.04%), Attempt CPR/Limited Interventions 2281 (7.3%), and Attempt CPR/Full Treatment 7473 (23.9%)., Conclusions: The most common order combinations were DNR/Comfort Measures Only, DNR/Limited Interventions and Attempt Resuscitation/Full Treatment. These three makes sense to health professionals. However, other order combinations that require interpretation at the time of a crisis were completed for about 10% of Registrants. These combinations need further investigation., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background: National benchmarks for trauma triage sensitivity (≥95%) and specificity (≥50%) have not been rigorously evaluated across broad populations of injured patients. We evaluated the impact of different field triage schemes for identifying seriously injured patients across a range of sensitivity values. Impact metrics included specificity and number of undertriaged and overtriaged patients compared with current triage practices., Methods: This was a retrospective cohort study of injured children and adults transported by 48 emergency medical service (EMS) agencies to 105 hospitals in 6 regions of the Western United States from 2006 through 2008. Hospital outcomes were probabilistically linked to EMS records through trauma registries, state discharge databases, and state emergency department databases. The primary outcome was an Injury Severity Score (ISS) of 16 or greater. We evaluated 40 field predictor variables, including 31 current field triage criteria, using classification and regression tree analysis and cross-validation to generate estimates for sensitivity and specificity., Results: A total of 89,261 injured patients were evaluated and transported by EMS providers during the 3-year period, of whom 5,711 (6.4%) had ISS of 16 or greater. As the 95% sensitivity target for triage was approached (from the current value of 87.5%), decision tree complexity increased, specificity decreased (from 62.8% to 18.7%), and the number of triage-positive patients without serious injury doubled (67,927 vs. 31,104). Analyses restricted to children and older adults were similar. The most consistent modification to the current triage algorithm to increase sensitivity without a major decrease in specificity was altering the Glasgow Coma Scale (GCS) score cutoff point from 13 or less to 14 or less (sensitivity increase to 90.4%)., Conclusion: Reaching the field triage sensitivity benchmark of 95% would require a large decrease in specificity (increase in overtriage). A 90% sensitivity target seems more realistic and may be obtainable by modest changes to the current triage algorithm.

Objectives: Among patients successfully resuscitated from out-of-hospital cardiac arrest (OHCA) and admitted to California hospitals, we examined how the placement of a do not resuscitate (DNR) order in the first 24h after admission was associated with patient care, procedures and inhospital survival. We further analyzed hospital and patient demographic factors associated with early DNR placement among patients admitted following OHCA., Methods: We identified post-OHCA patients from a statewide California database of hospital admissions from 2002 to 2010. Documentation of patient and hospital demographics, hospital interventions, and patient outcome were analyzed by descriptive statistics and multiple regression models to calculate odds ratios and 95% confidence intervals., Results: Of 5212 patients admitted to California hospitals after resuscitation from OHCA, 1692 (32.5%) had a DNR order placed in the first 24h after admission. These patients had decreased frequency of cardiac catheterization (1.1% vs. 4.3%), blood transfusion (7.6% vs. 11.2%), ICD placement (0.1% vs. 1.1%), and survival to discharge (5.2% vs. 21.6%, all p-values<0.0001). There was wide intrahospital variability and significant racial differences in the adjusted odds of early DNR orders (Asian, OR 0.67, 95% CI 0.48-0.95; Black, OR 0.49, 95% CI 0.35-0.69)., Conclusions: Early DNR placement is associated with a decrease in potentially critical hospital interventions, procedures, and survival to discharge, and wide variability in practice patterns between hospitals. In the absence of prior patient wishes, DNR placement within 24h may be premature given the lack of early prognostic indicators after OHCA., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: The Physician Orders for Life-Sustaining Treatment (POLST) form translates patient treatment preferences into medical orders. The Oregon POLST Registry provides emergency personnel 24-h access to POLST forms., Objective: To determine if Emergency Medical Technicians (EMTs) can use the Oregon POLST Registry to honor patient preferences., Methods: Two telephone surveys were developed: one for the EMT who made a call to the Registry and one for the patient or the surrogate. The EMT survey was designed to determine if the POLST form accessed through the Registry changed the care of the patient. The patient/surrogate survey was designed to determine if the care provided matched the preferences on the POLST. When feasible, the Emergency Medical Services (EMS) record was reviewed to determine whether or not treatment was provided., Results: During the study period there were 34 EMS calls with matches to patients' POLST forms, and 23 interviews were completed with EMS callers, for a response rate of 68%. In seven cases (30%) the patient was in cardiopulmonary arrest; one patient had a respiratory arrest with a pulse. Eight respondents (35%) reported that the patient was conscious and apparently able to make decisions about preferences. For 10 cases (44%) the POLST orders changed treatment, and in six instances (26%) they affected the decision to transport the patient. For the 10/11 patients or surrogates interviewed, the care reportedly matched their wishes., Conclusion: This small study suggests that an electronic registry of POLST forms can be used by EMTs to enhance their ability to locate and honor patient preferences regarding life-sustaining treatments., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Transport of out-of-hospital cardiac arrest (OHCA) patients expeditiously to appropriately equipped hospitals is of paramount importance., Objective: We sought to test the correlation of the centroids of geographic units with the actual transport distance for OHCA patients in order to determine the most appropriate surrogate marker of location for future planning, protocol development, and research projects., Methods: This was a prospective, observational analysis of OHCA events in Portland, Oregon. Using geographic information systems (GISs), the locations of OHCA events and receiving hospitals were identified and geocoded for visual inspection and analysis. Transport distance was calculated via network transport distance and Euclidean distance from multiple surrogate markers of location (centroids of ZIP code, census tract, census block group, and census block). Actual distance from the location of the event was then compared with these surrogate markers to determine the accuracy of alternative markers of OHCA location., Results: Two hundred seventy patients had location data recorded, 163 of whom were transported to a hospital for further care. The median transport distance was 5.17 miles. The transport distance of OHCA patients from the centroid of the census block had the best correlation (R(2) = 0.99) with actual transport distance, whereas the use of the centroid of ZIP codes as a surrogate location had the lowest correlation (R(2) = 0.21)., Conclusions: The use of centroids of census blocks via network distance is a valid surrogate for actual location of an OHCA event when calculating transport distance.

Objectives:   The objective was to compare case ascertainment, agreement, validity, and missing values for clinical research data obtained, processed, and linked electronically from electronic health records (EHR) compared to "manual" data processing and record abstraction in a cohort of out-of-hospital trauma patients., Methods:   This was a secondary analysis of two sets of data collected for a prospective, population-based, out-of-hospital trauma cohort evaluated by 10 emergency medical services (EMS) agencies transporting to 16 hospitals, from January 1, 2006, through October 2, 2007. Eighteen clinical, operational, procedural, and outcome variables were collected and processed separately and independently using two parallel data processing strategies by personnel blinded to patients in the other group. The electronic approach included EHR data exports from EMS agencies, reformatting, and probabilistic linkage to outcomes from local trauma registries and state discharge databases. The manual data processing approach included chart matching, data abstraction, and data entry by a trained abstractor. Descriptive statistics, measures of agreement, and validity were used to compare the two approaches to data processing., Results:   During the 21-month period, 418 patients underwent both data processing methods and formed the primary cohort. Agreement was good to excellent (kappa = 0.76 to 0.97; intraclass correlation coefficient [ICC] = 0.49 to 0.97), with exact agreement in 67% to 99% of cases and a median difference of zero for all continuous and ordinal variables. The proportions of missing out-of-hospital values were similar between the two approaches, although electronic processing generated more missing outcomes (87 of 418, 21%, 95% confidence interval [CI] = 17% to 25%) than the manual approach (11 of 418, 3%, 95% CI = 1% to 5%). Case ascertainment of eligible injured patients was greater using electronic methods (n = 3,008) compared to manual methods (n = 629)., Conclusions:   In this sample of out-of-hospital trauma patients, an all-electronic data processing strategy identified more patients and generated values with good agreement and validity compared to traditional data collection and processing methods., (© 2012 by the Society for Academic Emergency Medicine.)

Background: The American College of Surgeons Committee on Trauma (ACSCOT) has developed and updated field trauma triage protocols for decades, yet the ability to identify major trauma patients remains unclear. We estimate the diagnostic value of the Field Triage Decision Scheme for identifying major trauma patients (Injury Severity Score [ISS] ≥ 16) in a large and diverse multisite cohort., Study Design: This was a retrospective cohort study of injured children and adults transported by 94 emergency medical services (EMS) agencies to 122 hospitals in 7 regions of the Western US from 2006 through 2008. Patients who met any of the field trauma triage criteria (per EMS personnel) were considered triage positive. Hospital outcomes measures were probabilistically linked to EMS records through trauma registries, state discharge data, and emergency department data. The primary outcome defining a "major trauma patient" was ISS ≥ 16., Results: There were 122,345 injured patients evaluated and transported by EMS over the 3-year period, 34.5% of whom met at least 1 triage criterion and 5.8% had ISS ≥ 16. The overall sensitivity and specificity of the criteria for identifying major trauma patients were 85.8% (95% CI 85.0% to 86.6%) and 68.7% (95% CI 68.4% to 68.9%), respectively. Triage sensitivity and specificity, respectively, differed by age: 84.1% and 66.4% (0 to 17 years); 89.5% and 64.3% (18 to 54 years); and 79.9% and 75.4% (≥55 years). Evaluating the diagnostic value of triage by hospital destination (transport to Level I/II trauma centers) did not substantially improve these findings., Conclusions: The sensitivity of the Field Triage Decision Scheme for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders., (Copyright © 2011 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: In a departure from the previous strategy of immediate defibrillation, the 2005 resuscitation guidelines from the American Heart Association-International Liaison Committee on Resuscitation suggested that emergency medical service (EMS) personnel could provide 2 minutes of cardiopulmonary resuscitation (CPR) before the first analysis of cardiac rhythm. We compared the strategy of a brief period of CPR with early analysis of rhythm with the strategy of a longer period of CPR with delayed analysis of rhythm., Methods: We conducted a cluster-randomized trial involving adults with out-of-hospital cardiac arrest at 10 Resuscitation Outcomes Consortium sites in the United States and Canada. Patients in the early-analysis group were assigned to receive 30 to 60 seconds of EMS-administered CPR and those in the later-analysis group were assigned to receive 180 seconds of CPR, before the initial electrocardiographic analysis. The primary outcome was survival to hospital discharge with satisfactory functional status (a modified Rankin scale score of ≤3, on a scale of 0 to 6, with higher scores indicating greater disability)., Results: We included 9933 patients, of whom 5290 were assigned to early analysis of cardiac rhythm and 4643 to later analysis. A total of 273 patients (5.9%) in the later-analysis group and 310 patients (5.9%) in the early-analysis group met the criteria for the primary outcome, with a cluster-adjusted difference of -0.2 percentage points (95% confidence interval, -1.1 to 0.7; P=0.59). Analyses of the data with adjustment for confounding factors, as well as subgroup analyses, also showed no survival benefit for either study group., Conclusions: Among patients who had an out-of-hospital cardiac arrest, we found no difference in the outcomes with a brief period, as compared with a longer period, of EMS-administered CPR before the first analysis of cardiac rhythm. (Funded by the National Heart, Lung, and Blood Institute and others; ROC PRIMED ClinicalTrials.gov number, NCT00394706.).

Background: Statewide emergency medical services (EMS) data linked to outcomes are critical for promoting high-quality emergency care; however, many states do not have such a resource., Objective: To demonstrate the feasibility of creating such a statewide database using a one-month pilot sample., Methods: This was a prospective cohort study of all EMS patient encounters throughout Oregon during May 2008. Eighty-three National EMS Information System (NEMSIS) variables were obtained from EMS agencies via electronic or paper charts. We reformatted raw data, mapped NEMSIS fields, entered hard-copy records, and uploaded data files to a statewide electronic medical records platform. Records from transport and nontransport (first-responder) agencies caring for the same patients were matched using probabilistic linkage, then linked to three statewide outcome databases (Oregon Hospital Discharge Database [OHDD], Oregon Trauma Registry [OTR], and Oregon Department of Transportation [ODOT] Crash File) using similar methodology. We estimated population-adjusted case ascertainment by county and used descriptive statistics to characterize the process., Results: During the one-month period, we collected 27,474 EMS records in 36 (100%) counties from 106 (77%) licensed transport agencies and 10 nontransport agencies, representing 20,673 persons. There were 3,302 admission record matches, 285 trauma registry matches, and 392 crash record matches. Overall, 3,979 hospital outcomes were matched to EMS records for 80 (75%) transport and six (60%) first-responder agencies. Median per-agency match rates were 16.3% for OHDD (interquartile range [IQR] 8.3-22.2%, range 0-56.5%), 0.9% for OTR (IQR 0-2.5%, range 0-60.0%), and 1.6% for ODOT (IQR 0-3.5%, range 0-23.1%)., Conclusion: Developing a statewide EMS database linked to hospital outcomes is feasible. The processes used in this study and match rate estimates may provide a template for other states to follow, enhancing opportunities for outcomes-based EMS research and EMS quality assurance efforts.

Background: The decision-making processes used for out-of-hospital trauma triage and hospital selection in regionalized trauma systems remain poorly understood. The objective of this study was to assess the process of field triage decision making in an established trauma system., Methods: We used a mixed methods approach, including emergency medical services (EMS) records to quantify triage decisions and reasons for hospital selection in a population-based, injury cohort (2006-2008), plus a focused ethnography to understand EMS cognitive reasoning in making triage decisions. The study included 10 EMS agencies providing service to a four-county regional trauma system with three trauma centers and 13 nontrauma hospitals. For qualitative analyses, we conducted field observation and interviews with 35 EMS field providers and a round table discussion with 40 EMS management personnel to generate an empirical model of out-of-hospital decision making in trauma triage., Results: A total of 64,190 injured patients were evaluated by EMS, of whom 56,444 (88.0%) were transported to acute care hospitals and 9,637 (17.1% of transports) were field trauma activations. For nontrauma activations, patient/family preference and proximity accounted for 78% of destination decisions. EMS provider judgment was cited in 36% of field trauma activations and was the sole criterion in 23% of trauma patients. The empirical model demonstrated that trauma triage is driven primarily by EMS provider "gut feeling" (judgment) and relies heavily on provider experience, mechanism of injury, and early visual cues at the scene., Conclusions: Provider cognitive reasoning for field trauma triage is more heuristic than algorithmic and driven primarily by provider judgment, rather than specific triage criteria.

Study Objective: News media are used for community education and notification in exception from informed consent clinical trials, yet their effectiveness as an added safeguard in such research remains unknown. We assessed the number of callers requesting opt-out bracelets after each local media report and described the errors and content within each media report., Methods: We undertook a descriptive analysis of local media trial coverage (newspaper, television, radio, and Web log) and opt-out requests during a 41-month period at a single site participating in an exception from informed consent out-of-hospital trial. Two nontrial investigators independently assessed 41 content-based media variables (including background, trial information, graphics, errors, publication information, and assessment) with a standardized, semiqualitative data collection tool. Major errors were considered serious misrepresentation of the trial purpose or protocol, whereas minor errors included misinformation unlikely to mislead the lay reader about the trial. We plotted the temporal relationship between opt-out bracelet requests and media reports. Descriptive information about the news sources and the trial coverage are presented., Results: We collected 39 trial-related media reports (33 newspaper, 1 television, 1 radio, and 4 blogs). There were 13 errors in 9 (23%) publications, 7 of which were major and 6 minor. Of 384 requests for 710 bracelets, 310 requests (80%) occurred within 4 days after trial media coverage. Graphic timeline representation of the data suggested a close association between media reports about the trial and requests for opt-out bracelets., Conclusion: According to results from a single site, local media coverage for an exception from informed consent clinical trial had a substantial portion of errors and appeared closely associated with opt-out requests., (Copyright 2008. Published by Mosby, Inc.)

Study Objective: For trials involving exception from informed consent, some IRBs require that community members be allowed to "opt out" prior to enrollment. We tested for geospatial clustering of opt-out requests and the associated census tract characteristics in one study region., Methods: This was a retrospective study at a single site of a multicenter exception from informed consent resuscitation trial. We collected and geocoded mailing addresses for persons requesting opt-out bracelets over 16 months, then tested for geospatial clustering using geographic information systems (GIS) analysis. Characteristics for tracts with and without bracelet clustering were compared using univariate tests, multivariable regression, and classification and regression tree (CART) analysis., Results: We received 395 phone calls requesting 718 bracelets, of which 673 were analyzable. Of 397 census tracts in the region, 208 (52%) had at least one request and 38 (10%) demonstrated clustering. In multivariable models, an increasing proportion of family households (OR .90, 95%CI .85-.93), veterans (OR .91, 95%CI .81-1.02), and renters (OR .96, 95%CI .92-.99) were associated with lower odds of requesting an opt-out bracelet, while census tracts with higher income had higher odds of opting-out (OR 1.07, 95%CI 1.02-1.11). Using CART, the proportion of family households and graduate education identified the majority of opt-out requests by census tracts (cross-validation sensitivity 92%, specificity 56%)., Conclusions: Opt-out requests for an exception from informed consent trial at one study site were geographically clustered and associated with certain population demographics. These findings may help identify key target groups for community consultation in future trials.