Evidence of an association between the exposure to air pollution and overall cardiovascular morbidity and mortality is increasingly found in the literature. However, results from studies of the ...association between acute air pollution exposure and risk of out-of-hospital cardiac arrest (OHCA) are inconsistent for fine particulate matter, and, although pathophysiological evidence indicates a plausible link between OHCA and ozone, none has been reported. Approximately 300 000 persons in the United States experience an OHCA each year, of which >90% die. Understanding the association provides important information to protect public health.
The association between OHCA and air pollution concentrations hours and days before onset was assessed by using a time-stratified case-crossover design using 11 677 emergency medical service-logged OHCA events between 2004 and 2011 in Houston, Texas. Air pollution concentrations were obtained from an extensive area monitor network. An average increase of 6 µg/m(3) in fine particulate matter 2 days before onset was associated with an increased risk of OHCA (1.046; 95% confidence interval, 1.012-1.082). A 20-ppb ozone increase for the 8-hour average daily maximum was associated with an increased risk of OHCA on the day of the event (1.039; 95% confidence interval, 1.005-1.073). Each 20-ppb increase in ozone in the previous 1 to 3 hours was associated with an increased risk of OHCA (1.044; 95% confidence interval, 1.004-1.085). Relative risk estimates were higher for men, blacks, or those aged >65 years.
The findings confirm the link between OHCA and fine particulate matter and introduce evidence of a similar link with ozone.
Abstract Background Despite evidence to suggest significant spatial variation in out-of-hospital cardiac arrest (OHCA) and bystander cardiopulmonary resuscitation (BCPR) rates, geographic information ...systems (GIS) and spatial analysis have not been widely used to understand the reasons behind this variation. This study employs spatial statistics to identify the location and extent of clusters of bystander CPR in Houston and Travis County, TX. Methods Data were extracted from the Cardiac Arrest Registry to Enhance Survival for two U.S. sites – Austin-Travis County EMS and the Houston Fire Department – between October 1, 2006 and December 31, 2009. Hierarchical logistic regression models were used to assess the relationship between income and racial/ethnic composition of a neighborhood and BCPR for OHCA and to adjust expected counts of BCPR for spatial cluster analysis. The spatial scan statistic was used to find the geographic extent of clusters of high and low BCPR. Results Results indicate spatial clusters of lower than expected BCPR rates in Houston. Compared to BCPR rates in the rest of the community, there was a circular area of 4.2 km radius where BCPR rates were lower than expected (RR = 0.62; p < 0.0001 and RR = 0.55; p = 0.037) which persist when adjusted for individual-level patient characteristics (RR = 0.34; p = 0.027) and neighborhood-level race (RR = 0.34; p = 0.034) and household income (RR = 0.34; p = 0.046). We also find a spatial cluster of higher than expected BCPR in Austin. Compared to the rest of the community, there was a 23.8 km radius area where BCPR rates were higher than expected (RR = 1.75; p = 0.07) which disappears after controlling for individual-level characteristics. Conclusions A geographically targeted CPR training strategy which is tailored to individual and neighborhood population characteristics may be effective in reducing existing disparities in the provision of bystander CPR for out-of-hospital cardiac arrest.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Opioid-related overdose deaths are the top accidental cause of death in the United States, and development of regional strategies to address this epidemic should begin with a better understanding of ...where and when overdoses are occurring.
In this study, we relied on emergency medical services data to investigate the geographical and temporal patterns in opioid-suspected overdose incidents in one of the largest and most ethnically diverse metropolitan areas (Houston Texas). Using a cross sectional design and Bayesian spatiotemporal models, we identified zip code areas with excessive opioid-suspected incidents, and assessed how the incidence risks were associated with zip code level socioeconomic characteristics. Our analysis suggested that opioid-suspected overdose incidents were particularly high in multiple zip codes, primarily south and central within the city. Zip codes with high percentage of renters had higher overdose relative risk (RR = 1.03; 95% CI: 1.01, 1.04), while crowded housing and larger proportion of white citizens had lower relative risks (RR = 0.9; 95% CI: 0.84, 0.96, RR = 0.97, 95% CI: 0.95, 0.99, respectively).
Our analysis illustrated the utility of Bayesian spatiotemporal models in assisting the development of targeted community strategies for local prevention and harm reduction efforts.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Emergency medical services (EMS) agencies transport a significant majority of patients with low acuity and non-emergent conditions to local emergency departments (ED), affecting the entire emergency ...care system's capacity and performance. Opportunities exist for alternative models that integrate technology, telehealth, and more appropriately aligned patient navigation. While a limited number of programs have evolved recently, no empirical evidence exists for their efficacy. This research describes the development and comparative effectiveness of one large urban program.
The Houston Fire Department initiated the Emergency Telehealth and Navigation (ETHAN) program in 2014. ETHAN combines telehealth, social services, and alternative transportation to navigate primary care-related patients away from the ED where possible. Using a case-control study design, we describe the program and compare differences in effectiveness measures relative to the control group.
During the first 12 months, 5,570 patients participated in the telehealth-enabled program, which were compared against the same size control group. We found a 56% absolute reduction in ambulance transports to the ED with the intervention compared to the control group (18% vs. 74%,
<.001). EMS productivity (median time from EMS notification to unit back in service) was 44 minutes faster for the ETHAN group (39 vs. 83 minutes, median). There were no statistically significant differences in mortality or patient satisfaction.
We found that mobile technology-driven delivery models are effective at reducing unnecessary ED ambulance transports and increasing EMS unit productivity. This provides support for broader EMS mobile integrated health programs in other regions.
This study presents a framework for identifying “high-risk” days for asthma attacks associated with elevated concentrations of criteria pollutants using local information to warn citizens on days ...when the concentrations differ from Environmental Protection Agency Air Quality Index (AQI) warnings. Studies that consider the unique mixture of pollutants and the health data specific to a city provide additional information for asthma self-management. This framework is applied to air pollution and asthma data to identify supplemental warning days in Houston, Texas.
A four-step framework was established to identify days with pollutant levels that pose meaningful increased risk for asthma attacks compared with baseline. Historical associations between 18,542 ambulance-treated asthma attacks and air pollutant concentrations in Houston, Texas (2004–2016; analyzed in 2018), were analyzed using a case-crossover study design with conditional logistic regression. Days with historically high associations between pollution and asthma attacks were identified as supplemental warning days.
Days with 8-hour maximum ozone >66.6 parts per billion for the 3 previous days and same-day 24-hour nitrogen dioxide >19.3 parts per billion pose an RR of 15% above baseline; concentrations above these levels pose an increased risk of 15% (RR=1.15, 95% CI=1.14, 1.16) and 30% (RR=1.30, 95% CI=1.29, 1.32), respectively. These warnings add an additional 12% days per year over the AQI warnings.
Houston uses this framework to identify supplemental air quality warnings to improve asthma self-management. Supplemental days reflect risk lower than the National Ambient Air Quality Standards and consecutive poor air quality days, differing from the AQI.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Rationale
Mobile stroke units speed treatment for acute ischemic stroke, thereby possibly improving outcomes.
Aim
To compare mobile stroke unit and standard management clinical outcomes, healthcare ...utilization, and cost-effectiveness in tissue plasminogen activator-eligible acute ischemic stroke patients calling 911.
Sample size
693. Eighty percent power with 0.05 type I error rate to detect a difference of 0.09 in mean utility-weighted modified Rankin scale between groups.
Design
Phase III, multicenter, prospective cluster-randomized (mobile stroke unit versus standard management weeks) comparative effectiveness study in tissue plasminogen activator-eligible patients.
Outcomes
Primary: Ninety-day mean utility-weighted modified Rankin scale. Coprimary: cost-effectiveness based on EQ5D quality of life and one year poststroke costs.
Analysis
Two-sample t-test and linear regression adjusting for covariates; incremental cost-effectiveness ratio and net benefit regression.
Results
As of March 2017, 288 tissue plasminogen activator-eligible patients have been enrolled (173 in the mobile stroke unit arm and 115 in the standard management arm). Two new centers start in early 2017 with target end of recruitment September 2019.
Conclusion
This is the first randomized study to test for disability, healthcare utilization, and cost-effectiveness of a mobile stroke unit. The progress of the study suggests that it is feasible. Management of tissue plasminogen activator eligible acute ischemic stroke patients by a mobile stroke unit could potentially result in less disability and healthcare utilization, and be cost effective. Mobile stroke units are very costly. This trial may determine if the fixed cost can be justified by a reduction in disability and healthcare utilization.
Clinical Trial Registration
NCT02190500.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Prehospital pediatric endotracheal intubation has lower first-pass success rates compared to adult intubations and in general may not offer a survival benefit. Increasingly, emergency medical ...services (EMS) systems are deploying prehospital extraglottic airways (EGA) for primary pediatric airway management, yet little is known about their efficacy. We evaluated the impact of a pediatric prehospital airway management protocol change, inclusive of EGAs, on airway management and patient outcomes in children in cardiac arrest or respiratory failure.
Using data from a large, metropolitan, fire-based EMS service, we performed an observational study of pediatric patients with respiratory failure or cardiac arrest who were transported by EMS before and after implementation of an evidence-based airway management protocol inclusive of the addition of the EGA. The primary outcome was change in frequency of intubation attempts when paired with an initial EGA. Secondary outcomes included EGA and intubation success rates and patient survival to hospitalization and discharge.
We included 265 patients age <16 years old, with 142 pre- and 123 post-protocol change. Patient demographics and event characteristics were similar between groups. Intubation attempts declined from 79.6% pre- to 44.7% (p<0.01) post-protocol change. In patients with an intubation attempt, overall intubation success declined from 81.4% to 63.6% (p<0.01). Post-protocol change, an EGA was attempted in 52.8% of patients with 95.4% success.
Implementation of an evidenced-based airway management algorithm for pediatric patients, inclusive of an EGA device for all age groups, was associated with fewer prehospital intubations. Intubation success may be negatively impacted due to decreases in procedural frequency.
Establishment of stroke centers, combined with accurate paramedic diagnosis and rapid transport, is essential to deliver acute stroke therapy. We wanted to measure and improve paramedic and hospital ...performance through implementation of the Brain Attack Coalition and American Stroke Association guidelines.
Pre-intervention and active-intervention phases with parallel data measurement points were used. The study involved six hospitals comprising the majority of acute-stroke admissions in Houston, Tex. Hospital, paramedic, and patient data were collected prospectively pre-intervention and during the active-intervention phase on all suspected acute-stroke patients admitted by Houston Fire Department-Emergency Medical Services. A multilevel educational intervention included paramedic, hospital, and community education. Paramedic diagnostic accuracy, hospital-performance efficiency, and thrombolytic treatment rates were the main outcome measures of the study.
Four hundred forty-six patients (74 per month) were transported in the pre-intervention phase to participating hospitals (59.8% of all suspected stroke patients transported city wide by Houston Fire Department-Emergency Medical Services), compared with 1072 patients (89 per month, or 68.7%) transported in the active-intervention phase (P<0.001). Accuracy of paramedic diagnosis of stroke increased from 61% to 79%. Admission within 2 hours of symptom onset increased from 58% to 62% (P=0.002). Thrombolysis rates increased in 4 of 6 centers, with 1 post- tissue plasminogen activator hemorrhage (3.7%) reported.
A multilevel educational program improves rapid hospitalization and paramedic diagnostic accuracy and increases the number of patients presenting for evaluation within the 3-hour tissue plasminogen activator window. Stroke center development supports safe thrombolytic practice in community settings.
Introduction: Telehealth has been used nominally for trauma, neurological, and cardiovascular incidents in prehospital emergency medical services (EMS). Yet, much less is known about the use of ...telehealth for low-acuity primary care. We examine the development of one telehealth program and its impact on unnecessary ambulance transports. Objective: The objective of this study is to describe the development and impact of a large-scale telehealth program on ambulance transports. Methods: We describe the patient characteristics and results from a cohort of patients in Houston, Texas who received a prehospital telehealth consultation from an emergency medicine physician. Inclusion criteria were adults and pediatric patients with complaints considered to be non-urgent, primary care related. Data were analyzed for 36 months, from January 2015 through December 2017. Our primary dependent variable was the percentage of patients transported by ambulance. We used descriptive statistics to describe patient demographics, chi-square to examine differences between groups, and logistic regression to explore the effects with multivariate controls including age, gender, race, and chief complaint. Results: A total of 15,067 patients were enrolled (53% female; average age 44 years ± 19 years) over the three-year period. The 3 primary chief complaints were based on abdominal pains (13% of cases), nausea/vomiting/diarrhea (NVD) (9.4%), and back pain (9.3%). Ambulance transports represented 11.2% of all transports in the program, while alternative taxi transportation was used in 75.6%, and the remainder were self- or no-transports. Taxi transportation to an alternate, affiliated clinic (versus ED) was utilized in 5% of incidents. After multivariate controls, older age patients presenting with low-risk, non-acute chest pain, shortness of breath, and dizziness were much more likely to use ambulance transport. Race and gender were not significant predictors of ambulance transport. Conclusions: We found telehealth offers a technology strategy to address potentially unnecessary ambulance transports. Based on prior cost-effectiveness analyses, the reduction of unnecessary ambulance transports translates to an overall reduction in EMS agency costs. Telehealth programs offer a viable solution to support alternate destination and alternate transport programs.
Mumps is a highly contagious disease spread by airborne droplets, making control especially difficult in congregate, crowded settings such as shelters and jails. A mumps outbreak in Honduras, ...starting in 2018 among adults who were unvaccinated, spread northward with Central Americans migrating to the United States. We describe 2 mumps outbreaks in Houston during 2019 among migrants at the Houston Contract Detention Facility (HCDF) and among inmates at the Harris County Jail (HCJ).
We investigated cases of acute onset parotitis. Three or more mumps cases in a facility was considered an outbreak. Confirmed cases had positive polymerase chain reactions (PCR). Probable cases were linked epidemiologically to a confirmed case in the same unit and a positive serology for serum anti-mumps immunoglobulin M (IgM) antibody. Outbreak control measures included enhanced surveillance, isolation of housing units, educational outreach, and immunization with Measles, Mumps, Rubella (MMR) vaccine.
At HCDF, during a 10-month period, we investigated 42 possible cases. Of the possible cases, 28 were lab-confirmed with 9 probable, 4 ruled out, and 1 vaccine reaction. All were migrants. At HCJ, during a 3-month period, we investigated 60 suspect cases; 20 cases were lab-confirmed, 13 probable and 27 ruled out. All but 2 were inmates. Only about a third of those offered MMR vaccination accepted.
Successful outbreak resolution required close cooperation with HCDF and HCJ with ongoing surveillance, isolation of units with cases and MMR vaccination. Such facilities will have outbreaks; regular communications with local public health could improve response.
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