A Community‐Engaged Stroke Preparedness Intervention in Chicago

Background We evaluated a community‐engaged stroke preparedness intervention that aimed to increase early hospital arrival and emergency medical services (EMS) utilization among patients with stroke in the South Side of Chicago, Illinois. Methods and Results We compared change in early hospital arrival (<3 hours from symptom onset) and EMS utilization before and after our intervention among patients with confirmed ischemic stroke at an intervention hospital on the South Side of Chicago with concurrent data from 6 hospitals in nonintervention communities on the North Side of Chicago and 17 hospitals in St Louis, Missouri. We assessed EMS utilization for suspected stroke secondarily, using geospatial information systems analysis of Chicago ambulance transports before and after our intervention. Among 21 497 patients with confirmed ischemic stroke across all sites, early arrival rates at the intervention hospital increased by 0.5% per month (95% CI, −0.2% to 1.2%) after intervention compared with the preintervention period but were not different from North Side Chicago hospitals (difference of −0.3% per month [95% CI, −0.12% to 0.06%]) or St Louis hospitals (difference of 0.7% per month [95% CI, −0.1% to 1.4%]). EMS utilization at the intervention hospital decreased by 0.8% per month (95% CI, −1.7% to 0.2%) but was not different from North Side Chicago hospitals (difference of 0.004% per month [95% CI, −1.1% to 1.1%]) or St Louis hospitals (difference of −0.7% per month [95% CI, −1.7% to 0.3%]). EMS utilization for suspected stroke increased in the areas surrounding the intervention hospital (odds ratio [OR], 1.4; 95% CI, 1.2–1.6) and in the South Side (OR, 1.2; 95% CI, 1.1–1.3), but not in the North Side (OR, 1.0; 95% CI, 0.9–1.1). Conclusions Following a community stroke preparedness intervention, early hospital arrival and EMS utilization for confirmed ischemic stroke did not increase. However, ambulance transports for suspected stroke increased in the intervention community compared with other regions. Registration URL: https://www.clini​caltr​ials.gov ; Unique identifier: NCT02301299.

Effect of area-level factors on heat-associated morbidity and mortality in the Eastern Townships

Background Multiple individual risk factors for morbidity and mortality during heat waves have previously been identified. Based on these, five categories of area-level indicators are used in Quebec, Canada, to identify geographical regions with presumed increased vulnerability: economic, social and biological vulnerability, housing characteristics and urban environment. However, we do not know which indicators correlate with an increase in morbidity and mortality during heat waves. This study evaluated, among 13 different area-level vulnerability factors from these five categories, which ones predict an effect modification of hot temperatures on morbidity and mortality. Methods For 2008 to 2018, we first explored the association between average daily temperature and four daily health indicators for the Eastern Townships region in Quebec: all-cause ambulance transports, all-cause emergency department (ED) visits, all-cause mortality and heat-related hospitalizations. We then used Poisson regression linear mixed models to investigate effect modification from the 13 area-level risk factors. Results Three vulnerability factors significantly caused positive effect modification between temperature and daily all-cause ambulance counts: the chronic diseases index, the percentage of people aged 65 years or older and the percentage of people aged 65 or older and living alone. For heat-related hospitalizations, four factors caused positive effect modification: the same three as for ambulance counts, plus the proportion of people that spend 30% or more household income on rent. For the ED-temperature association, only the percentage of people with low income caused positive effect modification. There was no significant association between temperature and daily mortality. Conclusions This study will help public health officials target preventive interventions to areas with the vulnerability factors that most strongly predict heat-related morbidity. Key messages Some, but not all, individual risk factors are useful at the area-level to predict areas with the strongest increases in morbidity associated with hot temperatures. The chronic diseases index and the percentage of people 65 and older living alone both accentuated the association between hot temperatures and ambulance transports or hospitalizations.

Ambulance Transport of Patients with Mild Conditions in Hokkaido, Japan

Understanding the epidemiological distributions of ambulance transport for patients with mild conditions according to age, disease, and geographic region could help in achieving optimal use of ambulance services. In the present study, we explored the descriptive epidemiology of ambulance transports in Hokkaido, the northernmost prefecture of Japan, identifying potential factors that determine the frequency of transports for mild diseases. Of the total 153,667 ambulance transports in Hokkaido during 2016, we found that two-thirds were for older people, of which about 60% resulted in hospital admission. There were 74,485 transports for mild cases, which were most commonly for psychiatric disorders among working-age adults (n = 4805), heart diseases among older people (n = 4246), and sensory organ diseases among older people (n = 3589). Examining the ecological correlations over 58 geographic units of ambulance services, the total unemployment rate and distance to the nearest tertiary care hospital were, respectively, positively and negatively correlated with the standardized transport ratio for multiple mild diseases. The proportion of working-age adults was uniquely identified as a possible positive predictor in mild cases of psychiatric disorders. As the identified potential predictors could be helpful in considering countermeasures, the causal links should be examined in future studies.

Prehospital time and mortality in patients requiring a highest priority emergency medical response: a Danish registry-based cohort study

ObjectiveTo examine the association between time from emergency medical service vehicle dispatch to hospital arrival and 1-day and 30-day mortality.DesignRegister-based cohort study.SettingNorth Denmark Region (≈8000 km2, catchment population ≈600 000).ParticipantsWe included all highest priority dispatched ambulance transports in North Denmark Region in 2006–2012.InterventionsUsing logistic regression and the g-formula approach, we examined the association between time from emergency dispatch to hospital arrival and mortality for presumed heart, respiratory, cerebrovascular and other presumed medical conditions, as well as traffic or other accidents, as classified by emergency dispatch personnel.Main outcome measures1-day and 30-day mortality.ResultsAmong 93 167 individuals with highest priority ambulances dispatched, 1948 (2.1%) were dead before the ambulance arrived and 19 968 (21.4%) were transported to the hospital under highest priority (median total prehospital time from dispatch to hospital arrival 47 min (25%–75%: 35–60 min); 95th percentile 84 min). Among 18 709 with population data, 1-day mortality was 10.9% (n=2038), and was highest for patients with dyspnoea (20.4%) and lowest for patients with traffic accidents (2.8%). Thirty-day mortality was 18.3% and varied between 36.6% (patients with dyspnoea) and 3.7% (traffic accidents). One-day mortality was not associated with total prehospital time, except for presumed heart conditions, where longer prehospital time was associated with decreased mortality: adjusted OR for >60 min vs 0–30 min was 0.61 (95% CI 0.40 to 0.91). For patients with dyspnoea, OR for >60 min vs 0–30 min was 0.90 (95% CI 0.56 to 1.45), for presumed cerebrovascular conditions OR 1.41 (95% CI 0.53 to 3.78), for other presumed medical conditions OR 0.84 (95% CI 0.70 to 1.02), for traffic accidents OR 0.65 (95% CI 0.29 to 1.48) and for other accidents OR 0.84 (95% CI 0.47 to 1.51). Similar findings were found for 30-day mortality.ConclusionsIn this study, where time from emergency dispatch to hospital arrival mainly was <80 min, there was no overall relation between this prehospital time measure and mortality.

Helping Runners Under Extreme Heat: The 2017 Montreal Half-Marathon Experience

Introduction:The 2017 Montreal Half-Marathon was held on September 24th despite a record-breaking, out-of-season heatwave. The Urgences-santé Corporation (USC), Quebec’s largest emergency medical service (EMS), was tasked with coordinating and delivering prehospital response for over 15,000 runners at a time when the province’s paramedics were on strike.Aim:USC’s mission was to ensure runner safety under extreme conditions with limited staffing. In conjunction with the event’s medical teams, we implemented a new approach that oriented patients to the event’s clinic with the aim of limiting ambulance transports off-site and thus optimizing resources by promoting a “treat and release” principle.Methods:Emergency response was organized around the event’s clinic, which offered a level of care comparable to proximate emergency departments, including mass-cooling capacities. This capacity allowed us to modify provincial protocols, and thus prioritize treating patients on-site instead of transporting them to a hospital. Consequently, the prehospital response on the course could be assured with only 15 ambulances (staffed by managers) and a single team deployed at the event’s clinic, acting as transport officers. Heatstroke identification protocols were reinforced for the safety of the runners and spectators.Results:A total of 1,071 participants received medical attention, including 24 who were treated for a heat-related incident. On the course, 32 were evaluated by paramedics and 20 were transported to the event’s clinic. Only 7 patients were transferred from the clinic to a hospital, of which only one was for a heat-related incident. No deaths resulted from the race.Discussion:By anticipating and preparing for the extreme heat, the coordinated prehospital response safely reduced off-site transports, minimizing treatment delays for patients, and maximizing the use of on-site resources. We attribute this success to a strong collaboration with the race organizers, the presence of an on-site clinic, and an increase in prehospital resources.