Liedl, Chad P.

ABSTRACT Background Older adults experience age‐related physiological changes that alter the pharmacokinetics and pharmacodynamics of certain medications, which may necessitate reduced dosing. Our objective was to assess emergency department (ED) and hospital outcomes of older patients administered opioids by emergency medical services (EMS) clinicians. Methods Retrospective cohort study of adults ≥ 65 years who received an opioid between 2019 and 2024 within a health system‐affiliated EMS agency. We excluded patients with an advanced airway and those with no documented weight. Maximum single and cumulative weight‐based opioid dosages were classified as low, therapeutic, or high. Outcomes were measured in the ED/hospital and compared using Poisson regression with Huber/White standard errors, adjusted for age, sex, vitals, Glascow Coma Scale, emergency severity index, and chief concern. Results were reported as adjusted risk ratios (aRRs). Results A total of 6406 patients, including 747 (11.7%, 95% CI: 10.9–12.5) with a high opioid dose, 3663 (57.2%, 95% CI: 56.0–58.4) with a therapeutic dose, and 1996 (31.2%, 95% CI: 30.0–32.3) with a low dose, were included. Receipt of a high maximum single opioid dose versus a low/therapeutic dose (excluding patients receiving a concomitant sedative) was associated with increased risk of altered responsiveness (aRR = 1.28, 95% CI: 1.03–1.58) and delirium (aRR = 2.43, 95% CI: 1.08–5.45) in the ED/hospital setting. When 311 (4.9%) patients who received a concomitant sedative were included, patients who received a high opioid dose similarly had an increased risk of altered responsiveness (aRR = 1.28, 95% CI: 1.06–1.56) and delirium (RR = 2.65, 95% CI: 1.25–5.59), compared to a low/therapeutic dose. There was no difference in outcomes of hypoxia, death within 30 days, or ED length of stay between dose groups. Conclusion Prehospital administration of high opioid doses to older patients was associated with increased rates of altered responsiveness and delirium. These findings highlight how out‐of‐hospital care can impact a patient's ED and hospital course.

OBJECTIVE To evaluate the impact of community paramedic (CP)-delivered, in-home diabetes self-management education and support (DSMES) for adults with poorly managed diabetes. RESEARCH DESIGN AND METHODS In a pragmatic, single-arm pilot trial, adults with HbA1c ≥9% and a recent emergency department or hospital visit received a 1-month CP-led DSMES intervention. Outcomes included HbA1c, health care engagement, and patient-reported satisfaction. RESULTS Seventy participants (median age 61 years, 50% rural, 84% with type 2 diabetes) completed the intervention. HbA1c declined from 9.8% to 8.2% at 4 months (P < 0.001). Engagement with primary care, endocrinology, and DSMES improved. Satisfaction was high (mean rating 9 out of 10). CONCLUSIONS CP-led DSMES improved glycemic management and care engagement in underserved populations. This scalable model warrants further study.

Abstract Background Community Paramedic (CP) programs use specially trained paramedics to provide healthcare in the community to increase access to care, reduce unnecessary emergency department visits, and improve timeliness of care. Mayo Clinic in Rochester, MN recently launched a CP Program to provide in-home care for patients who require regular intravenous medications, wound care, diuresis for heart failure, medication reconciliation, care plan compliance/education. CP utilizes i-STAT1 CHEM8+ and Lactate (CG4+) testing (Abbott Point of Care, Abbott Park, IL) to make therapy decisions primarily for heart failure patients based on rapid laboratory results. Having results available at the point of care (POC) eliminates delays between testing and treatments, expediting care for the patient. Prior to using i-STAT, CP traveled to the patient’s residence, drew blood tubes, delivered the tubes to Mayo Clinic, waited for test results, returned to the patient’s home, and provided treatment. In this observational study, we assessed the benefit of in-home POC i-STAT1 testing performed by our CP Program to improve patient care and increase efficiency. Methods Patients within a 40-mile radius of Mayo Clinic were eligible to receive CP service. Whole blood venous specimens were collected and tested using the i-STAT1 CHEM8+ metabolic panel cartridge according to manufacturer instructions to measure: ionized calcium, chloride, glucose, hematocrit, total carbon dioxide, blood urea nitrogen, creatinine, potassium, sodium, anion gap while the i-STAT1 CG4+ cartridge measures lactate. The laboratory information system was used to extract laboratory results, and Excel (Microsoft, Redmond, WA) was used to filter data and perform calculations. Results November 2022 through December 2024, CP performed testing with 353 i-STAT cartridges (3862 tests) on 102 unique patients who each had 1-12 separate orders. Patient ages were 25 to 97 years. 41.2% (1590/3862) of the individual results obtained were outside of our reference intervals (23.0% high, 18.0% low), with 10.8% being ionized calcium, 10.2% chloride, 10.3% glucose, 13.0% hematocrit, 7.6% total carbon dioxide, 18.2% blood urea nitrogen, 16.4% creatinine, 6.7% potassium and 6.9% sodium. Additionally, 0.13% of results were critically high (ionized calcium, potassium, and sodium) and 0.10% were critically low (potassium and ionized calcium). Hypokalemic patients were sent to the infusion therapy center for IV potassium. Patients experiencing hyperkalemia were retested and sent to the emergency department (ED). Hyponatremic and hypercalcemic patients were sent to the ED for further treatment. Abnormal (non-critical) results were reviewed by CP personnel to make treatment recommendations or medication adjustments. Conclusion i-STAT1 home testing performed by CP facilitated rapid therapeutic interventions and expedited decision-making. POC testing has increased the group’s efficiency—alleviating the need to transport specimens to the central laboratory and wait on test results before returning to the patient for treatment. Paramedicine emphasizes a proactive and preventative approach to medicine. We anticipate that this model of care and testing will expand to cover other chronic health conditions due to the program’s early success.

ImportanceThere is a clear benefit to body armor against firearms; however, it remains unclear how these vests may influence day-to-day patient encounters when worn by emergency medical services (EMS).ObjectiveTo determine the association of ballistic vests worn by EMS clinicians with workplace violence (WPV) and disparities in care among racial and/or ethnic minority patients.Design, Setting, and ParticipantsProspective cohort study of a volunteer-based sample of EMS clinicians at a large, multistate EMS agency encompassing 15 ground sites across the Midwest from April 1, 2023, to March 31, 2024. Data were analyzed from May to June 2024.ExposureExternal ballistic armor being used by a group of self-selected clinicians on every run.Main Outcomes and MeasuresPrevalence and characteristics associated with WPV and with declines of treatment and/or transport compared between crews with 1 or more vested vs no vested members.ResultsA total of 156 of 415 staff (37.6%) opted in to wear the vests, including 77 male participants (49.4%). Prevalence of WPV was higher for vested crews (1.11 vs 0.85 cases per 100 runs; adjusted risk ratio [aRR], 1.28; 95% CI, 1.10 to 1.50; P = .001) and was due to higher rates of verbal abuse. The presence of 1 or more vested crew members increased the likelihood of all patients declining EMS treatment and/or transport; however, effect size was highest among patients with an unknown race and/or ethnicity (2234 [21.1%] vs 2134 [16.5%] patients; aRR, 1.19; 95% CI, 1.10 to 1.27; P < .001), followed by racial and/or ethnic minority patients (708 [16.7%] vs 399 [13.8%] patients; aRR, 1.18; 95% CI, 1.05 to 1.33; P = .01). Analyses of individual minority groups revealed a significant increase only in Black or African American patients declining treatment and/or transport by vested crews (461 [17.6%] vs 223 [13.7%] patients; RR, 1.28; 95% CI, 1.10 to 1.49; P = .002).Conclusions and RelevanceIn this cohort study, vested crews experienced increased prevalence of WPV compared with nonvested crews. Use of vests increased the frequency of all patients declining EMS treatment and/or transport. Among minority groups, there was a significant increase in Black or African American patients declining treatment and/or transport. Agencies should consider benefits and unintended consequences of EMS clinicians wearing body armor.

Abstract Introduction: Pragmatic trials aim to speed translation to practice by integrating study procedures in routine care settings. This study evaluated implementation outcomes related to clinician and patient recruitment and participation in a trial of community paramedicine (CP) and presents successes and challenges of maintaining pragmatic study features. Methods: Adults in the pre-hospital setting, emergency department (ED), or hospital being considered for referral to the ED/hospital or continued hospitalization for intermediate-level care were randomized 1:1 to CP care or usual care. Referral and enrollment data were tracked administratively, and patient characteristics were abstracted from the electronic health record (EHR). Enrolled patients completed baseline surveys, and a subset of intervention patients were interviewed. All CPs and a sample of clinicians and administrators were invited to complete a survey and interview. Results: Between January 2022 and February 2023, 240 enrolled patients (42% rural) completed surveys, and 22 completed an interview; 63 staff completed surveys and 20 completed an interview. Ninety-three clinicians in 27 departments made at least one referral. Factors related to referrals included program awareness and understanding the CP practice scope. Most patients were enrolled in the hospital, but characteristics were similar to the primary care population and included older and medically complex patients. Challenges to achieving representativeness included limited EHR infrastructure, constraints related to patient consenting, and clinician concerns about patient randomization disrupting preferred care. Conclusion: Future pragmatic trials in busy clinical settings may benefit from regulatory policies and EHR capabilities that allow for real-world study conduct and representative participation. Trial registration: NCT05232799.