Brendan G Carr

University of Pennsylvania, Philadelphia, Pennsylvania, United States

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Publications (93)339.57 Total impact

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    ABSTRACT: As emergency care becomes increasingly regionalized, systems planners must determine how system expansion impacts existing system assets. We hypothesized that accrediting new Level II and III trauma centers impacted the trauma patient census and severity at a nearby Level I trauma center and estimated the magnitude of the impact. We conducted an interrupted time series analysis using monthly patient counts during the past 10 years for five trauma centers located near one another in Pennsylvania. The Level I center (TC-A) operated for the entire period. A Level II center 39 miles away was accredited after 70 months (TC-B), one Level III center 46 miles away was accredited after 95 months but lost accreditation after 11 months (TC-C), and two other Level III centers 40 miles and 45 miles away were accredited after 107 months (TC-D and TC-E). Monthly patient volume at the Level I center, which increased gradually over the study and summed to 25,120 patients, decreased by 10.8% (p < 0.05) when TC-B was accredited and decreased by an additional 12.9% (p < 0.05) when TC-D and TC-E were accredited simultaneously. No change stemmed from temporarily accrediting TC-C. Ultimately, the Level I center treated 1,903 fewer patients than expected over 51 months, an 11.9% volume reduction, and patient severity remained consistent but mortality decreased. Accrediting Level II and Level III trauma centers reduced patient volume and reduced overall mortality at a nearby Level I center. Strategic planning of statewide trauma systems can help balance rapid access to care with maintenance of adequate annual patient volumes of critically injured patients. Epidemiologic study, Level IV.
    The Journal of Trauma and Acute Care Surgery 11/2014; 77(5):764-768. · 1.97 Impact Factor
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    ABSTRACT: Time to achieve target temperature varies substantially for patients who undergo targeted temperature management (TTM) after cardiac arrest. The association between arrival at target temperature and neurologic outcome is poorly understood. We hypothesized that shorter time from initiation of cooling to target temperature (“induction”) will be associated with worse neurologic outcome, reflecting more profound underlying brain injury and impaired thermoregulatory control.
    Resuscitation 10/2014; · 3.96 Impact Factor
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    ABSTRACT: We examine whether the proportion of the US population with ≤60 minute access to Primary Stroke Centers (PSCs) varies based on geographic and demographic factors.
    Stroke 10/2014; 45(11). · 6.02 Impact Factor
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    ABSTRACT: To assess whether increased use of targeted temperature management (TTM) within an integrated healthcare delivery system resulted in improved rates of good neurologic outcome at hospital discharge (Cerebral Performance Category score of 1 or 2).
    Resuscitation 08/2014; · 3.96 Impact Factor
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    ABSTRACT: Only 3% to 5% of patients with acute ischemic stroke receive intravenous recombinant tissue-type plasminogen activator (r-tPA) and <1% receive endovascular therapy. We describe access of the US population to all facilities that actually provide intravenous r-tPA or endovascular therapy for acute ischemic stroke.
    Stroke 08/2014; 45(10). · 6.02 Impact Factor
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    ABSTRACT: Rationale: Severe sepsis is increasing in incidence and has a high rate of in-patient mortality. Hospitals that treat a larger number of patients with severe sepsis may offer a survival advantage. Objectives: We sought to assess the effect of severe sepsis case volume on mortality, hypothesizing that higher volume centers would have lower rates of inpatient death. Methods: We performed a retrospective cohort study over a 7-year period (2004-2010), utilizing a nationally representative sample of hospital admissions, examining the relation between volume, urban location, organ dysfunction and survival. Measurements: To identify potential differences in outcomes, hospitals were divided into 5 categories (<50, 50-99, 100-249, 250-499, 500+ annual cases) and adjusted mortality was compared by volume. Results: A total of 914,200 patients with severe sepsis were identified over a 7-year period (2004-2010). Overall in-hospital mortality was 28.1%. In a fully adjusted model, there was an inverse relationship between severe sepsis case volume and in-patient mortality. Hospitals in the highest volume category had substantially improved survival compared to hospitals with the lowest case volume [adjusted OR 0.64 (95% CI 0.60 - 0.69)]. In cases of severe sepsis with one reported organ dysfunction, a mortality of 18.9% was found in hospitals with < 50 annual cases compared to 10.4% in hospitals treating 500+ cases [adjusted OR 0.54 (95% CI 0.49-0.59)]. Similar differences were found in patients with up to three total organ dysfunctions. Conclusions: Patients with severe sepsis treated in hospitals with higher case volumes had improved adjusted outcomes.
    American Journal of Respiratory and Critical Care Medicine 08/2014; · 11.04 Impact Factor
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    ABSTRACT: Objectives Although 72-hour emergency department (ED) revisits are increasingly used as a hospital metric, there is no known empirical basis for this 72-hour threshold. The objective of this study was to determine the timing of ED revisits for adult patients within 30 days of ED discharge.Methods This was a retrospective cohort study of all nonfederal ED discharges in Florida and Nebraska from April 1, 2010, to March 31, 2011, using data from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP). ED discharges were followed forward to identify ED revisits occurring at any hospital within the same state within 30 days. The cumulative hazard of an ED revisit was plotted. Parametric and nonparametric modeling was performed to characterize the rate of ED revisits.ResultsThere were 4,782,045 ED discharges, with 7.5% (95% confidence interval [CI] = 7.4% to 7.5%) associated with 3-day revisits, and 22.4% (95% CI = 22.3% to 22.4%) associated with 30-day revisits, inclusive of the 3-day revisits. A double-exponential model fit the data best (p < 0.0001), and a single hinge point at 9 days (multivariate adaptive regression splines [MARS] model) yielded the best linear fit to the data, suggesting 9 days as the most reasonable cutoff for identification of acute ED revisits. Multiple stratified and subgroup analyses produced similar results. Future work should focus on identifying primary reasons for potentially avoidable return ED visits instead of on the revisit occurrence itself, thus more directly measuring potential lapses in delivery of high-quality care.Conclusions Almost one-quarter of ED discharges are linked to 30-day ED revisits, and the current 72-hour ED metric misses close to 70% of these patients. Our findings support 9 days as a more inclusive cutoff for studies of ED revisits.ResumenObjetivosAunque las reconsultas a las 72 horas al servicio de urgencias (SU) son cada vez más utilizadas como una medida hospitalaria, no existe base empírica conocida para este umbral de 72 horas. El objetivo de este estudio fue determinar el tiempo de las reconsultas al SU para los pacientes adultos durante los primeros 30 días tras el alta del SU.MetodologíaEstudio de cohorte retrospectivo de todas al altas de SU no federales en Florida y Nebrasca del 1 de abril de 2010 al 31 de marzo de 2011 usando los datos de la Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project. Las altas del SU fueron seguidas para identificar las reconsultas al SU que ocurrieran en cualquier hospital del estado en los primeros 30 días. Se representó gráficamente el riesgo acumulado de una reconsulta al SU. Se realizaron modelos paramétricos y no paramétricos para caracterizar el porcentaje de reconsultas al SU.ResultadosHubo 4.782.045 de altas del SU, un 7,5% (IC 95% = 7,4% a 7,5%) asociado con una reconsulta a los 3 días y un 22,4% (IC 95% = 22,3% a 22,4%) asociado con una reconsulta a los 30 días (incluyendo las reconsultas a los 3 días). Un modelo exponencial doble alcanzó los mejores datos (p < 0.0001), en tanto que un único punto de inflexión a los 9 días (modelo de regresión multivariable) alcanzó el mejor ajuste lineal para los datos. Esto indicaba a los 9 días como el punto de corte más razonable para la identificación de las reconsultas agudas al SU. Los análisis múltiples estratificados y por subgrupos produjeron resultados similares. El trabajo futuro deberá centrarse en la identificación de las razones principales para consultas al SU potencialmente evitables en lugar de la ocurrencia de la reconsulta en sí misma y, más directamente, medir potenciales errores en la atención de alta calidad.ConclusionesCasi una cuarta parte de las altas del SU están unidas a una reconsulta a los 30 días, y la medición actual de las reconsultas a las 72 horas pierde casi un 70% de estos pacientes. Nuestros hallazgos soportan los 9 días como un punto de corte más concluyente para los estudios de reconsultas al SU.
    Academic Emergency Medicine 08/2014; · 2.20 Impact Factor
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    ABSTRACT: Study objective Reasons for recurrent emergency department (ED) visits have been examined primarily through administrative data review. Inclusion of patients’ perspectives of reasons for ED return may help inform future initiatives aimed at reducing recurrent utilization. The objective of this study is to describe the personal experiences and challenges faced by patients transitioning home after an ED discharge. Methods We performed semistructured qualitative interviews of adult patients with an unscheduled return to the ED within 9 days of an index ED discharge. Questions focused on problems with the initial discharge process, medications, outpatient care access, social support, and health care decisionmaking. Themes were identified with a modified grounded theory approach. Results Sixty interviews were performed. Most patients were satisfied with the discharge process at the index discharge, but many had complaints about the clinical care delivered, including insufficient evaluation and treatment. The primary reason for returning to the ED was fear or uncertainty about their condition. Most patients had a primary care physician, but they rarely visited a physician before returning to the ED. Patients cited convenience and more expedited evaluations as primary reasons for seeking care in the ED versus the clinic. Conclusion Postdischarge factors, including perceived inability to access timely follow-up care and uncertainty and fear about disease progression, are primary motivators for return to the ED. Many patients prefer hospital-based care because of increased convenience and timely results. Further work is needed to develop alternative pathways for patients to ask questions and seek guidance when and where they want.
    Annals of Emergency Medicine 08/2014; · 4.33 Impact Factor
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    ABSTRACT: To examine the impact of telemedicine on access to acute stroke care and expertise in the state of Texas. Texas hospitals were surveyed using a standard questionnaire and categorized as: (1) stand-alone Primary Stroke Centers not using telemedicine for acute stroke care, (2) Primary Stroke Centers using telemedicine for acute stroke care, (3) non-Primary Stroke Center hospitals using telemedicine for acute stroke care, or (4) non-Primary Stroke Center hospitals not using telemedicine for acute stroke care. Population data were obtained from the US Census Bureau and the Neilson Claritas Demographic Estimation Program. Access within 60 minutes to a designated facility was calculated at the block group level. Over 75% of Texans had 60-minute access to a stand-alone Primary Stroke Center. Including Primary Stroke Centers using telemedicine increased access by 6.5%. Adding non- Primary Stroke Centers that use telemedicine for acute stroke care provided 60-minute access for an additional 2% of Texans, leaving 16% of Texans without 60-minute access to acute stroke care. Approximately 62% of Texans had 60-minute access to more than one type of facility that provided acute stroke care. The use of telemedicine in the state of Texas brought 60-minute access to >2 million Texans who otherwise would not have had access to acute stroke expertise. Our findings demonstrate that using telemedicine for acute stroke has the ability to provide neurologically underserved areas access to acute stroke care.
    Annals of clinical and translational neurology. 06/2014; 1(1):27-33.
  • Academic Emergency Medicine 05/2014; 21(5). · 2.20 Impact Factor
  • Brendan G Carr, Zachary F Meisel
    Academic Emergency Medicine 01/2014; · 2.20 Impact Factor
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    ABSTRACT: Optimal care of adults with severe acute respiratory failure requires specific resources and expertise. We sought to measure geographic access to these centers in the United States. Cross-sectional analysis of geographic access to high capability severe acute respiratory failure centers in the United States. We defined high capability centers using two criteria: (1) provision of adult extracorporeal membrane oxygenation (ECMO), based on either 2008-2013 Extracorporeal Life Support Organization reporting or provision of ECMO to 2010 Medicare beneficiaries; or (2) high annual hospital mechanical ventilation volume, based 2010 Medicare claims. Nonfederal acute care hospitals in the United States. We defined geographic access as the percentage of the state, region and national population with either direct or hospital-transferred access within one or two hours by air or ground transport. Of 4,822 acute care hospitals, 148 hospitals met our ECMO criteria and 447 hospitals met our mechanical ventilation criteria. Geographic access varied substantially across states and regions in the United States, depending on center criteria. Without interhospital transfer, an estimated 58.5% of the national adult population had geographic access to hospitals performing ECMO and 79.0% had geographic access to hospitals performing a high annual volume of mechanical ventilation. With interhospital transfer and under ideal circumstances, an estimated 96.4% of the national adult population had geographic access to hospitals performing ECMO and 98.6% had geographic access to hospitals performing a high annual volume of mechanical ventilation. However, this degree of geographic access required substantial interhospital transfer of patients, including up to two hours by air. Geographic access to high capability severe acute respiratory failure centers varies widely across states and regions in the United States. Adequate referral center access in the case of disasters and pandemics will depend highly on local and regional care coordination across political boundaries.
    PLoS ONE 01/2014; 9(4):e94057. · 3.53 Impact Factor
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    ABSTRACT: Two decades ago, Philadelphia began allowing police transport of patients with penetrating trauma. We conduct a large, multiyear, citywide analysis of this policy. We examine the association between mode of out-of-hospital transport (police department versus emergency medical services [EMS]) and mortality among patients with penetrating trauma in Philadelphia. This is a retrospective cohort study of trauma registry data. Patients who sustained any proximal penetrating trauma and presented to any Level I or II trauma center in Philadelphia between January 1, 2003, and December 31, 2007, were included. Analyses were conducted with logistic regression models and were adjusted for injury severity with the Trauma and Injury Severity Score and for case mix with a modified Charlson index. Four thousand one hundred twenty-two subjects were identified. Overall mortality was 27.4%. In unadjusted analyses, patients transported by police were more likely to die than patients transported by ambulance (29.8% versus 26.5%; OR 1.18; 95% confidence interval [CI] 1.00 to 1.39). In adjusted models, no significant difference was observed in overall mortality between the police department and EMS groups (odds ratio [OR] 0.78; 95% CI 0.61 to 1.01). In subgroup analysis, patients with severe injury (Injury Severity Score >15) (OR 0.73; 95% CI 0.59 to 0.90), patients with gunshot wounds (OR 0.70; 95% CI 0.53 to 0.94), and patients with stab wounds (OR 0.19; 95% CI 0.08 to 0.45) were more likely to survive if transported by police. We found no significant overall difference in adjusted mortality between patients transported by the police department compared with EMS but found increased adjusted survival among 3 key subgroups of patients transported by police. This practice may augment traditional care.
    Annals of emergency medicine 12/2013; · 4.33 Impact Factor
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    ABSTRACT: Collective knowledge and coordination of vital interventions for time-sensitive conditions (ST-segment elevation myocardial infarction [STEMI], stroke, cardiac arrest, and septic shock) could contribute to a comprehensive statewide emergency care system, but little is known about population access to the resources required. We seek to describe existing clinical management strategies for time-sensitive conditions in Pennsylvania hospitals. All Pennsylvania emergency departments (EDs) open in 2009 were surveyed about resource availability and practice patterns for time-sensitive conditions. The frequency with which EDs provided essential clinical bundles for each condition was assessed. Penalized maximum likelihood regressions were used to evaluate associations between ED characteristics and the presence of the 4 clinical bundles of care. We used geographic information science to calculate 60-minute ambulance access to the nearest facility with these clinical bundles. The percentage of EDs providing each of the 4 clinical bundles in 2009 ranged from 20% to 57% (stroke 20%, STEMI 32%, cardiac arrest 34%, sepsis 57%). For STEMI and stroke, presence of a board-certified/board-eligible emergency physician was significantly associated with presence of a clinical bundle. Only 8% of hospitals provided all 4 care bundles. However, 53% of the population was able to reach this minority of hospitals within 60 minutes. Reliably matching patient needs to ED resources in time-dependent illness is a critical component of a coordinated emergency care system. Population access to critical interventions for the time-dependent diseases discussed here is limited. A population-based planning approach and improved coordination of care could improve access to interventions for patients with time-sensitive conditions.
    Annals of emergency medicine 12/2013; · 4.33 Impact Factor
  • Ricardo Martinez, Brendan Carr
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    ABSTRACT: Emergency care is an essential component of the care delivery system in the United States, but it received little attention during the debates about health care reform. As a result, US emergency care remains outdated and fragmented. We provide an overview of efforts to regionalize emergency care in the United States, and we both identify challenges to change and recommend next steps in five domains: people, quality and processes, technology, finances, and jurisdictional politics. We offer a commonsense approach to increasing the value of emergency care delivery by developing regionalized integrated networks of emergency care that take advantage of emerging changes in the health system and are designed to meet time-sensitive patient needs.
    Health Affairs 12/2013; 32(12):2082-90. · 4.64 Impact Factor
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    ABSTRACT: To use the natural experiment of health insurance reform in Massachusetts to study the impact of increased insurance coverage on ICU utilization and mortality. Population-based cohort study. Massachusetts and four states (New York, Washington, Nebraska, and North Carolina) that did not enact reform. All nonpregnant nonelderly adults (age 18-64 yr) admitted to nonfederal acute care hospitals in one of the five states of interest were eligible, excluding patients who were not residents of a respective state at the time of admission. We used a difference-in-differences approach to compare trends in ICU admissions and outcomes of in-hospital mortality and discharge destination for ICU patients. Healthcare reform in Massachusetts was associated with a decrease in ICU patients without insurance from 9.3% to 5.1%. There were no significant changes in adjusted ICU admission rates, mortality, or discharge destination. In a sensitivity analysis excluding a state that enacted Medicaid reform prior to the study period, our difference-in-differences analysis demonstrated a significant increase in mortality of 0.38% per year (95% CI, 0.12-0.64%) in Massachusetts, attributable to a greater per-year decrease in mortality postreform in comparison states (-0.37%; 95% CI, -0.52% to -0.21%) compared with Massachusetts (0.01%; 95% CI, -0.20% to 0.11%). Massachusetts healthcare reform increased the number of ICU patients with insurance but was not associated with significant changes in ICU use or discharge destination among ICU patients. Reform was also not associated with changed in-hospital mortality for ICU patients; however, this association was dependent on the comparison states chosen in the analysis.
    Critical care medicine 11/2013; · 6.15 Impact Factor
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    ABSTRACT: Many hospitals in the United States are seeking to obtain and maintain trauma credentialing. Assessment of trauma center success has traditionally focused on mortality without directed measure of surgical subspecialization. However, survival alone may not be a sufficient marker of success with modern health care. The purpose of this study was to determine the number of trauma patients nationally who would benefit from subspecialized care by an orthopedic traumatologist. A list of musculoskeletal DRG International Classification of Diseases-9th Rev. codes representing injuries warranting care by subspecialized orthopedic traumatologists was generated by survey to each of two cohorts: one consisting of 10 subspecialized orthopedic traumatologists and one consisting of 10 nontraumatologists. The 2006 National Inpatient Sample data set was used to estimate the national volume of patients sustaining an orthopedic injury and the number requiring subspecialty orthopedic trauma care, as defined by the DRG International Classification of Diseases-9th Rev. lists generated by our survey. Survey response rate was 100%. In 2006, 2,068,349 patients sustained a traumatic injury; 46.7% of these had an orthopedic injury. Our cohort of subspecialized orthopedic traumatologists identified 25.7% of all trauma patients as requiring an orthopedic traumatologist. Our cohort of general orthopedists identified 13.5% of all trauma patients as requiring an orthopedic traumatologist. Rates of polytrauma, injury severity, and treatment at trauma centers were similar between the two groups. Between 13.5% and 25.7% of all injured patients should, if resources permit, receive subspecialty orthopedic trauma care. The magnitude of this figure highlights the importance, from a public health perspective, of policy interventions aimed at better coordinating the field of orthopedic traumatology. Detailed outcome measures beyond mortality and triage guidelines suggesting which patients should receive subspecialty orthopedic trauma care should be developed. In addition, resources, including fellowship training, should be allocated in a methodical manner that matches supply to the national demand for this type of care. Economic/decision analysis, level IV.
    The journal of trauma and acute care surgery. 10/2013; 75(4):687-92.
  • Annals of Emergency Medicine 10/2013; 62(4):S142-S143. · 4.33 Impact Factor
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    ABSTRACT: The Institute of Medicine (IOM)'s "Future of Emergency Care" report recommended the categorization and regionalization of emergency care, but no uniform system to categorize hospital emergency care capabilities has been developed. The absence of such a system limits the ability to benchmark outcomes, to develop regional systems of care, and of patients to make informed decisions when seeking emergency care. The authors sought to pilot the deployment of an emergency care categorization system in two states. A five-tiered emergency department (ED) categorization system was designed, and a survey of all Pennsylvania and Wisconsin EDs was conducted. This 46-item survey described hospital staffing, characteristics, resources, and practice patterns. Based on responses, EDs were categorized as limited, basic, advanced, comprehensive, and pediatric critical care capable. Prehospital transport times were then used to determine population access to each level of care. A total of 247 surveys were received from the two states (247 of 297, 83%). Of the facilities surveyed, roughly one-quarter of hospitals provided advanced care, 10.5% provided comprehensive care, and 1.6% provided pediatric critical care. Overall, 75.1% of the general population could reach an advanced or comprehensive ED within 60 minutes by ground transportation. Among the pediatric population (age 14 years and younger), 56.2% could reach a pediatric critical care or comprehensive ED, with another 19.5% being able to access an advanced ED within 60 minutes. Using this categorization system, fewer than half of all EDs provide advanced or comprehensive emergency care. While the majority of the population has access to advanced or comprehensive care within an hour, a significant portion (25%) does not. This article describes how an ED categorization scheme could be developed and deployed across the United States. There are implications for prehospital planning, patient decision-making, outcomes measurement, interfacility transfer coordination, and development of regional emergency care systems.
    Academic Emergency Medicine 09/2013; 20(9):894-903. · 2.20 Impact Factor
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    ABSTRACT: Organ failure after injury is a significant cause of morbidity and mortality, yet its true incidence is unknown. We sought to benchmark the incidence of organ failure following injury at trauma centers and nontrauma centers using a nationally representative sample of hospital discharges. We hypothesized that injured patients receiving care at trauma centers would have a lower incidence of organ failure than those at nontrauma centers. We used the 2006 Nationwide Inpatient Sample to identify injured adults (age ≥ 15 years) with organ dysfunction using specific DRG International Classification of Diseases-9th Rev. codes by system. After adjusting for hospital size, geographic region, comorbidities, Injury Severity Score (ISS), age, and sex, a multivariate logistic regression model was created to compare rates of organ dysfunction between trauma centers and nontrauma centers. We identified 396,276 injured patients, representing the patient care experience of a total of 1,939,473 patients. Among these patients, 6.5% had concurrent organ failure. Injured patients who had acute organ failure were more likely to die than injured patients without organ failure (12.4% vs. 1.7%, p < 0.001). Mortality increased with the number of organ system failures. Patients treated at trauma centers had a higher incidence of respiratory and cardiac failure compared with nontrauma centers. We offer the first national benchmark of rates of acute organ failure among injured patients. Postinjury organ failure is uncommon, but incidence increases with injury severity and correlates with mortality. Patients at trauma centers had higher rates of respiratory and cardiac failure, possibly representing differences in referral patterns or resuscitation strategies. Prognostic and epidemiologic study, level III.
    The journal of trauma and acute care surgery. 09/2013; 75(3):426-431.

Publication Stats

823 Citations
339.57 Total Impact Points


  • 2007–2014
    • University of Pennsylvania
      • • Center for Clinical Epidemiology and Biostatistics
      • • Department of Surgery
      • • Department of Emergency Medicine
      • • Division of Trauma and Surgical Critical Care
      Philadelphia, Pennsylvania, United States
  • 2009–2013
    • The Children's Hospital of Philadelphia
      • Department of Pediatrics
      Philadelphia, PA, United States
  • 2006–2013
    • Hospital of the University of Pennsylvania
      • • Department of Biostatistics and Epidemiology
      • • Department of Emergency Medicine
      • • Department of Surgery
      Philadelphia, Pennsylvania, United States
  • 2011
    • University of Cincinnati
      • Department of Emergency Medicine
      Cincinnati, OH, United States
    • University of California, San Francisco
      • Department of Emergency Medicine
      San Francisco, CA, United States
  • 2010
    • Emory University
      Atlanta, Georgia, United States
  • 2008
    • Robert Wood Johnson University Hospital
      New Brunswick, New Jersey, United States
    • Robert Wood Johnson Foundation
      Princeton, New Jersey, United States
    • University of Michigan
      • Department of Internal Medicine
      Ann Arbor, MI, United States