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ABSTRACT: BACKGROUND AND PURPOSE: Evaluation at primary stroke centers (PSCs) has the potential to improve outcomes for patients with stroke. We looked for differences in evaluation at Joint Commission certified PSCs by race, education, income, and geography (urban versus nonurban; Southeastern Stroke Belt versus non-Stroke Belt). METHODS: Community-dwelling, black and white participants from the national Reasons for Geographic And Racial Differences in Stroke (REGARDS) prospective population-based cohort were enrolled between January 2003 and October 2007. Participants were contacted at 6-month intervals for suspected stroke events. For suspected stroke events, it was determined whether the evaluating hospital was a certified PSC. RESULTS: Of 1000 suspected strokes, 204 (20.4%) strokes were evaluated at a PSC. A smaller proportion of women than men (17.8% versus 23.0%; P=0.04), those with a previous stroke (15.1% versus 21.6%; P=0.04), those living in the Stroke Belt (14.7% versus 27.3%; P<0.001), and those in a nonurban area (9.1% versus 23.1%; P<0.001) were evaluated at a PSC. There were no differences by race, education, or income. In multivariable analysis, subjects were less likely to be evaluated at a PSC if they lived in a nonurban area (odds ratio, 0.39; 95% confidence interval, 0.22-0.67) or lived in the Stroke Belt (odds ratio, 0.54; 95% confidence interval, 0.38-0.77) or had a previous stroke (odds ratio, 0.46; 95% confidence interval, 0.27-0.78). CONCLUSIONS: Disparities in evaluation by PSCs are predominately related to geographic factors but not to race, education, or low income. Despite an increased burden of cerebrovascular disease in the Stroke Belt, subjects there were less likely to be evaluated at certified hospitals.
Stroke 05/2013; · 5.73 Impact Factor
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ABSTRACT: BACKGROUND:: In 1992, the first consensus definition of severe sepsis was published. Subsequent epidemiologic estimates were collected using administrative data, but ongoing discrepancies in the definition of severe sepsis produced large differences in estimates. OBJECTIVES:: We seek to describe the variations in prevalence and mortality of severe sepsis in the United States using four methods of database abstraction. We hypothesized that different methodologies of capturing cases of severe sepsis would result in disparate estimates of prevalence and mortality. DESIGN, SETTING, PARTICIPANTS:: Using a nationally representative sample, four previously published methods (Angus et al, Martin et al, Dombrovskiy et al, and Wang et al) were used to gather cases of severe sepsis over a 6-yr period (2004-2009). In addition, the use of new ICD-9 sepsis codes was compared with previous methods. MEASUREMENTS:: Annual national prevalence and in-hospital mortality of severe sepsis. RESULTS:: The average annual prevalence varied by as much as 3.5-fold depending on method used and ranged from 894,013 (300/100,000 population) to 3,110,630 (1,031/100,000) using the methods of Dombrovskiy et al and Wang et al, respectively. Average annual increase in the prevalence of severe sepsis was similar (13.0% to 13.3%) across all methods. In-hospital mortality ranged from 14.7% to 29.9% using abstraction methods of Wang et al and Dombrovskiy et al. Using all methods, there was a decrease in in-hospital mortality across the 6-yr period (35.2% to 25.6% [Dombrovskiy et al] and 17.8% to 12.1% [Wang et al]). Use of ICD-9 sepsis codes more than doubled over the 6-year period (158,722 - 489,632 [995.92 severe sepsis], 131,719 - 303,615 [785.52 septic shock]). CONCLUSION:: There is substantial variability in prevalence and mortality of severe sepsis depending on the method of database abstraction used. A uniform, consistent method is needed for use in national registries to facilitate accurate assessment of clinical interventions and outcome comparisons between hospitals and regions.
Critical care medicine 02/2013; · 6.37 Impact Factor
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ABSTRACT: The Joint Commission began certifying primary stroke centers (PSCs) in December 2003 and provides a standardized definition of stroke center care. It is unknown if PSCs outperform noncertified hospitals. We hypothesized that PSCs would use more recombinant tissue plasminogen activator (rt-PA) for ischemic stroke than would non-PSCs.
Data were obtained from the Nationwide Inpatient Sample from 2004 to 2009. The analysis was limited to states that publicly reported hospital identity. All patients ≥18 years with a primary diagnosis of acute ischemic stroke were included. Subjects were excluded if the treating hospital was not identified, if it was not possible to determine the temporal relationship between certification and admission, and/or if admitted as a transfer. Rt-PA was defined by ICD9 procedure code 99.10. All eligibility criteria were met by 323 228 discharges from 26 states. There were 63 145 (19.5%) at certified PSCs. Intravenous rt-PA was administered to 3.1% overall: 2.2% at non-PSCs and 6.7% at PSCs. Between 2004 and 2009, rt-PA administration increased from 1.4% to 3.3% at non-PSCs and from 6.0% to 7.6% at PSCs. In a multivariable model incorporating year, age, sex, race, insurance, income, comorbidities, DRG-based disease severity, and hospital characteristics, evaluation at a PSC was significantly associated with rt-PA utilization (OR, 1.87; 95% CI, 1.61 to 2.16).
Subjects evaluated at PSCs were more likely to receive rt-PA than those evaluated at non-PSCs. This association was significant after adjustment for patient and hospital-level variables. Systems of care are necessary to ensure stroke patients have rapid access to PSCs throughout the United States.
Journal of the American Heart Association. 01/2013; 2(2):e000071.
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ABSTRACT: Object A positive correlation between outcomes and the volume of patients seen by a provider has been supported by numerous studies. Volume-outcome relationships (VORs) have been well documented in the setting of both neurosurgery and trauma care and have shaped regionalization policies to optimize patient outcomes. Several authors have also investigated the correlation between patient volume and cost of care, known as the volume-cost relationship (VCR), with mixed results. The purpose of the present study was to investigate VORs and VCRs in the treatment of common intracranial injuries by testing the hypotheses that outcomes suffer at small-volume centers and costs rise at large-volume centers. Methods The authors performed a cross-sectional cohort study of patients with neurological trauma using the 2006 Nationwide Inpatient Sample, the largest nationally representative all-payer data set. Patients were identified using ICD-9 codes for subdural, subarachnoid, and extradural hemorrhage following injury. Transfers were excluded from the study. In the primary analysis the association between a facility's neurotrauma patient volume and patient survival was tested. Secondary analyses focused on the relationships between patient volume and discharge status as well as between patient volume and cost. Analyses were performed using logistic regression. Results In-hospital mortality in the overall cohort was 9.9%. In-hospital mortality was 14.9% in the group with the smallest volume of patients, that is, fewer than 6 cases annually. At facilities treating 6-11, 12-23, 24-59, and 60+ patients annually, mortality was 8.0%, 8.3%, 9.5%, and 10.0%, respectively. For these groups there was a significantly reduced risk of in-hospital mortality as compared with the group with fewer than 6 annual patients; the adjusted ORs (and corresponding 95% CIs) were 0.45 (0.29-0.68), 0.56 (0.38-0.81), 0.63 (0.44-0.90), and 0.59 (0.41-0.87), respectively. For these same groups (once again using < 6 cases/year as the reference), there were no statistically significant differences in either estimated actual cost or duration of hospital stay. Conclusions A VOR exists in the treatment of neurotrauma, and a meaningful threshold for significantly improved mortality is 6 cases per year. Emergency and interfacility transport policies based on this threshold might improve national outcomes. Cost of care does not differ significantly with patient volume.
Journal of Neurosurgery 12/2012; · 2.96 Impact Factor
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Annals of emergency medicine 11/2012; 60(5):673-4. · 4.23 Impact Factor
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ABSTRACT: BACKGROUND: Sudden cardiac arrest (SCA) is a leading cause of death in the US. Recent innovations in post-arrest care have been demonstrated to increase survival. However, little is known about the impact of Emergency Department (ED) and hospital characteristics on survival to hospital admission and ultimate outcome. OBJECTIVE: We sought to describe the incidence of SCA presenting to the ED and to identify ED and hospital characteristics associated with survival to hospital admission. METHODS: We identified patients with diagnoses of atraumatic cardiac arrest or ventricular fibrillation (ICD-9 427.5 or 427.41) in the 2007 Nationwide Emergency Department Sample (NEDS), a nationally representative estimate of all ED admissions in the United States. We defined SCA as cardiac arrest in the out-of-hospital or ED settings. We used the NEDS sample design to generate nationally representative estimates of the incidence of SCA that presents to EDs. We performed unadjusted and adjusted analyses to examine the relation between patient, ED, and hospital characteristics and outcome using logistic regression. Our primary outcome was survival to hospital admission. Survival to hospital discharge was a secondary outcome. Data are presented as odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Of the 966 hospitals in the NEDS, 933 (96.6%) reported at least one SCA and were included in the analysis. We identified 38,593 cases of cardiac arrest representing an estimated 174,982 cases nationally. Overall ED SCA survival to hospital admission was 26.2% and survival to discharge was 15.7%. Greater survival to admission was seen in teaching hospitals (OR 1.3 95% CI 1.1-1.5, p=0.001), hospitals with ≥ 20,000 annual ED visits (OR 1.3 95% CI 1.1-1.6, p=0.003), and hospitals with percutaneous coronary intervention capability (OR 1.6 95% CI 1.4-1.8, p<0.001). Higher SCA volume (>40 annually) was associated with lower survival overall (OR 0.7 95% 0.6-0.9, p=0.010), but not when transferred patients were excluded from the analysis (OR 0.8 95% CI 0.6-1.1, p=0.116). CONCLUSIONS: An estimated 175,000 cases of SCA present to or occur in US EDs each year. Percutaneous coronary intervention capability, ED volume, and teaching status were associated with higher survival to hospital admission. Emergency departments with higher annual SCA volume had lower survival rates, possibly because they transfer fewer patients. An improved understanding of the contribution of ED care to survival following SCA may be useful in advancing our understanding of how best to organize a system of care to ensure optimal outcomes for patients with SCA.
Resuscitation 10/2012; · 3.60 Impact Factor
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ABSTRACT: Aim: The study aimed to evaluate the relationship between insurance status and the management and outcome of acute diverticulitis in a nationally representative sample. Method: A retrospective cohort analysis of a nationally representative sample of 1,031,665 hospital discharges of patients admitted for acute diverticulitis in the 2006-2009 Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project dataset. The main outcome measures included state at presentation (complicated/ uncomplicated), management (medical /surgical), time to surgical intervention, type of operation and in-patient death. Results: 207,838 discharges were identified (including 37.0% private insurance, 49.3% Medicare, 5.6% Medicaid, and 5.8% uninsured) representing 1,031,665 total discharges nationally. Medicare patients were more likely to present with complicated diverticulitis compared to private insurance patients (23.8% vs. 15.1%). Time to surgical intervention differed by insurance status. After adjusting for patient, hospital, and treatment factors, Medicare patients were less likely than those with private insurance to undergo a procedure (Medicare OR=0.86, 95% CI 0.82-0.91); while the uninsured were more likely to undergo drainage (OR=1.30, 95% CI 1.16-1.46) or a colostomy ONLY(OR=1.70, 95% CI 1.24-2.33). All patients without private insurance were more likely to die in-hospital (Medicaid OR=1.29, 95% CI 1.09-1.52, Medicaid OR=1.55, 95% CI 1.22-1.97, uninsured OR=1.41, 95% CI 1.07-1.87). Conclusion: In a nationally representative sample of patients with acute diverticulitis, patient management and outcome varied significantly by insurance status despite adjustment for potential confounders. Providers might need to heighten surveillance for complications when treating patients without private insurance to improve outcome. © 2012 The Authors Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland.
Colorectal Disease 10/2012; · 2.93 Impact Factor
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ABSTRACT: Unintentional injuries are one of the leading causes of death in the United States. Many of these injuries are preventable, and unintentional firearm injuries, in particular, may be responsive to prevention efforts. We investigated the relationship between unintentional firearm death and urbanicity among adults.
This study was a retrospective analysis of national death certificate data. Unintentional adult firearm deaths in the United States from 1999 to 2006 were identified using the Multiple Cause of Death Data files from the National Center for Health Statistics. Decedents were assigned to a county of death and classified along an urban-rural continuum defined by population density and proximity to metropolitan areas. Total unintentional firearm death rates by county were analyzed in adjusted analyses using negative binomial regression.
A total of 4,595 unintentional firearm injury deaths of adults occurred in the United States during the study period (a mean of 574.4 per year). Adjusted rates of unintentional firearm death showed increases from urban to rural counties. Americans in the most rural counties were significantly more likely to die of unintentional firearm deaths than those in the most urban counties (relative rate, 2.16; 95% confidence interval, 1.44-3.21, p = 0.002).
Rates of unintentional firearm death are significantly higher in rural counties than in urban counties. Prevention strategies should be tailored to account for both geographic location and manner of firearm injury.
Epidemiologic study, level III.
The journal of trauma and acute care surgery. 09/2012; 73(4):1006-10.
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ABSTRACT: Federal legislation placed comparative effectiveness research and patient-centered outcomes research at the center of current and future national investments in health care research. The role of this research in emergency care has not been well described. This article proposes an agenda for researchers and health care providers to consider comparative effectiveness research and patient-centered outcomes research methods and results to improve the care for patients who seek, use, and require emergency care. This objective will be accomplished by (1) exploring the definitions, frameworks, and nomenclature for comparative effectiveness research and patient-centered outcomes research; (2) describing a conceptual model for comparative effectiveness research in emergency care; (3) identifying specific opportunities and examples of emergency care-related comparative effectiveness research; and (4) categorizing current and planned funding for comparative effectiveness research and patient-centered outcomes research that can include emergency care delivery.
Annals of emergency medicine 04/2012; 60(3):309-16. · 4.23 Impact Factor
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Raina M Merchant,
Lin Yang,
Lance B Becker,
Robert A Berg,
Vinay Nadkarni,
Graham Nichol, Brendan G Carr,
Nandita Mitra,
Steven M Bradley,
Benjamin S Abella,
Peter W Groeneveld
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ABSTRACT: It is unknown how in-hospital cardiac arrest (IHCA) rates vary across hospitals and predictors of variability.
Measure variability in IHCA across hospitals and determine if hospital-level factors predict differences in case-mix adjusted event rates.
Get with the Guidelines Resuscitation (GWTG-R) (n=433 hospitals) was used to identify IHCA events between 2003 and 2007. The American Hospital Association survey, Medicare, and US Census were used to obtain detailed information about GWTG-R hospitals.
Adult patients with IHCA.
Case-mix-adjusted predicted IHCA rates were calculated for each hospital and variability across hospitals was compared. A regression model was used to predict case-mix adjusted event rates using hospital measures of volume, nurse-to-bed ratio, percent intensive care unit beds, palliative care services, urban designation, volume of black patients, income, trauma designation, academic designation, cardiac surgery capability, and a patient risk score.
We evaluated 103,117 adult IHCAs at 433 US hospitals. The case-mix adjusted IHCA event rate was highly variable across hospitals, median 1/1000 bed days (interquartile range: 0.7 to 1.3 events/1000 bed days). In a multivariable regression model, case-mix adjusted IHCA event rates were highest in urban hospitals [rate ratio (RR), 1.1; 95% confidence interval (CI), 1.0-1.3; P=0.03] and hospitals with higher proportions of black patients (RR, 1.2; 95% CI, 1.0-1.3; P=0.01) and lower in larger hospitals (RR, 0.54; 95% CI, 0.45-0.66; P<0.0001).
Case-mix adjusted IHCA event rates varied considerably across hospitals. Several hospital factors associated with higher IHCA event rates were consistent with factors often linked with lower hospital quality of care.
Medical care 02/2012; 50(2):124-30. · 3.24 Impact Factor
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ABSTRACT: Neurocritical care provides multidisciplinary, specialized care to critically ill neurological patients, yet an understanding of the proportion of the population able to rapidly access specialized Neurocritical Care Units (NCUs) in the United States is currently unknown. We sought to quantify geographic access to NCUs by state, division, region, and for the US as a whole. In addition, we examined how mode of transportation (ground or air ambulance), and prehospital transport times affected population access to NCUs.
Data were obtained from the Neurocritical Care Society (NCS), US Census Bureau and the Atlas and Database of Air Medical Services. Empirically derived prehospital time intervals and validated models estimating prehospital ground and air travel times were used to calculate total prehospital times. A discrete total prehospital time interval was calculated for each small unit of geographic analysis (block group) and block group populations were summed to determine the proportion of Americans able to reach a NCU within discrete time intervals (45, 60, 75, and 90 min). Results are presented for different geographies and for different modes of prehospital transport (ground or air ambulance).
There are 73 NCUs in the US using ground transportation alone, 12.8, 20.5, 27.4, and 32.6% of the US population are within 45, 60, 75, and 90 min of an NCU, respectively. Use of air ambulances increases access to 36.8, 50.4, 60, and 67.3 within 45, 60, 75, and 90 min, respectively. The Northeast has the highest access rates in the US using ground ambulances and for 45, 60, and 75 min transport times with the addition of air ambulances. At 90 min, the West has the highest access rate. The Southern region has the lowest ground and air access to NCUs access rates for all transport times.
Using NCUs registered with the NCS, current geographic access to NCUs is limited in the US, and geographic disparities in access to care exist. While additional NCUs may exist beyond those identified by the NCS database, we identify geographies with limited access to NCUs and offer a population-based planning perspective on the further development of the US neurocritical care system.
Neurocritical Care 11/2011; 16(2):232-40. · 2.47 Impact Factor
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Annals of emergency medicine 09/2011; 59(4):253-4. · 4.23 Impact Factor
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ABSTRACT: Necrotizing fasciitis (NF) is a rapidly progressive disease that requires urgent surgical debridement for survival. Interhospital transfer (IT) may be associated with delay to operation, which could increase mortality. We hypothesized that mortality would be higher in patients undergoing surgical debridement for necrotizing fasciitis after IT compared to Emergency Department (ED) admission.
We performed a retrospective cohort analysis from 2000-2006 using the Nationwide Inpatient Sample. Inclusion criteria were age >18 years, primary diagnosis of NF, and surgical therapy within 72 hours of admission. Logistic regression was used to assess the relationship between admission source, patient and hospital variables, and mortality.
We identified 9,958 cases over the study period. Patients in the ED group were more likely to be nonwhite and of lower income when compared with patients in the IT group. Unadjusted mortality was higher in the IT group than ED group (15.5% vs 8.7%, P < .001). After adjusting for potential confounders, odds of mortality were still greater in the IT (OR 2.04, CI 95% 1.60-2.59, P < .001).
Interhospital transfer is associated with increased risk of in-hospital mortality after surgical therapy for NF, a finding which persists after controlling for patient and hospital level variables.
Surgery 07/2011; 150(3):363-70. · 3.10 Impact Factor
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Raina M Merchant,
Lin Yang,
Lance B Becker,
Robert A Berg,
Vinay Nadkarni,
Graham Nichol, Brendan G Carr,
Nandita Mitra,
Steven M Bradley,
Benjamin S Abella,
Peter W Groeneveld
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ABSTRACT: The incidence and incidence over time of cardiac arrest in hospitalized patients is unknown. We sought to estimate the event rate and temporal trends of adult inhospital cardiac arrest treated with a resuscitation response.
Three approaches were used to estimate the inhospital cardiac arrest event rate. First approach: calculate the inhospital cardiac arrest event rate at hospitals (n = 433) in the Get With The Guidelines-Resuscitation registry, years 2003-2007, and multiply this by U.S. annual bed days. Second approach: use the Get With The Guidelines-Resuscitation inhospital cardiac arrest event rate to develop a regression model (including hospital demographic, geographic, and organizational factors), and use the model coefficients to calculate predicted event rates for acute care hospitals (n = 5445) responding to the American Hospital Association survey. Third approach: classify acute care hospitals into groups based on academic, urban, and bed size characteristics, and determine the average event rate for Get With The Guidelines-Resuscitation hospitals in each group, and use weighted averages to calculate the national inhospital cardiac arrest rate. Annual event rates were calculated to estimate temporal trends.
Get With The Guidelines-Resuscitation registry.
Adult inhospital cardiac arrest with a resuscitation response.
The mean adult treated inhospital cardiac arrest event rate at Get With The Guidelines-Resuscitation hospitals was 0.92/1000 bed days (interquartile range 0.58 to 1.2/1000). In hospitals (n = 150) contributing data for all years of the study period, the event rate increased from 2003 to 2007. With 2.09 million annual U.S. bed days, we estimated 192,000 inhospital cardiac arrests throughout the United States annually. Based on the regression model, extrapolating Get With The Guidelines-Resuscitation hospitals to hospitals participating in the American Hospital Association survey projected 211,000 annual inhospital cardiac arrests. Using weighted averages projected 209,000 annual U.S. inhospital cardiac arrests.
There are approximately 200,000 treated cardiac arrests among U.S. hospitalized patients annually, and this rate may be increasing. This is important for understanding the burden of inhospital cardiac arrest and developing strategies to improve care for hospitalized patients.
Critical care medicine 06/2011; 39(11):2401-6. · 6.37 Impact Factor
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ABSTRACT: Trauma system planners use patient home address as a proxy for injury location, although this proxy has not been validated. We sought to determine the precision of this proxy by evaluating the relationship between the location of injury death and the location of residence.
This national descriptive analysis used the Multiple Cause of Death data files from 1999 to 2006 to determine the proportion of subjects in which county of residence (RC) matched county of death for all US injury deaths. Subgroup analyses were completed by age and injury intentionality using two sample tests of proportions. χ(2) tests were used to evaluate differences in concordance over time and by size of the RC.
Analysis included 3,141 US counties and 1,255,881 subjects. A total of 73.4% of subjects died in the RC and 87.7% died in the RC or a contiguous county. Intentional injury deaths were more likely than unintentional to happen within a decedent's RC (85.1% vs. 68.1%, p < 0.001) and within the RC or contiguous county (93.4% vs. 85.2%, p < 0.001). Adult injury deaths were more likely than pediatric to happen within a decedent's RC (73.6% vs. 68.4%, p < 0.001) and within the RC or contiguous county (87.9% vs. 84.2%, p < 0.001). Subjects from larger counties were more likely to die within the RC or a contiguous county (same p < 0.001, same or adjacent p < 0.001).
The preponderance of fatal injury deaths occur close to home. This supports the practice of trauma system's planning using home location available in administrative data to proxy injury location.
The Journal of trauma 05/2011; 71(5):1428-34. · 2.48 Impact Factor
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ABSTRACT: To evaluate whether mortality and clinical outcomes vary for injured patients in a mature trauma system on weeknights and weekends compared with weekdays.
Retrospective cohort study.
Pennsylvania trauma system.
A total of 90,461 patients over 5 years.
Treatment at a level I, II, or III trauma center.
In-hospital mortality, time to procedures, and length of stay.
In adjusted analyses, patients presenting on weeknights were no more likely to die than patients presenting during weekdays, and patients presenting on weekends were less likely to die than patients presenting on weekdays (odds ratio = 0.89; 95% confidence interval, 0.81-0.97). Presenting on weeknights was associated with longer intensive care unit stay (incidence rate ratio = 1.06; 95% confidence interval, 1.02-1.10) and longer hospital stay (incidence rate ratio = 1.02; 95% confidence interval, 1.00-1.04). Presenting on weekends was associated with longer intensive care unit stay (incidence rate ratio = 1.04; 95% confidence interval, 1.02-1.10) but not longer hospital stay. Delays to laparotomy or craniotomy were not seen in either group.
We demonstrate comparable mortality among injured patients presenting on weeknights vs weekdays and lower mortality among injured patients on weekends vs weekdays. Systems-based solutions of the trauma model are protective against the weekend effect and inform care for other emergency care-sensitive conditions.
Archives of surgery (Chicago, Ill.: 1960) 03/2011; 146(7):810-7. · 4.32 Impact Factor
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ABSTRACT: The 2010 Academic Emergency Medicine consensus conference on regionalization in emergency care began with an update on the Institute of Medicine (IOM) reports on the Future of Emergency Care. This was followed by two presentations from federal officials, focusing on regionalization from the perspective of the White House National Security Staff and the Emergency Care Coordination Center. This article summarizes the content of these presentations. It should be noted that this summary is the perspective of the authors and does not represent the official policy of the U.S. government.
Academic Emergency Medicine 12/2010; 17(12):1351-3. · 1.86 Impact Factor
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ABSTRACT: The 2010 Academic Emergency Medicine (AEM) consensus conference "Beyond Regionalization" aimed to place the design of a 21st century emergency care delivery system at the center of emergency medicine's (EM's) health policy research agenda. To examine the lessons learned from existing regional systems, consensus conference organizers convened a panel discussion made up of experts from the fields of acute care surgery, interventional cardiology, acute ischemic stroke, cardiac arrest, critical care medicine, pediatric EM, and medical toxicology. The organizers asked that each member provide insight into the barriers that slowed network creation and the solutions that allowed them to overcome barriers. For ST-segment elevation myocardial infarction (STEMI) management, the American Heart Association's (AHA's) Mission: Lifeline aims to increase compliance with existing guidelines through improvements in the chain of survival, including emergency medical services (EMS) protocols. Increasing use of therapeutic hypothermia post-cardiac arrest through a network of hospitals in Virginia has led to dramatic improvements in outcome. A regionalized network of acute stroke management in Cincinnati was discussed, in addition to the effect of pediatric referral centers on pediatric capabilities of surrounding facilities. The growing importance of telemedicine to a variety of emergencies, including trauma and critical care, was presented. Finally, the importance of establishing a robust reimbursement mechanism was illustrated by the threatened closure of poison control centers nationwide. The panel discussion added valuable insight into the possibilities of maximizing patient outcomes through regionalized systems of emergency care. A primary challenge remaining is for EM to help to integrate the existing and developing disease-based systems of care into a more comprehensive emergency care system.
Academic Emergency Medicine 12/2010; 17(12):1354-8. · 1.86 Impact Factor
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ABSTRACT: More than a decade ago, the city of Philadelphia began allowing police transport of penetrating trauma patients.
The objective was to determine the relation between prehospital mode of transport (police department [PD] vs. Philadelphia Fire Department (PFD) emergency medical services [EMS]) and survival in subjects with proximal penetrating trauma.
The authors performed a retrospective cohort study of prospectively collected trauma registry data. All subjects who sustained proximal penetrating trauma and who presented to a Level I urban trauma center over a 5-year period (January 1, 2003, to December 31, 2007) were included. Mortality for subjects presenting by EMS was compared to that of those who arrived by PD transport in unadjusted and adjusted analyses. Unadjusted analyses were performed using the chi-square test, Wilcoxon rank sum test, and Student's t-test. Adjusted analyses were performed using logistic regression using the Trauma Injury Severity Score (TRISS) methodology. Data are presented as percentages, odds ratios (ORs), and 95% confidence intervals (CIs). Total hospital length of stay was examined as a secondary outcome.
Of the 2,127 subjects, 26.8% were transported to the emergency department (ED) by PD, and 73.2% by EMS. The mean(±standard deviation [SD]) age of PD subjects was 26.3 (±9.1) years and 92% were male versus EMS subjects whose mean (±SD) age was 31.5 (±11.8) years and of whom 87% were male. Overall, 70.8% sustained a gunshot wound (GSW), and 29.2% sustained a stab wound (SW). Overall Injury Severity Score (ISS) was 11.21 (ISS for PD, 14.2±17.5; for EMS, 10.1±14.5; p<0.001), and 16.6% of the subjects died (PD, 21.4±0.41%; EMS, 14.8±0.36%; p<0.001). In unadjusted analyses, PD subjects were more likely to die than EMS subjects (OR=1.6, 95% CI=1.2 to 2.0; p<0.001). When adjusting for injury severity using TRISS, there was no difference in survival between PD and EMS subjects (OR=1.01, 95% CI=0.63 to 1.61). Median length of hospital stay was 1 day and did not differ according to mode of prehospital transport (p=0.159).
Although unadjusted mortality appears to be higher in PD subjects, these findings are explained by the more severely injured population transported by PD. The current practice of permitting police officers to transport penetrating trauma patients should be continued.
Academic Emergency Medicine 12/2010; 18(1):32-7. · 1.86 Impact Factor
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ABSTRACT: Rapid access to emergency care can be life-saving, and geography is an important determinant of access to care. In this article, the authors review the organization of emergency care in the United States and describe the use of geographic information systems (GIS) to describe and solve health-related problems. The distribution of and access to medical resources, especially in the case of time-sensitive conditions, embodies the core concepts of geography—the relationship between place, time, and physical phenomena. The authors propose the expanded use of GIS in the development of the emergency care system and suggest that a transparent inventory of emergency care resources, coupled with an understanding of how access to appropriate care influences outcomes, can inform the creation of a regionalized, coordinated, and accountable emergency care system.ACADEMIC EMERGENCY MEDICINE 2010; 17: 1274–1278 © 2010 by the Society for Academic Emergency Medicine
Academic Emergency Medicine 11/2010; 17(12):1274 - 1278. · 1.86 Impact Factor
