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Global-scale disasters, such as the Haiti earthquake, generate huge numbers of casualties and simultaneously damage local infrastructure, including medical facilities. In such cases, the mix of resources sent to the scene by the international community may determine how many lives can be saved. Unfortunately, there is no internationally sanctioned afteraction process to enable national disaster relief agencies and large nongovernmental organizations to learn from their experiences so that the next global response is more efficient and effective than the last. For example, data from 6 recent earthquakes suggest that the tradition of dispatching large numbers of urban search and rescue teams provides scant benefit relative to the substantial resources involved. Sending fewer urban search and rescue teams and more medical teams might save more lives. Earthquakes are one of the most devastating forms of natural disaster. They usually strike without warning, produce widespread damage, and can cause massive loss of life. The recent quakes that struck Chile, New Zealand, and Japan showed that temblors of sufficient magnitude can wreak havoc in the best-built and most well-prepared nations. But earthquakes of lesser magnitude can produce even greater loss of life if they strike densely populated regions filled with poorly constructed buildings. When a disaster clearly exceeds the afflicted nation’s capacity to respond, the international community is often asked to assist. In such cases, actions taken in the first days after the event can save many lives. Currently, national delegations and nongovernmental organizations generally act on their own, without the benefit of a unified command structure. As a result, they have little knowledge of one another’s plans and resources. And because major earthquakes invariably disrupt communications, little is known about conditions on the ground during the initial hours after a catastrophic event. Lacking specific information about local needs, international aid missions often rush whatever manpower, equipment, and supplies they have readily at hand to the scene, regardless of what is needed. The primary motivation for this practice is a strong desire to help, but national pride and organizational selft

This report describes the rationale, purpose, structure, and content of the emergency medical services (EMS) injury prevention program "Accidents Aren't." The program is introduced with a review of injuries' toll professionally, epidemiologically, and economically in terms of the demand on medical care resources and the expense of care. With recognition that most EMS resources are expended on clinical care of non-critical but potentially catastrophic injuries, "Accidents Aren't" was designed to offer a more cost-effective means of care for this population and more efficient utilization of finite resources. The report describes the program's formulation process, its modular design, the instructor guidelines, the core training tool, the STARR mnemonic, and five clinical cases involving a wide array of injury mechanisms to which the mnemonic is applicable. Physician involvement in teaching and implementing the program is discussed. The relationship of the program to the future of EMS concludes the report.

Community Health Center (CHC)–Academic Medical Partnerships (CHAMPs) would combine academic medical centers' subspecialist expertise, technology, and inpatient care with CHCs' primary care expertise, creating a distinctive form of accountable care organization.

Many believe that fear of malpractice lawsuits drives physicians to order otherwise unnecessary care and that legal reforms could reduce such wasteful spending. Emergency physicians practice in an information-poor, resource-rich environment that may lend itself to costly defensive practice. Three states, Texas (in 2003), Georgia (in 2005), and South Carolina (in 2005), enacted legislation that changed the malpractice standard for emergency care to gross negligence. We investigated whether these substantial reforms changed practice.Using a 5% random sample of Medicare fee-for-service beneficiaries, we identified all emergency department visits to hospitals in the three reform states and in neighboring (control) states from 1997 through 2011. Using a quasi-experimental design, we compared patient-level outcomes, before and after legislation, in reform states and control states. We controlled for characteristics of the patients, time-invariant hospital characteristics, and temporal trends. Outcomes were policy-attributable changes in the use of computed tomography (CT) or magnetic resonance imaging (MRI), per-visit emergency department charges, and the rate of hospital admissions.For eight of the nine state-outcome combinations tested, no policy-attributable reduction in the intensity of care was detected. We found no reduction in the rates of CT or MRI utilization or hospital admission in any of the three reform states and no reduction in charges in Texas or South Carolina. In Georgia, reform was associated with a 3.6% reduction (95% confidence interval, 0.9 to 6.2) in per-visit emergency department charges.Legislation that substantially changed the malpractice standard for emergency physicians in three states had little effect on the intensity of practice, as measured by imaging rates, average charges, or hospital admission rates. (Funded by the Veterans Affairs Office of Academic Affiliations and others.).

Underrepresented minority and first-generation college students are more likely than white students to attend a community college before transferring to a four-year school. Talamantes and colleagues report in this issue that, according to their study of 2012 medical school applicants and matriculants, community-college-first applicants were significantly less likely to be admitted to medical school even after other important predictors, including grade point average and Medical College Admission Test scores, were taken into consideration. These findings suggest that rather than appreciating the "distance traveled" and obstacles overcome by applicants who got their start at a community college, medical school admissions committees may be consciously or subconsciously discounting their achievements. The authors of this Commentary consider the study by Talamantes and colleagues as well as other recent data related to community college graduates and emphasize that community colleges attract many high-achieving applicants who for any of several reasons-limited finances, inadequate advising, insufficient financial aid, or a need to stay close to home-choose not to enroll in a four-year college right away. They argue that if medical school leaders are serious about lowering the social, racial, and economic barriers to medical school, they must start viewing two years of premedical education at a community college as an asset rather than a liability.

Background: Trauma centers are an effective but costly element of the US health care infrastructure. Some Level I and II trauma centers regularly incur financial losses when these high fixed costs are coupled with high burdens of uncompensated care for disproportionately young and uninsured trauma patients. As a result, they are at risk of reducing their services or closing. The impact of these closures on patient outcomes, however, has not been previously assessed. Methods: We performed a retrospective study of all adult patient visits for injuries at Level I and II, nonfederal trauma centers in California between 1999 and 2009. Within this population, we compared the in-hospital mortality of patients whose drive time to their nearest trauma center increased as the result of a nearby closure with those whose drive time did not increase using a multivariate logit-linked generalized linear model. Our sensitivity analysis tested whether this effect was limited to a 2-year period following a closure. Results: The odds of inpatient mortality increased by 21% (odds ratio, 1.21; 95% confidence interval, 1.04-1.40) among trauma patients who experienced an increased drive time to their nearest trauma center as a result of a closure. The sensitivity analyses showed an even larger effect in the 2 years immediately following a closure, during which patients with increased drive time had 29% higher odds of inpatient death (odds ratio, 1.29; 95% confidence interval, 1.11-1.51). Conclusion: Our results show a strong association between closure of trauma centers in California and increased mortality for patients with injuries who have to travel further for definitive trauma care. These adverse impacts were intensified within 2 years of a closure. LEVEL OF EVIDENCE: Prognostic and epidemiologic, level III. © 2014 2014 Lippincott Williams & Wilkins.

This systematic review sought to identify the best available evidence regarding strategies for allocating scarce resources during mass casualty events (MCEs). Specifically, the review addresses the following questions: (1) What strategies are available to policymakers to optimize the allocation of scarce resources during MCEs? (2) What strategies are available to providers to optimize the allocation of scarce resources during MCEs? (3) What are the public's key perceptions and concerns regarding the implementation of strategies to allocate scarce resources during MCEs? (4) What methods are available to engage providers in discussions regarding the development and implementation of strategies to allocate scarce resources during MCEs?We searched Medline, Scopus, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Global Health, Web of Science®, and the Cochrane Database of Systematic Reviews from 1990 through 2011. To identify relevant non-peer-reviewed reports, we searched the New York Academy of Medicine's Grey Literature Report. We also reviewed relevant State and Federal plans, peer-reviewed reports and papers by nongovernmental organizations, and consensus statements published by professional societies. We included both English- and foreign-language studies.Our review included studies that evaluated tested strategies in real-world MCEs as well as strategies tested in drills, exercises, or computer simulations, all of which included a comparison group. We reviewed separately studies that lacked a comparison group but nonetheless evaluated promising strategies. We also identified consensus recommendations developed by professional societies or government panels. We reviewed existing State plans to examine the current state of planning for scarce resource allocation during MCEs. Two investigators independently reviewed each article, abstracted data, and assessed study quality.We considered 5,716 reports for this comparative effectiveness review (CER); we ultimately included 170 in the review. Twenty-seven studies focus on strategies for policymakers. Among this group were studies that examined various ways to distribute biological countermeasures more efficiently during a bioterror attack or influenza pandemic. They provided modest evidence that the way these systems are organized influences the speed of distribution. The review includes 119 studies that address strategies for providers. A number of these studies provided evidence suggesting that commonly used triage systems do not perform consistently in actual MCEs. The number of high-quality studies addressing other specific strategies was insufficient to support firm conclusions about their effectiveness. Only 10 studies included strategies that consider the public's perspective. However, these studies were consistent in their findings. In particular, the public believes that resource allocation guidelines should be simple and consistent across health care facilities but should allow facilities some flexibility to make allocation decisions based on the specific demand and supply situation. The public also believes that a successful allocation system should balance the goals of ensuring the functioning of society, saving the greatest number of people, protecting the most vulnerable people, reducing deaths and hospitalizations, and treating people fairly and equitably. The remaining 14 studies provided strategies for engaging providers in discussions about allocating and managing scarce medical resources. These studies did not identify one engagement approach as clearly superior; however, they consistently noted the importance of a broad, inclusive, and systematic engagement process.Scientific research to identify the most effective adaptive strategies to implement during MCEs is an emerging area. While it remains unclear which of the many options available to policymakers and providers will be most effective, ongoing efforts to develop a focused, well-organized program of applied research should help to identify the optimal methods, techniques, and technologies to strengthen our nation's capacity to respond to MCEs.

Of the approximately four million women who give birth each year in the United States, nearly 13 percent experience one or more major complications. But the extent to which the rates of major obstetrical complications vary across hospitals in the United States is unknown. We used multivariable logistic regression models to examine the variation in obstetrical complication outcomes across US hospitals among a large, nationally representative sample of more than 750,000 obstetrical deliveries in 2010.We found that 22.55 percent of patients delivering vaginally at low-performing hospitals experienced major complications, compared to 10.42 percent of similar patients delivering vaginally at highperforming hospitals. Hospitals were classified as having low, average, or high performance based on a calculation of the relative risk that a patient would experience a major complication. Patients undergoing a cesarean delivery at low-performing hospitals had nearly five times the rate of major complications that patients undergoing a cesarean delivery at high-performing hospitals had (20.93 percent compared to 4.37 percent). Our finding that the rate of major obstetrical complications varies markedly across US hospitals should prompt clinicians and policy makers to develop comprehensive quality metrics for obstetrical care and focus on improving obstetrical outcomes. © 2014 by Project HOPE - The People-to-People Health Foundation.

In the United States, firearms are used to commit homicide more frequently than all other methods combined. According to the US Department of Justice, firearms are used to commit more than 1 million crimes each year. Despite the magnitude of this problem, little is known about the epidemiology of firearm crimes and assaults. Many states require medical personnel to report all nonfatal shootings to law enforcement, but the rate of compliance with this requirement is unknown. To enhance cooperation between community emergency departments and law enforcement agencies, we created a unified firearm injury notification system for the City of Atlanta, Georgia, and 5 surrounding counties: Fulton, DeKalb, Cobb, Gwinnett, and Clayton. Our findings are reported here.

Objectives.To determine how boys behave when they find a handgun in a presumably safe environment and to compare parental expectations of their child's interest in real guns with this observed behavior.Methods.A convenience sample of 8- to 12-year-old boys was recruited from families that completed a survey on firearm ownership, storage practices, and parental perceptions. Parents were asked to rate their child's interest in real guns on a scale from 1 to 5: 1–2 = low interest, 3 = moderate interest, and 4–5 = high interest. Parents of an eligible child were asked to bring to the exercise 1 of their son's playmates and/or a sibling in the same age range. After informed parental consent was obtained, each pair or trio of boys was placed in a room with a 1-way mirror and observed for up to 15 minutes. Two water pistols and an actual .380 caliber handgun were concealed in separate drawers. The handgun contained a radio transmitter that activated a light whenever the trigger was depressed with sufficient force to discharge the firearm. After the exercise, each boy was asked whether he thought that the pistol was real or a toy. Before leaving, each child was counseled about safe behavior around guns.Results.Twenty-nine groups of boys (n= 64) took part in the study. The mean age of participants was 9.8 years. Twenty-one of the groups (72%) discovered the handgun (n = 48 boys); 16 groups (76%) handled it (n = 30 boys). One or more members in 10 of the groups (48%) pulled the trigger (n = 16 boys). Approximately half of the 48 boys who found the gun thought that it was a toy or were unsure whether it was real. Parental estimates of their child's interest in guns did not predict actual behavior on finding the handgun. Boys who were believed to have a low interest in real guns were as likely to handle the handgun or pull the trigger as boys who were perceived to have a moderate or high interest in guns. More than 90% of the boys who handled the gun or pulled the trigger reported that they had previously received some sort of gun safety instruction.Conclusion.Many 8- to 12-year-old boys will handle a handgun if they find one. Guns that are kept in homes should be stored in a manner that renders them inaccessible to children.guns, weapons, firearms, children, childhood behavior, injury prevention.

The aim of this study was to examine psychological and interpersonal risk factors for suicidal behavior in low income, African American women; 285 African American women who reported being in a relationship with a partner in the past year were studied, 148 presented to the hospital following a suicide attempt, and 137 presented for general medical care. Cases were compared to controls with respect to psychological symptoms, alcohol and drug abuse, family violence (intimate partner abuse, childhood trauma), relationship discord, and social support. Psychological risk factors for suicide attempts at the univariate level included psychological distress [Crude Odds Ratio (COR) = 6.5], post traumatic stress disorder (PTSD) symptoms (COR = 3.8), hopelessness (COR = 7.7), and drug abuse (COR = 4.2). Interpersonal risk factors at the univariate level included relationship discord (COR = 4.0), physical partner abuse (COR = 2.5), nonphysical partner abuse (COR = 2.8), childhood maltreatment (COR = 3.2), and low levels of social support (COR = 2.6). A multivariate logistic regression model identified four variables that were strongly and independently associated with an increased risk for suicide attempts: psychological distress, hopelessness, drug abuse, and relationship discord. The model predicted suicide attempt status correctly 77% of the time. The results reveal that African American women who report high levels of psychological distress, hopelessness, drug use, and relationship discord should be assessed carefully for suicidal ideation and referred for appropriate mental health care.

Dr. Arthur Kellermann and Lawrence Lewin predict the ramifications of a failure to pass health care reform, in terms of coverage, costs, access to care, and the health of the population.

Study objective: Despite the proven efficacy of cardiopulmonary resuscitation (CPR), only a small fraction of the population knows how to perform it. As a result, rates of bystander CPR and rates of survival from cardiac arrest are low. Bystander CPR is particularly uncommon in the African American community. Successful development of a simplified approach to CPR training could boost rates of bystander CPR and save lives. We conducted the following randomized, controlled study to determine whether video self-instruction (VSI) in CPR results in comparable or better performance than traditional CPR training. Methods: This randomized, controlled trial was conducted among congregational volunteers in an African American church in Atlanta, GA. Subjects were randomly assigned to receive either 34 minutes of VSI or the 4-hour American Heart Association "Heartsaver" CPR course. Two months after training, blinded observers used explicit criteria to assess CPR performance in a simulated cardiac arrest setting. A recording manikin was used to measure ventilation and chest compression characteristics. Participants also completed a written test of CPR-related knowledge and attitudes. Results: VSI trainees displayed a comparable level of performance to that achieved by traditional trainees. Observers scored 40% of VSI trainees competent or better in performing CPR, compared with only 16% of traditional trainees (absolute difference 24%, 95% confidence interval 8% to 40%). Data from the recording manikin confirmed these observations. VSI trainees and traditional trainees achieved comparable scores on tests of CPR-related knowledge and attitudes. Conclusion: Thirty-four minutes of VSI can produce CPR of comparable quality to that achieved by traditional training methods. VSI provides a simple, quick, consistent, and inexpensive alternative to traditional CPR instruction, and may be used to extend CPR training to historically underserved populations. [Todd KH, Heron SL, Thompson M, Dennis R, O'Connor J, Kellermann AL: Simple CPR: A randomized, controlled trial of video self-instructional cardiopulmonary resuscitation training in an African American church congregation. Ann Emerg Med December 1999;34:730-737.]

Background. Each year, thousands of children are injured or killed from unintentional gunshot wounds. Discovering a gun while playing in the home places children at risk of being injured by the firearm. Objectives. To determine parental firearm storage practices and parental perceptions of the behavior of their children around guns. Methods. Cross-sectional survey of parents of children from 4 to 12 years of age. A sample of 424 parents, bringing their children to one of five pediatric ambulatory care centers, were asked to complete a 20-point self-administered questionnaire at the time of their visit. Results. A total of 400 parents (94%) completed the questionnaire; 113 parents (28%) reported keeping a firearm (most often a handgun) in the home. Firearm owners were predominantly male, 30 years of age or older, white, and married. Of the gun owners, 52% stored their firearms loaded or unlocked, and 13% kept one or more guns loaded and unlocked. Three fourths of gun-owning parents believed that their 4- to 12-year-old child could tell the difference between a toy gun and a real gun, and 23% believed that their child could be trusted with a loaded gun. Although the majority of gun-owning parents (53%) endorsed safe storage as the best firearm injury prevention strategy, 61% of parents who do not own firearms endorse not owning guns as the best way to prevent pediatric firearm injuries. Conclusion. A majority of gun-owning parents store their firearms loaded or unlocked, substantially underestimating the risk of injury to their children. Many firearm-owning parents trust their child with a loaded gun and believe that their young child can tell the difference between a toy gun and a real gun.

Public health surveillance seeks answers to five questions: who, what, when, where, and why? For most health events, answers can be readily obtained from the patient’s medical record. Injuries are a different story. Medical records are generally adequate for telling us who was injured, what type of injury was sustained, and when the injury occurred. Unfortunately, the medical record is less useful for telling us where the injury took place, and most importantly, why.1 This is particularly true of injuries caused by firearms. There are several reasons why medical records alone are inadequate for local surveillance of firearm injuries. First, emergency physicians and trauma surgeons rarely bother to record information that is not immediately relevant to the care of their patients. The location and circumstances of an incident may be interesting to an epidemiologist or a police investigator, but they have little bearing on the decision to take a patient to the operating room. Second, many shooting victims are too injured, or too chemically impaired, to provide a reliable history at the time they are brought to the emergency department (ED). When confronted with a critically injured patient, ED personnel treat first, and worry about the history later. Finally, some victims provide inaccurate or misleading information to avoid arrest or retaliation. In one study, 25% of firearm assault victims claimed that their shooting was unprovoked.2 The difference between “victim” and “offender” is sometimes defined by who shot first, or had better aim. Without detailed information about the location and the circumstances surrounding each shooting, firearm injury surveillance provides little more than wound and body counts.3 This may suffice for national and statelevel surveillance, but it is inadequate for local problem-solving. Community officials (especially heads of public safety agencies) need more complete data to plan, implement, and evaluate counter-measures. To generate this level of detail, hospital records must be supplemented by other sources of data.2,4,5 Emergency Medical Services (EMS) records can provide useful information about patients who were transported by ambulance, but EMS records miss victims who reached the hospital by foot or private vehicle. Medical examiner records capture detailed information about victims who are found dead on the scene, but ME records are limited to fatalities. In urban areas, nonfatal shootings outnumber firearm suicides, homicides, and unintentional deaths by a ratio of four to one.2 Law enforcement records are the best source of information about what happened on the scene. Police respond to the vast majority of shootings, and they have a legal responsibility to determine what happened. They routinely interview witnesses and others who have information about the shooting, and they document their findings. As a result, police reports contain valuable information about incident location, the circumstances surrounding the shooting, victim-offender relationship, and the type of weapon involved.5 Unfortunately, it is not always easy to gain access to police files. Law enforcement agencies are notoriously reluctant to share information, especially to “outsiders.”6 In the absence of a legal obligation to share data, it may be difficult to convince them that the effort is worth the trouble. Once access is granted, logistical barriers may hamper acquisition and linkage of data. Many law enforcement agencies lack sufficient resources to computerize their records,7 and budget cuts have forced many police departments to reduce the size and scope of their crime analysis units. Manual retrieval of records is a tedious and uncertain process. Since most departments do not allow outsiders to search their files, this can greatly prolong the time required to answer requests for data. The high cost of photocopying, and the poor legibility of hand-written records pose additional problems. The task is much simpler when reports are stored in an electronic format. Officials at the California Department of Public Health obtained computerized copies of their state’s Federal Bureau of Investigation (FBI) Uniform Crime Reports (UCR) Supplemental Homicide Reports (SHR), and linked these records to state death certificates.8 Unfortunately, UCR data cannot be used to supplement documentation of nonfatal firearm injuries, because the UCR From the Center for Injury Control, Rollins School of Public Health of Emory University, Atlanta, Georgia 30322. Address Correspondence to: Arthur L. Kellermann, MD, MPH, Center for Injury Control, Rollins School of Public Health, 1518 Clifton Road, NE, Atlanta, Georgia 30322.

New policy options are emerging in the debate regarding the regulation of firearms in the United States. These options include the treatment of firearms as consumer products, the design of which can be regulated for safety; denial of gun ownership to those convicted of misdemeanors; and strategies to curtail the illegal sale of guns. The public's opinion of these innovative gun-policy options has not been thoroughly assessed.We conducted two telephone surveys of 1200 adults each in the United States in 1996 and 1997-1998. Cognitive interviews and pretests were used in the development of the survey instruments. Potential participants were then contacted by random-digit dialing of telephone numbers.A majority of the respondents favored safety standards for new handguns. These standards included childproofing (favored by 88 percent of respondents), personalization (devices that permit firing only by an authorized person; 71 percent), magazine safeties (devices that prevent firing after the magazine or clip is removed; 82 percent), and loaded-chamber indicators (devices that show whether the handgun is loaded; 73 percent). There was strong support for policies prohibiting persons convicted of specific misdemeanors from purchasing a firearm. Support for such prohibitions was strongest for crimes involving violence or the illegal use of a firearm (83 to 95 percent) or substance abuse (71 to 92 percent). There was also widespread support for policies designed to reduce the illegal sale of guns, such as mandatory tamper-resistant serial numbers (90 percent), a limit of one handgun purchase per customer per month (81 percent), and mandatory registration of handguns (82 percent). Even among the subgroup of respondents who were gun owners, a majority were in favor of stricter gun regulations with regard to 20 of the 22 proposals covered in the poll.Strong public support, even among gun owners, for innovative strategies to regulate firearms suggests that these proposals warrant serious consideration by policy makers.

PURPOSE: To assess knowledge, attitudes, and formal instruction related to injury control among fourth-year medical students. Injury is the leading cause of death among Americans aged 1 to 44 years. METHOD: The authors conducted a cross-sectional survey of fourth-year students at six U.S. medical schools, four of which maintain federally funded injury prevention research centers. Main outcome measures included injury-related knowledge scores, three attitude measures, and self-reported exposures to injury prevention education. RESULTS: Six hundred and thirty-five fourth-year medical students (73% of those eligible) participated. The responding students were, on average, unable to correctly answer half of the questions testing injury-related knowledge. They rated medical problems more important and more preventable than injury problems, and they felt more comfortable asking their patients about risk factors for medical problems. These findings may be explained, in part, by the students' reported minimal exposure to injury control education in medical school. The students encountered the topic more frequently on rotations in pediatrics (84%), family medicine (73%), and preventive medicine (66%) than on rotations in emergency medicine (47%), internal medicine (41%), or obstetrics and gynecology (34%). Injury control was encountered least often on rotations in psychiatry (23%) and surgery (14%). CONCLUSIONS: These findings suggest that injury control is given limited coverage in the curricula of U.S. medical schools. As a result, students have little understanding of the principles and benefits of injury control.

Four decades ago, the National Academy of Sciences and National Research Council published Accidental Death and Disability: The Neglected Disease of Modern Society. Release of this landmark report was a watershed event in the development of emergency medical services (EMS) in the United States. Emergency care has dramatically evolved since then. Breakthroughs in biomedical research have given us tools to rapidly diagnose life-threatening conditions and the capacity to intervene to blunt or prevent their effects. This increase in capability produced a commensurate increase in expectations. Once, emergency physicians admitted acutely ill patients to the hospital for a diagnostic evaluation. Now, they must complete the evaluation themselves to justify the need for admission. Thanks to television shows such as ER and stories on the evening news, the public expects miracles to happen when they enter an emergency department (ED). Many are quick to blame the doctor if it doesn’t work out that way. To guarantee that patients have access to emergency care, Congress enacted the Emergency Medical Treatment and Active Labor Act (EMTALA), a federal law that mandates treatment without regard for the patient’s ability to pay. But success came at a price. No funding was appropriated to defray the costs of EMTALA-mandated care. As the number of uninsured Americans increased and even fully insured patients encountered problems securing timely appointments outside the ED, use grew at a rapid rate. It now exceeds 114 million visits per year, more than 10% of all outpatient encounters in the United States. Some visits are for relatively minor problems, but most involve potentially serious illnesses or injuries. Recently, the Agency for Healthcare Research and Quality reported that in 2003, 55% of community hospital admissions for conditions other than maternal and neonatal ones began in the ED. Unfortunately, the rapid growth in ED use collided with equally dramatic reductions in hospital capacity. The result is that in cities across the United States, patients on stretchers line the hallways of EDs, waiting for the next available inpatient bed. There was a time when the notion of diverting an inbound ambulance was unthinkable. Today, it happens more than a half million times per year.

Five decades ago, hospitals staffed their emergency rooms with rotating community physicians or unsupervised hospital staff. Ambulance service was frequently provided by a local funeral home. Beginning in the late 1960s and accelerating thereafter, emergency care swiftly evolved into its current form. Today, modern emergency departments not only are capable of providing around-the-clock lifesaving care in individual emergencies and disasters. They also conduct timely diagnostic workups, provide access to after-hours acute care, and serve as the "safety net of the safety net" for millions of low-income and uninsured patients. But the field's success has led to a new set of challenges. To overcome them, emergency care must become more integrated, regionalized, prevention oriented, and innovative. © 2013 Project HOPE-The People-to-People Health Foundation, Inc.

The primary objective of this study was to determine how EMS organizations that are piloting patient-centered treatment and transport protocols are approaching the challenges of implementation, reimbursement, and quality assurance. We were particularly interested in determining if these pilot efforts have raised any patient safety concerns.We conducted a set of discussions with a small group of key EMS stakeholders regarding the status of pioneering efforts to develop and evaluate innovative approaches to EMS in the United States.We had discussions with 9 EMS agencies to better understand their innovative programs, including: the history of their service policy and procedure for transports that do not require emergency department care; the impact of their innovative program on service costs and/or cost savings; any reimbursement issues or changes; patient safety; patient satisfaction; and overall impression as well as recommendations for other EMS systems considering adoption of this policy.In general, EMS systems are not reimbursed for service unless the patient is transported to an ED. Spokespersons for all nine sites covered by this project said that this policy creates a powerful disincentive to implementing pilot programs to safely reduce EMS use by directing patients to more appropriate sites of care or proactively treating them in their homes. Even though private and public hospitals and payers typically benefit from these programs, they have been generally reluctant to offer support. This raises serious questions about the long-term viability of these programs.

The Boston Marathon bombing and the medical response offer several important lessons, including that the remarkably low mortality rate (1%) was attributable in part to several factors favoring the rescuers and that disaster preparedness still requires planning.

The Institute of Medicine and other national organizations have asserted that current payment policies strongly discourage emergency medical services (EMS) providers from transporting selected patients who call 911 to non-ED settings (eg, primary care clinics, mental health centers, dialysis centers) or from treating patients on scene. The limited literature available is consistent with the view that current payment policies incentivize transport of all 911 callers to a hospital ED, even those who might be better managed elsewhere. However, the potential benefits and risks of altering existing policy have not been adequately explored. There are theoretical benefits to encouraging EMS personnel to transport selected patients to alternate settings or even to provide definitive treatment on scene; however, existing evidence is insufficient to confirm the feasibility or safety of such a policy. In light of growing concerns about the high cost of emergency care and heavy use of EDs, assessing EMS transport options should be a high-priority topic for outcomes research.

Objectives To characterize the reasons ambulatory patients use hospital emergency departments (EDs) for outpatient care and to determine the proportion of ED patients who initially are assessed as having nonurgent conditions, but subsequently are hospitalized. Design Cross-sectional survey during a single 24-hour period of time. Setting Fifty-six hospital EDs nationwide. Patients or other participants Consecutive ambulatory patients presenting for care. Patents who arrived by ambulance were excluded. Results Of 6441 ambulatory patients (79 percent of all ED visits) who were eligible for study, interviews were obtained from 6187 (96 percent). A total of 5323 patients (86 percent) had clinical reasons or preferences for seeking care at an ED, including 2799 (45 percent) who thought they had an emergency or an urgent condition or were too sick to go elsewhere. Nineteen percent (n=1199) reported that they were sent to the ED by a health care professional. Patients with a regular clinician or with insurance cited similar reasons for seeking care at an ED. A total of 3062 patients (50 percent) cited 1 or more nonfinancial barriers to care as an important reason for coming to the ED, and 949 (15 percent) cited financial considerations. A total of 3045 patents (49 percent of ambulatory patients and 37 percent of total ED visits) were assessed at triage as having a nonurgent condition; 166 of them (5.5 percent; 95 percent confidence interval, 4.7 percent-6.3 percent) were admitted to the hospital. Conclusions Most ambulatory patients seek care in an ED because of worrisome symptoms or nonfinancial barriers to care. Although many ambulatory patients appear to have nonurgent conditions based on triage classification, a small but disturbing percentage of nonurgent patients are hospitalized.

The goal of emergency medicine is to improve health while preventing and treating disease and illness in patients seeking emergency medical care. Improvements in emergency medical care and the delivery of this care can be achieved through credible and meaningful research efforts. Improved delivery of emergency medical care through research requires careful planning and the wise use of limited resources. To achieve this goal, emergency medicine must provide appropriate training of young investigators and attract support for their work. Promotion of multidisciplinary research teams will help the specialty fulfill its goals. The result will be the improvement of emergency medical care, which will benefit not only the patients emergency physicians serve but also, ultimately, the nation's health.

Treating gunshot wounds is an important skill for emergency physicians. It is therefore fitting that our specialty’s premier journal devotes space to this topic. Over the past several years, Annals has published important studies, reports, and editorials on the terminal ballistics of projectiles,1 out-of-hospital trauma care,2,3 fluid resuscitation of shock,4 ultrasonographic examinations in the setting of penetrating abdominal trauma5 and exploding bullets,6 and clinical evaluation of penetrating extremity trauma.7,8 But no matter how vigorously we treat firearm injuries, we cannot fully reverse the damage wrought by bullets. A population-based study of fatal and nonfatal shootings in 3 US cities served by Level I trauma centers and advanced life support emergency medical services (EMS) systems determined that 56% of gunshot fatalities were pronounced dead on the scene. Another 23% died before or shortly after arrival in the emergency department. Fully 97% of those who died succumbed within 24 hours of the shooting.9 Gunshot victims who survive the initial insult often face a difficult, costly, and uncertain road to recovery.10-12 Hospitalized victims of serious firearm injury may experience months, if not a lifetime, of physical and/or psychological disability.13 Facts like these suggest that we may be reaching the limit on what can be accomplished with postevent care. This does not mean that firearm-related deaths and injuries are inevitable. Much more may be accomplished by directing our attention upstream, to the chain of events that takes place before the 911 call.14,15 Many firearm assaults are preceded by a sequence of discrete decisions and actions, many of which are already illegal under our nation’s existing gun laws (Figure). For example, adult felons and juvenile offenders are not legally entitled to purchase or carry a firearm; however, many choose to do so anyway. The reason is that they have concluded, rightfully or wrongfully, that the risks associated with being caught with a gun are outweighed by the anticipated benefits of having one for crime or self-defense.16-20 To feed this illegal demand, offenders require various sources of supply. Burglary or theft from legal owners provides approximately one half million guns per year. A few scofflaw firearms dealers knowingly sell large numbers of guns to criminals. Others unwittingly sell to legally proscribed individuals who “lie and buy” using a false ID or some other subterfuge. A common way criminals obtain new guns is to find a “straw purchaser”—someone who is willing to legally purchase the gun and hand it over for a fee. In strict gun control states, felons and juvenile offenders sometimes turn to interstate traffickers, who purchase quantities of firearms in lax gun control states, then drive across state lines to resell them on the street.21-24 Once a criminal acquires a gun, he must choose to carry it. Again, the calculus of benefits and risk applies. If the perceived benefits of carrying the gun are perceived to outweigh the risks and legal consequences of being caught, the deterrent value of laws that prohibit carrying by felons will be low. Once the decision to carry is made, it is largely a matter of time before it will be used. Whether that moment arrives during a crime of opportunity or an altercation with a rival, the likelihood that serious injury or death will result is greater when a gun is involved.25-27 The result is another 911 call. It doesn’t have to be this way. A growing body of evidence suggests that it is possible to block this chain of events through strategic enforcement of the nation’s existing gun laws.28,29 In the same way that certain antibiotics block the metabolic pathway of pathogenic bacteria, strategic firearms I N J U R Y P R E V E N T I O N / E D I T O R I A L

Study objective: The alteration of a knee immobilizer into a sharp weapon by a prisoner prompted us to survey neighboring penal institutions to determine the frequency of such events. Design: We mailed a nine-item survey to all detention facilities in Tennessee, Arkansas, and Mississippi. A second survey was sent to nonresponding institutions 6 weeks after the initial mailing. Setting: The Regional Medical Center at Memphis, the designated facility for evaluation and treatment of prisoners from the county jail and state penitentiary. Participants: Survey respondents included 25 state penitentiaries, 31 county jails, 1 state minimum-security facility, 1 state maximum-security facility, 1 work-release center, 1 county detention center for drunken-driving offenders, and 1 federal penitentiary. Results: Of the 81 institutions surveyed, 77% responded to one of the two mailings. Forty percent responded in the affirmative when asked whether stolen or unauthorized medical equipment from outside their institutions had been discovered among inmates. When respondents were questioned as to whether medical equipment, prescribed or not, had been used or altered in a criminal manner, 34% responded "yes." Medications and medical appliances were listed in the responses. Conclusion: A survey of 81 local and neighboring penal institutions in a three-state area revealed that the illicit use of medicine and medical devices by prisoners is a legitimate safety concern of prison personnel and health care workers when medical care for inmates must be sought outside the security of their institutions. The modification of medical equipment into weapons by incarcerated patients, although clearly recognized as a security and safety problem by police authorities, appears to be unappreciated by health care workers providing episodic care to inmates. [Hayden JW, Laney C, Kellermann AL: Medical devices made into weapons by prisoners: An unrecognized risk. Ann Emerg Med December 1995;26:739-742.]

Importance Self-triage using web-based decision support could be a useful way to encourage appropriate care-seeking behavior and reduce health system surge in epidemics. However, the feasibility and safety of this strategy have not previously been evaluated. Objective To assess the usability and safety of Strategy for Off-site Rapid Triage (SORT) for Kids, a web-based decision support tool designed to translate clinical guidance developed by the Centers for Disease Control and Prevention to help parents and adult caregivers determine if a child with influenza-like illness requires immediate care in an emergency department (ED). Design Prospective pilot validation study conducted between February 8 and April 30, 2012. Staff who abstracted medical records and made follow-up calls were blinded to the SORT algorithm's assessment of the child's level of risk. Setting Two pediatric emergency departments in the National Capital Region. Participants Convenience sample of 294 parents and adult caregivers who were at least 18 years of age; able to read and speak English; and the parent or legal guardian of a child 18 years or younger presenting to 1 of 2 EDs with signs and symptoms meeting Centers for Disease Control and Prevention criteria for influenza-like illness. Intervention Completion of the SORT for Kids survey. Main Outcome Measures Caregiver ratings of the website's usability and the sensitivity of the underlying algorithm for identifying children who required immediate ED management of influenza-like illness, defined as receipt of 1 or more of 5 essential clinical services. Results Ninety percent of participants reported that the website was “very easy” to understand and use. Ratings did not differ by respondent race, ethnicity, or educational attainment. Of the 15 patients whose initial ED visit met explicit criteria for clinical necessity, the Centers for Disease Control and Prevention algorithm classified 14 as high risk, resulting in an overall sensitivity of 93.3% (exact 95% CI, 68.1%-99.8%). Specificity of the algorithm was poor. Conclusions and Relevance This pilot study suggests that web-based decision support to help parents and adult caregivers self-triage children with influenza-like illness is feasible. However, prospective refinement of the clinical algorithm is needed to improve its specificity without compromising patient safety.

For persons who have an out-of-hospital cardiac arrest, the probability of receiving bystander-initiated cardiopulmonary resuscitation (CPR) may be influenced by neighborhood characteristics.We analyzed surveillance data prospectively submitted from 29 U.S. sites to the Cardiac Arrest Registry to Enhance Survival between October 1, 2005, and December 31, 2009. The neighborhood in which each cardiac arrest occurred was determined from census-tract data. We classified neighborhoods as high-income or low-income on the basis of a median household income threshold of $40,000 and as white or black if more than 80% of the census tract was predominantly of one race. Neighborhoods without a predominant racial composition were classified as integrated. We analyzed the relationship between the median income and racial composition of a neighborhood and the performance of bystander-initiated CPR.Among 14,225 patients with cardiac arrest, bystander-initiated CPR was provided to 4068 (28.6%). As compared with patients who had a cardiac arrest in high-income white neighborhoods, those in low-income black neighborhoods were less likely to receive bystander-initiated CPR (odds ratio, 0.49; 95% confidence interval [CI], 0.41 to 0.58). The same was true of patients with cardiac arrest in neighborhoods characterized as low-income white (odds ratio, 0.65; 95% CI, 0.51 to 0.82), low-income integrated (odds ratio, 0.62; 95% CI, 0.56 to 0.70), and high-income black (odds ratio, 0.77; 95% CI, 0.68 to 0.86). The odds ratio for bystander-initiated CPR in high-income integrated neighborhoods (1.03; 95% CI, 0.64 to 1.65) was similar to that for high-income white neighborhoods.In a large cohort study, we found that patients who had an out-of-hospital cardiac arrest in low-income black neighborhoods were less likely to receive bystander-initiated CPR than those in high-income white neighborhoods. (Funded by the Centers for Disease Control and Prevention and others.).

Early death after emergency department (ED) discharge may signal opportunities to improve care. Prior studies are limited by incomplete mortality ascertainment and lack of clinically important information in administrative data. The goal in this hypothesis-generating study was to identify patient and process of care themes that may provide possible explanations for early postdischarge mortality.This was a qualitative analysis of medical records of adult patients who visited the ED of any of six hospitals in an integrated health system (Kaiser Permanente Southern California [KPSC]) and died within 7 days of discharge in 2007 and 2008. Nonmembers, visits to non-health plan hospitals, patients receiving or referred to hospice care, and patients with do not attempt resuscitation or do not intubate orders (DNAR/DNI) were excluded. Under the guidance of two qualitative research scientists, a team of three emergency physicians used grounded theory techniques to identify patient clinical presentations and processes of care that serve as potential explanations for poor outcome after discharge.The source population consisted of a total of 290,092 members with 446,120 discharges from six KPSC EDs in 2007 and 2008. A total of 203 deaths occurred within 7 days of ED discharge (0.05%). Sixty-one randomly chosen cases were reviewed. Patient-level themes that emerged included an unexplained persistent acute change in mental status, recent fall, abnormal vital signs, ill-appearing presentation, malfunctioning indwelling device, and presenting symptoms remaining at discharge. Process-of-care factors included a discrepancy in history of present illness, incomplete physical examination, and change of discharge plan by a third party, such as a consulting or admitting physician.In this hypothesis-generating study, qualitative research techniques were used to identify clinical and process-of-care factors in patients who died within days after discharge from an ED. These potential predictors will be formally tested in a future quantitative study.

The Patient Protection and Affordable Care Act (ACA), passed in 2010, has important implications for emergency physicians (EPs). In addition to dramatically reducing the number of uninsured in the United States, this comprehensive health care reform legislation seeks to curb the escalating costs of health care delivery, optimize resource utilization, eliminate waste, and improve the quality of service delivered by the health care system. At the annual Association of American Medical Colleges (AAMC) meeting on November 5, 2011, an expert panel from public health, emergency medicine, and health services research was convened by the Association of Academic Chairs of Emergency Medicine (AACEM) and the Society for Academic Emergency Medicine (SAEM) to discuss possible future models for the emergency care system and academic emergency medicine in the era of the ACA.

Vaccine-preventable diseases take a heavy toll on U.S. adults despite the widespread availability of vaccines. Office-based providers can do more to promote adult vaccinations but need clearer guidance and a better business case to offer them.

[Augustine JJ, Kellermann AL. The emergency medicine workforce study: more questions than answers. Ann Emerg Med . July 2002;40:16-18.]

Objective: Describe commercially available products and services designed to convey personal health information in emergencies.Methods: The search engine Google®, supplemented by print ads, was used to identify companies and organizations that offer relevant products and services to the general market. Disease-specific, health system, and health plan-specific offerings were excluded. Vendor web sites were the primary sources of information, supplemented by telephone and e-mail queries to sales representatives. Perfect inter-rater agreement was achieved.Results: Thirty-nine unique vendors were identified. Eight sell engraved jewelry. Three offer an embossed card or pamphlet. Twelve supply USB drives with various features. Eleven support password-protected web sites. Five maintain national call centers. Available media differed markedly with respect to capacity and accessibility. Quoted prices ranged from a one-time expenditure of $3.50 to an annual fee of $200. Associated features and annual fees varied widely.Conclusion: A wide range of products and services exist to help patients convey personal health information. Health care providers should be familiar with their features, so they can access the information in a disaster or emergency.(Disaster Med Public Health Preparedness. 2011;5:261–265)

A 1958 study from Hartford Hospital showed that ER use had increased nearly 400% between 1940 and 1955 in many U.S. communities. Today, despite many changes in emergency care, ER visits continue to increase at twice the rate of population growth.

Context Between 1998 and 2008, the number of hospital-based emergency departments (EDs) in the United States declined, while the number of ED visits increased, particularly visits by patients who were publicly insured and uninsured. Little is known about the hospital, community, and market factors associated with ED closures. Federal law requiring EDs to treat all in need regardless of a patient's ability to pay may make EDs more vulnerable to the market forces that govern US health care. Objective To determine hospital, community, and market factors associated with ED closures. Design Emergency department and hospital organizational information from 1990 through 2009 was acquired from the American Hospital Association (AHA) Annual Surveys (annual response rates ranging from 84%-92%) and merged with hospital financial and payer mix information available through 2007 from Medicare hospital cost reports. We evaluated 3 sets of risk factors: hospital characteristics (safety net [as defined by hospitals caring for more than double their Medicaid share of discharges compared with other hospitals within a 15-mile radius], ownership, teaching status, system membership, ED size, case mix), county population demographics (race, poverty, uninsurance, elderly), and market factors (ownership mix, profit margin, location in a competitive market, presence of other EDs). Setting All general, acute, nonrural, short-stay hospitals in the United States with an operating ED anytime from 1990-2009. Main Outcome Measure Closure of an ED during the study period. Results From 1990 to 2009, the number of hospitals with EDs in nonrural areas declined from 2446 to 1779, with 1041 EDs closing and 374 hospitals opening EDs. Based on analysis of 2814 urban acute-care hospitals, constituting 36 335 hospital-year observations over an 18-year study interval (1990-2007), for-profit hospitals and those with low profit margins were more likely to close than their counterparts (cumulative hazard rate based on bivariate model, 26% vs 16%; hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.5-2.1, and 36% vs 18%; HR, 1.9; 95% CI, 1.6-2.3, respectively). Hospitals in more competitive markets had a significantly higher risk of closing their EDs (34% vs 17%; HR, 1.3; 95% CI, 1.1-1.6), as did safety-net hospitals (10% vs 6%; HR, 1.4; 95% CI, 1.1-1.7) and those serving a higher share of populations in poverty (37% vs 31%; HR, 1.4; 95% CI, 1.1-1.7). Conclusion From 1990 to 2009, the number of hospital EDs in nonrural areas declined by 27%, with for-profit ownership, location in a competitive market, safety-net status, and low profit margin associated with increased risk of ED closure.

Between 1990 and 2009, the number of emergency rooms (ERs) in nonrural U.S. hospitals declined by 27 percent (from 2,446 to 1,779). Economic factors play a central role in an ER's ability to remain open.