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RAND researchers found that less than half of U.S. adults received flu vaccinations in 2010. Strategies to increase flu vaccination rates should include stronger efforts to address public skepticism and negative perceptions.

It is unknown whether keeping a firearm in the home confers protection against crime or, instead, increases the risk of violent crime in the home. To study risk factors for homicide in the home, we identified homicides occurring in the homes of victims in three metropolitan counties.After each homicide, we obtained data from the police or medical examiner and interviewed a proxy for the victim. The proxies' answers were compared with those of control subjects who were matched to the victims according to neighborhood, sex, race, and age range. Crude and adjusted odds ratios were calculated with matched-pairs methods.During the study period, 1860 homicides occurred in the three counties, 444 of them (23.9 percent) in the home of the victim. After excluding 24 cases for various reasons, we interviewed proxy respondents for 93 percent of the victims. Controls were identified for 99 percent of these, yielding 388 matched pairs. As compared with the controls, the victims more often lived alone or rented their residence. Also, case households more commonly contained an illicit-drug user, a person with prior arrests, or someone who had been hit or hurt in a fight in the home. After controlling for these characteristics, we found that keeping a gun in the home was strongly and independently associated with an increased risk of homicide (adjusted odds ratio, 2.7; 95 percent confidence interval, 1.6 to 4.4). Virtually all of this risk involved homicide by a family member or intimate acquaintance.The use of illicit drugs and a history of physical fights in the home are important risk factors for homicide in the home. Rather than confer protection, guns kept in the home are associated with an increase in the risk of homicide by a family member or intimate acquaintance.

Firearms are second only to motor vehicles as a cause of fatal injury in the United States. Approximately 59% of suicides and 61% of homicides involve firearms. Handguns comprise less than one third of all firearms in private hands in the United States, but they kill more Americans each year than all types of shotguns and rifles combined. Several analyses strongly suggest a link between readily available firearms and rates of violent death; two case-control studies strongly suggest that keeping a gun in the home is associated with an increased risk of suicide. Potential strategies to prevent firearm injuries include banning or restricting the supply of particularly dangerous firearms, educating the public about the risks of keeping a gun in the home, modifying existing firearm designs to make them more resistant to unauthorized use of unintentional discharge, altering weapons or ammunition to limit wound severity, and using bulletproof barriers more widely. Given adequate knowledge and the will to act, many firearm-related deaths and injuries can be prevented.

In contrast to the current consensus that governs the mechanics of prehospital advanced cardiac life support (ACLS), uniform criteria for determining when to initiate, withhold, or terminate ACLS in the field do not exist. Most emergency medical services (EMS) permit paramedics and other prehospital providers to withhold resuscitation when the victim obviously is dead, but the accuracy and appropriateness of this judgment in the field have not been subjected to empiric research. Do-not-resuscitate orders on patients in community settings often are problematic when paramedics and other prehospital providers are governed by standing orders that require them to initiate CPR when it is indicated medically. To date, eight states and a number of local EMS systems have developed a varity of policies to address this dilemma. Currently, few services permit paramedics to terminate ACLS in the field when such efforts failt to achieve return to spontaneous circulation. Studies have demonstrated convincingly that the rapid transport of such patients for further attempts at resuscitation in the hospital yields dismal rates of survival. The costs, risks, and benefits of this practice in community settings must be reviewed carefully to allocate EMS resources in an optimal manner.

This article is response to a paper by Gary Kleck which attacked the study done by Kellermann on gun ownership as a risk factor for homicide in the home. Kellermann states that Kleck's critique is flawed. Kleck's most notable oversight is the assumption that the only way keeping a gun in the home might increase a family's risk of homicide is if it is used as the murder weapon. Kellermann asserts that his study had identified at least 21 incidents (5% of the study's total) in which the victim died while unsuccessfully attempting to use a gun in self-defense. Kellermann also states that he never considered the possibility that keeping a gun in a bedside drawer influences an individual's risk of homicide in any setting other than the home. Kellermann suggests that, instead of relying on Professor Kleck's secondhand description of his team's work, the curious reader should examine the original report [New Engl J Med 1993; 329(15): 1084-91.].

On August 10, 2010, the World Health Organization (WHO) declared an end to the 2009 influenza A (H1N1) pandemic. It is fortunate that the virus that had spread worldwide so quickly turned out to be less severe than was first feared. It is worth remembering, though, that an earlier strain of H1N1 influenza — the one that emerged in 1918 — sparked the worst closely observed and recorded pandemic in history, killing an estimated 20 million to 40 million people worldwide. The 2009 H1N1 virus did give us one gift of inestimable value: it provided a full-scale test of the . . .

To understand the association between neighborhood and individual characteristics in determining whether or not bystanders perform cardiopulmonary resuscitation (CPR) in cases of out-of-hospital cardiac arrest (OHCA).Between October 1, 2005 to November 30, 2008, 1108 OHCA cases from Fulton County (Atlanta), GA, were eligible for bystander CPR. We conducted multi-level non-linear regression analysis and derived Empirical Bayes estimates for bystander CPR by census tract.279 (25%) cardiac arrest victims received bystander CPR. Provision of bystander CPR was significantly more common in witnessed events (odds ratio [OR] 1.64; 95% confidence interval [CI] 1.21-2.22, p0.001) and those that occurred in public locations (OR 1.67; 95% CI 1.16-2.40, p0.001). Other individual-level characteristics were not significantly associated with bystander CPR. Cardiac arrests in the census tracts that rank in the highest income quintile, as compared to the lowest income quintile were much more likely (OR 4.98; 95% CI 1.65-15.04) to receive bystander CPR.Cardiac arrest victims in the highest income census tracts were much more likely to receive bystander CPR than in the lowest income census tracts, even after controlling for individual and arrest characteristics. Low-income neighborhoods may be particularly appropriate targets for community-based CPR training and awareness efforts.

The incidence and outcomes of out-of-hospital cardiac arrest vary widely across cities. It is unknown whether similar differences exist at the neighborhood level.To determine the extent to which neighborhoods have persistently high rates of cardiac arrest but low rates of bystander cardiopulmonary resuscitation (CPR).Multilevel Poisson regression of 1108 cardiac arrests from 161 census tracts as captured by the Cardiac Arrest Registry to Enhance Survival (CARES).Fulton County, Georgia, between 1 October 2005 to 30 November 2008.Incidence of cardiac arrest, by census tract and year and by rates of bystander CPR.Adjusted rates of cardiac arrest varied across neighborhoods (interquartile range [IQR], 0.57 to 0.73 per 1000 persons; mean, 0.64 per 1000 persons [SD, 0.11]) but were stable from year to year (intraclass correlation, 0.36 [95% CI, 0.26 to 0.50]; P0.001). Adjusted bystander CPR rates also varied by census tract (IQR, 19% to 29%; mean, 25% [SD, 10%]).Analysis was based on data from a single county.Surveillance data can identify neighborhoods with a persistently high incidence of cardiac arrest and low rates of bystander CPR. These neighborhoods are promising targets for community-based interventions.Robert Wood Johnson Foundation Clinical Scholars Program, National Institutes of Health, and Centers for Disease Control and Prevention.

Study objective In 2003, the Institute of Medicine Committee on the Future of Emergency Care in the United States Health System convened and identified a crisis in emergency care in the United States, including a need to enhance the research base for emergency care. As a result, the National Institutes of Health (NIH) formed an NIH Task Force on Research in Emergency Medicine to enhance NIH support for emergency care research. Members of the NIH Task Force and academic leaders in emergency care participated in 3 roundtable discussions to prioritize current opportunities for enhancing and conducting emergency care research. The objectives of these discussions were to identify key research questions essential to advancing the scientific underpinnings of emergency care and to discuss the barriers and best means to advance research by exploring the role of research networks and collaboration between the NIH and the emergency care community. Methods The Medical-Surgical Research Roundtable was convened on April 30 to May 1, 2009. Before the roundtable, the emergency care domains to be discussed were selected and experts in each of the fields were invited to participate in the roundtable. Domain experts were asked to identify research priorities and challenges and separate them into mechanistic, translational, and clinical categories. After the conference, the lists were circulated among the participants and revised to reach a consensus. Results Emergency care research is characterized by focus on the timing, sequence, and time sensitivity of disease processes and treatment effects. Rapidly identifying the phenotype and genotype of patients manifesting a specific disease process and the mechanistic reasons for heterogeneity in outcome are important challenges in emergency care research. Other research priorities include the need to elucidate the timing, sequence, and duration of causal molecular and cellular events involved in time-critical illnesses and injuries, and the development of treatments capable of halting or reversing them; the need for novel animal models; and the need to understand why there are regional differences in outcome for the same disease processes. Important barriers to emergency care research include a limited number of trained investigators and experienced mentors, limited research infrastructure and support, and regulatory hurdles. The science of emergency care may be advanced by facilitating the following: (1) training emergency care investigators with research training programs; (2) developing emergency care clinical research networks; (3) integrating emergency care research into Clinical and Translational Science Awards; (4) developing emergency care–specific initiatives within the existing structure of NIH institutes and centers; (5) involving emergency specialists in grant review and research advisory processes; (6) supporting learn-phase or small, clinical trials; and (7) performing research to address ethical and regulatory issues. Conclusion Enhancing the research base supporting the care of medical and surgical emergencies will require progress in specific mechanistic, translational, and clinical domains; effective collaboration of academic investigators across traditional clinical and scientific boundaries; federal support of research in high-priority areas; and overcoming limitations in available infrastructure, research training, and access to patient populations.

Less than half of acute care visits in the United States involve a patient's personal physician. Emergency physicians, who comprise only 4 percent of doctors, handle 28 percent of all acute care encounters and nearly all after-hours and weekend care.

To study the potential differences that distinguish homicides involving women as victims or offenders from those involving men, we analyzed Federal Bureau of Investigation Uniform Crime Reports data on homicides that occurred in the United States between 1976 and 1987. Only cases that involved victims aged 15 years or older were included. Persons killed during law enforcement activity and cases in which the victim's gender was not recorded were excluded. A total of 215,273 homicides were studied, 77% of which involved male victims and 23% female victims. Although the overall risk of homicide for women was substantially lower than that of men (rate ratio [RR] = 0.27), their risk of being killed by a spouse or intimate acquaintance was higher (RR = 1.23). In contrast to men, the killing of a woman by a stranger was rare (RR = 0.18). More than twice as many women were shot and killed by their husband or intimate acquaintance than were murdered by strangers using guns, knives, or any other means. Although women comprise more than half the U.S. population, they committed only 14.7% of the homicides noted during the study interval. In contrast to men, who killed nonintimate acquaintances, strangers, or victims of undetermined relationship in 80% of cases, women killed their spouse, an intimate acquaintance, or a family member in 60% of cases. When men killed with a gun, they most commonly shot a stranger or a non-family acquaintance.(ABSTRACT TRUNCATED AT 250 WORDS)

OBJECTIVE: The purpose of this study was to determine if a brief educational intervention (INT) on the treatment of acute asthma improved prescribing patterns of internal medicine residents in an emergency department (ED). Additional objectives were to determine if optimal therapy reduced length of stay (LOS) in the ED and to determine if discharge prescribing patterns could be improved. DESIGN: Nonrandomized, single-blind INT study. SETTING: A large, urban, county-owned, university-affiliated ED. PATIENTS AND OTHER PARTICIPANTS: Eight internal medicine residents in each of three study periods; numbers of adult asthmatics for each period were: control group, 129 (Nov—Dec 1989); INT group A, 82 (Jan—Feb 1990); and INT group B, 139 (Nov—Dec 1990). INTERVENTIONS: INT consisted of a ten-minute verbal presentation, a three-page summary of the literature, and a posted protocol in the ED. Control data were collected prior to any INT. Prescribing patterns were covertly evaluated in each of the three study periods. Because discharge prescribing of long-term antiinflammatory therapy with inhaled corticosteroids was not improved in group A, emphasis on this point was added for group B. MAIN OUTCOME MEASURES: Percentage of patients who received desired acute and discharge therapies and LOS for each study period. RESULTS: Increased prescribing of desired acute therapy in the ED was seen in both INT groups. For discharge prescribing, the INT was partially successful. Reduced LOS was not found for the INT groups. CONCLUSIONS: A brief INT effectively improves prescribing of optimal acute therapy of asthma in the ED, yet does not appear to reduce LOS. Further strategies are needed to impact on therapy prescribed at discharge from the ED.

To evaluate factors influencing emergency physician staffing patterns in an important subset of US hospitals.Survey of emergency department directors and hospital administrators.Member institutions of the National Association of Public Hospitals and the Council of Teaching Hospitals.Of 498 hospitals enrolled, two mailings and telephone follow-up yielded 277 replies (56% response rate). To adjust for differences in ED size and volume, levels of staffing were converted to full-time equivalents (FTEs) per 10,000 annual ED visits.Responding institutions included 160 private and 115 public hospitals, 74 of which were Veterans Administration hospitals. Formal medical school affiliation was noted by 86% of responding institutions, and 82 (30%) supported emergency medicine residency programs. Full-time attending emergency physician staffing varied widely, from less than one to more than three FTEs per 10,000 visits; however, mean levels of staffing at public hospitals did not differ significantly from private institutions (2.7 +/- 1.6 vs 2.5 +/- 3.1, respectively; P = .50). Three of four hospitals reported using part-time emergency physician attending but only 33% used nurse practitioners or physicians' assistants. Two thirds of responding hospitals used rotating house officers-in-training. Of note, hospitals that supported emergency medicine residency programs reported significantly higher levels of staffing by housestaff (2.2 +/- 1.8 vs 1.0 +/- 1.2 FTEs/10,000 visits; P less than .0004), but levels of total staffing by full- and part-time attending physicians were virtually identical (2.69 +/- 1.6 vs 2.67 +/- 2.6 FTEs/10,000 visits; respectively; P = .95). Marked variability in levels and patterns of ED staffing at public and teaching hospitals currently exists, but the differences are not explained by hospital ownership. The reasons for such variations and their implications for patient care must be explored.

[Wears RL, Janiak B, Moorhead JC, Kellermann AL, Yeh CS, Rice MM, Jay G, Perry SJ, Woolard R. Human error in medicine: promise and pitfalls, part 2. Ann Emerg Med. August 2000;36:142-144.]

[Wears RL, Janiak B, Moorhead JC, Kellermann AL, Yeh CS, Rice MM, Jay G, Perry SJ, Woolard RJ. Human error in medicine: promise and pitfalls, part 1. Ann Emerg Med. July 2000;36:58-60.]

Michael Spivey and Dr. Arthur Kellermann write that, despite federal stimulus support for state Medicaid programs, some cash-strapped states have cut Medicaid payments, and others are considering such cuts. As a result, hospitals that treat large numbers of uninsured patients are struggling to survive.

The objective of this study was to evaluate the impact of a simple educational intervention on the prescribing habits of internal medicine residents in the treatment of acute asthma in a busy emergency department (ED). Prescribing habits for 16 residents were documented for 4 months. The first 2 months served as a control period during which eight residents managed asthma patients without the benefit of any specific educational intervention beyond standard department protocols. A total of 129 patients treated by the residents during this initial phase were assessed. During the second 2-month period, a 10-minute verbal presentation and explicit written treatment protocol were provided to another eight residents, and their treatment of 83 patients was covertly evaluated. Increased prescribing of desired therapy was significantly improved in every area except that of prescribing an inhaled steroid metered dose inhaler for use as a discharge medication. The 10-minute verbal presentation given in conjunction with a three-page handout was found to be highly effective for eliciting improvement in treatment practices during short clinical rotations. The duration of this effect beyond each rotation is unknown. This educational intervention should be presented by the ED medical director, clinical pharmacist, or other appropriate clinician in virtually any ED as quality of patient care can be dramatically improved.

Hospital and emergency department overcrowding is a serious and growing problem nationwide. Although EDs are organized around the goals of rapid patient assessment, stabilization, and prompt admission to the hospital, an increasing number are being required to hold admitted floor and critical care patients for extended periods due to lack of vacant inpatient beds. Provision of acceptable patient care under such circumstances requires a fundamental reordering of ED priorities and procedures. Overcrowding is the result of inadequate funding for emergency health care services during a period of increasing demand. The initial focus of management strategies to resolve this problem is the inpatient area and includes evaluation of length of stay, "intent to discharge" policies, flexible bed designations, restriction of in-house transfers, and the use of "over-census beds." If in-hospital management strategies fail, modifications in ED management may include staffing contingency plans, definition of physician responsibility, inpatient charts, revised pharmacy formulary, new floor plans, and modified accounting systems. Successful resolution of hospital and ED overcrowding may be the greatest challenge facing emergency medicine today.

Despite 3 decades of scientific progress, rates of survival from out-of-hospital cardiac arrest remain low. The Cardiac Arrest Registry to Enhance Survival (CARES) was created to provide communities with a means to identify cases of out-of-hospital cardiac arrest, measure how well emergency medical services (EMS) perform key elements of emergency cardiac care, and determine outcomes through hospital discharge. CARES collects data from 3 sources—911 dispatch, EMS, and receiving hospitals—and links them to form a single record. Once data entry is completed, individual identifiers are stripped from the record. The anonymity of CARES records allows participating agencies and institutions to compile cases without informed consent. CARES generates standard reports that can be used to characterize the local epidemiology of cardiac arrest and help managers determine how well EMS is delivering out-of-hospital cardiac arrest care. After pilot implementation in Atlanta, GA, and subsequent expansion to 7 surrounding counties, CARES was implemented in 22 US cities with a combined population of 14 million people. Additional cities are interested in joining the registry. CARES currently contains more than 13,000 cases and is growing rapidly.

Objectives: One of the first stages in the development of new clinical decision rules (CDRs) is determination of need. This study examined the clinical priorities of emergency physicians (EPs) working in Australasia, Canada, the United Kingdom, and the United States for the development of future CDRs. Methods: The authors administered an e-mail and postal survey to members of the national emergency medicine (EM) associations in Australasia, Canada, the United Kingdom, and the United States. Results were analyzed via frequency distributions. Results: The total response rate was 54.8% (1,150/2,100). The respondents were primarily male (74%), with a mean age of 42.5 years (SD ± 8), and a mean of 12 years of experience (SD ± 7). The top 10 clinical priorities (% selected) were: 1) investigation of febrile child

To investigate a possible association between firearm regulations and suicide, we compared the incidence of suicide from 1985 through 1987 in King County, Washington, with that in the Vancouver metropolitan area, British Columbia, where firearm regulations are more restrictive. The risk of death from suicide was not found to differ significantly between King County and the Vancouver area (relative risk, 0.97; 95 percent confidence interval, 0.87 to 1.09). The rate of suicide by firearms, however, was higher in King County (relative risk, 2.34; 95 percent confidence interval, 1.90 to 2.88), because the rate of suicide by handguns was 5.7 times higher there. The difference in the rates of suicide by firearms was offset by a 1.5-fold higher rate of suicide by other means in the Vancouver area. Persons 15 to 24 years old had a higher suicide rate in King County than in the Vancouver area (relative risk, 1.38; 95 percent confidence interval, 1.02 to 1.86). Virtually all the difference was due to an almost 10-fold higher rate of suicide by handguns in King County. We conclude that restricting access to handguns might be expected to reduce the suicide rate in persons 15 to 24 years old, but that it probably would not reduce the overall suicide rate.

Firearm injuries, by virtue of the number of deaths, years of life lost, and cost to society, represent an important and persistent public health problem. It is also a problem that crosses several disciplines, particularly public health, clinical medicine, mental health, criminology, and criminal justice. Approaches to controlling injuries due to guns involve all of these disciplines and include many strategies that have been effective for other injury control problems. In 2005, the U.S. Task Force on Community Preventive Services published a systematic review of gun laws and effects on homicide and suicide (Hahn et al., 2005). That review contains detailed tables about the effect of a variety of laws. The National Academies was recently asked to assess “the strengths and limitations of the existing research and data on gun violence.” Their report (National Research Council, 2005) provides another comprehensive review, with detailed tables, weighing the evidence for various interventions. Due to space constraints, neither document can be summarized here. The intended audience and the goals of these two reports differ from those of this chapter. The National Research Council (NRC) report was targeted at researchers, and its recommendations were directed at stimulating a stronger evidence base for gun policy through rigorous research. The Task Force report was narrowly focused on legislative approaches and, similar to the NRC report, was directed at assessing the quality of the current research evidence on gun policy. This chapter, on the other hand, is directed at public health practitioners and policy makers—individuals who must base their actions and decisions on the evidence that is available now. Although the total fl uctuates from year to year, fi rearms consistently rank second only to motor vehicle crashes as a cause of fatal injury in the United States. More than 95% of fatal fi rearm injuries are the result of self-directed or interpersonal violence (Figs. 17.1 and 17.2). Data on deaths and injuries from fi rearms can be obtained from a number of sources. Deaths are almost completely captured by the vital statistics systems. While complete, these data provide no information

We determine the impact of a screening, brief intervention, and referral for treatment (SBIRT) program in reducing alcohol consumption among emergency department (ED) patients.Patients drinking above National Institute of Alcohol Abuse and Alcoholism low-risk guidelines were recruited from 14 sites nationwide from April to August 2004. A quasiexperimental comparison group design was used in which control and intervention patients were recruited sequentially at each site. Control patients received a written handout. The intervention group received the handout and a brief intervention, the Brief Negotiated Interview, to reduce unhealthy alcohol use. Follow-up surveys were conducted at 3 months by telephone using an interactive voice response system.Of 7,751 patients screened, 2,051 (26%) exceeded the low-risk limits set by National Institute of Alcohol Abuse and Alcoholism; 1,132 (55%) of eligible patients consented and were enrolled (581 control, 551 intervention). Six hundred ninety-nine (62%) completed a 3-month follow-up survey, using the interactive voice response system. At follow-up, patients receiving a Brief Negotiated Interview reported consuming 3.25 fewer drinks per week than controls (coefficient [B] -3.25; 95% confidence interval [CI] -5.76 to -0.75), and the maximum number of drinks per occasion among those receiving Brief Negotiated Interview was almost three quarters of a drink less than controls (B -0.72; 95% CI -1.42 to -0.02). At-risk drinkers (CAGE2) appeared to benefit more from a Brief Negotiated Interview than dependent drinkers (CAGE2). At 3-month follow-up, 37.2% of patients with CAGE less than 2 in the intervention group no longer exceeded National Institute of Alcohol Abuse and Alcoholism low-risk limits compared with 18.6% in the control group (delta 18.6%; 95% CI 11.5% to 25.6%).SBIRT appears effective in the ED setting for reducing unhealthy drinking at 3 months.

BACKGROUND: Firearm injuries are the second leading cause of fatal injury in the US, and several medical specialty societies encourage patient counseling about firearm injury prevention. Because personal choices. influence physicians' willingness to counsel, it would be valuable to know how frequently guns are kept in the homes of physicians-in-training, as well as their perceptions and current rates of counseling about firearm injury prevention. METHODS: At a nationally representative sample of 16 medical schools, we surveyed the class of 2003 at freshman orientation, entrance to wards, and during senior year. RESULTS: A total of 2,316 students provided data (response rate = 80.3%). Among freshmen, 16% reported living in a home with a firearm, 13% did so at entry to wards, as did 14% of seniors (14% overall, women = 9%, men = 19%). Only 34% of seniors reported counseling their patients more often than "never/rarely" about firearm possession and storage. CONCLUSIONS: US medical students reported substantially lower rates of household gun ownership than the general population, but their participation in firearm-related counseling is also low.

Progesterone (PC) has been shown to provide substantial neuroprotection after traumatic brain injury (TBI) in multiple animal models. As a first step in assessing applicability to humans, the authors examined the effects of acute TBI and extracranial trauma on the pharmacokinetics of PG given by intravenous infusion. Multiple blood samples were obtained from 11 female and 21 male trauma patients receiving PG and 1 female and 3 male patients receiving placebo infusions for 72 hours. Values for C S S , CL, t 1 / 2 , and V d were obtained using AUC ( 0 - 7 2 ) and postinfusion blood samples. C S S values were 337 ′ 135 ng/mL, which were significantly lower than the target concentration of 450 ′ 100 ng/mL. The lower C S S is attributed to the CL, which was higher than anticipated. In addition, t 1 / 2 was longer and V d was higher than anticipated. These results demonstrate that stable PG concentrations can be rapidly achieved following TBI.

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.

Although much is known about injury-related deaths from the use of external cause of injury codes (ecodes) on death certificates, the contribution of nonfatal injury is unknown, with most information based on estimates from national surveys. Some states mandate ecoding of charts for hospitalized patients, but few require ecode assignment for emergency department (ED) records. Missouri and Nebraska mandated ecoding of ED records in 1993 and 1994, respectively, allowing for a more complete description of injuries in those states. We describe fatal and nonfatal injury frequencies in Missouri and Nebraska by using ecodes, with graphic representation in the form of injury pyramids.Ecode frequencies for 1996 to 1998 for all injury causes in Missouri and Nebraska were reported directly from their respective health departments. The ecode frequencies were grouped according to the Centers for Disease Control and Prevention's ecode matrix for presenting injury and mortality data.During the study period, 13,052 deaths, 131,210 hospitalizations, and 1,914,140 ED visits occurred as the result of injury. The most frequent lethal injuries were unintentional motor vehicle crashes (32.3% of total deaths), self-inflicted gunshot wound (13.2%), unintentional falls (11.3%), gunshot wound from an assault (7.7%), and unintentional poisoning (4.3%). The leading causes of injury-related hospitalization were unintentional falls (47.8% of total hospitalizations), unintentional motor vehicle crashes (15.5%), self-inflicted poisoning (6.5%), and overexertion or strenuous movements (2.4%). Of 1.9 million ED injury visits, unintentional falls accounted for 24.3%, unintentionally being struck by an object or person for 14.6%, unintentional motor vehicle crashes for 11.4%, unintentionally being cut or pierced for 10.7%, and overexertion or strenuous movements for 8.5%.Ecoding in Missouri and Nebraska provides a comprehensive data retrieval system that allows for a graphic depiction of the burden of injury derived from real patient encounters within specific geographic regions.

Prevention is a core value of any health system. Nonetheless, many health problems will continue to occur despite preventive services. A significant burden of diseases in developing countries is caused by time-sensitive illnesses and injuries, such as severe infections, hypoxia caused by respiratory infections, dehydration caused by diarrhoea, intentional and unintentional injuries, postpartum bleeding, and acute myocardial infarction. The provision of timely treatment during life-threatening emergencies is not a priority for many health systems in developing countries. This paper reviews evidence indicating the need to develop and/or strengthen emergency medical care systems in these countries. An argument is made for the role of emergency medical care in improving the health of populations and meeting expectations for access to emergency care. We consider emergency medical care in the community, during transportation, and at first-contact and regional referral facilities. Obstacles to developing effective emergency medical care include a lack of structural models, inappropriate training foci, concerns about cost, and sustainability in the face of a high demand for services. A basic but effective level of emergency medical care responds to perceived and actual community needs and improves the health of populations.

The purpose of this study was to determine the health status and psychological distress of gunshot injury victims 8 months after hospital discharge.Sixty patients admitted to a Level I trauma center for firearm-related injuries were interviewed during their hospitalization and again 8 months postdischarge. Health status was measured using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). Symptoms of posttraumatic stress (avoidance and intrusion) were assessed using the Impact of Event Scale.Subjects were predominantly young (mean age, 30 years), male (92%), and African-American (95%). Mean SF-36 scores at follow-up were significantly worse than preinjury scores for all subscales (p0.05). Symptoms of posttraumatic stress were common; 39% of respondents reported severe intrusive thoughts and 42% reported severe avoidance behaviors. Admission Injury Severity Scores did not predict poor health status 8 months postdischarge, but intrusion symptoms were strongly associated with lower SF-36 scores.Many hospitalized survivors of gunshot injuries report significant long-term declines in physical and/or mental health. Injury severity at hospital admission may not be predictive of long-term health status.

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.

Importance Hospital readmissions are believed to be an indicator of suboptimal care and are the focus of efforts by the Centers for Medicare and Medicaid Services to reduce health care cost and improve quality. Strategies to reduce surgical readmissions may be most effective if applied prospectively to patients who are at increased risk for readmission. Hospitals do not currently have the means to identify surgical patients who are at high risk for unplanned rehospitalizations. Objective To examine whether the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) predicted risk of major complications can be used to identify surgical patients at risk for rehospitalization. Design, Setting, and Participants Retrospective cohort study of 142 232 admissions in the ACS NSQIP registry for major noncardiac surgery. Main Outcomes and Measures The association between unplanned 30-day readmission and the ACS NSQIP predicted risk of major complications, controlling for severity of disease and surgical complexity. Results Of the 143 232 patients undergoing noncardiac surgery, 6.8% had unplanned 30-day readmissions. The rate of unplanned 30-day readmissions was 78.3% for patients with any postdischarge complication, compared with 12.3% for patients with only in-hospital complications and 4.8% for patients without any complications. Patients at very high risk for major complications (predicted risk of ACS NSQIP complication >10%) had 10-fold higher odds of readmission compared with patients at very low risk for complications (adjusted odds ratio = 10.35; 95% CI, 9.16-11.70), whereas patients at high (adjusted odds ratio = 6.57; 95% CI, 5.89-7.34) and moderate (adjusted odds ratio = 3.96; 95% CI, 3.57-4.39) risk of complications had 7- and 4-fold higher odds of readmission, respectively. Conclusions and Relevance Unplanned readmissions in surgical patients are common in patients experiencing postoperative complications and can be predicted using the ACS NSQIP risk of major complications. Prospective identification of high-risk patients, using the NSQIP complication risk index, may allow hospitals to reduce unplanned rehospitalizations.

Study Objective: To determine whether reminder signs placed at the exits to parking decks increase the rate of safety belt use. Methods: The subjects in this study were drivers of automobiles with permits to park in campus decks at a major university. Volunteer observers were positioned near the exits of 5 parking decks around the campus. Rates of safety belt use were noted before and at 2 intervals after reminder signs were installed. Results: A total of 6,780 observations were collected. The baseline rate of safety belt use was 83%. Female drivers were significantly more likely to wear a safety belt than male drivers (85.3% versus 79.6%, P P =.86). Conclusion: Placing reminder signs at the exits to parking decks did not boost the rate of safety belt use at our institution. Other strategies are needed to achieve the National Highway Traffic Safety Administration's goal of increasing the overall rate of safety belt usage to 90% by the year 2005. [Clack ZA, Pitts SR, Kellermann AL. Do reminder signs promote use of safety belts? Ann Emerg Med. December 2000;36:597-601.]

This paper discusses the need for a firearm injury surveillance system in the United States that is patterned after existing systems such as FARS.

Firearms contribute significantly to morbidity and mortality in family violence. This article discusses the debate on gun use for protection and guns in the home. Weapons-related risks in the setting of intimate partner violence are closely reviewed. Recommendations for physicians are discussed in the context of firearms and family violence.