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Background: Many hospitals in the United States are seeking to obtain and maintain trauma credentialing. Assessment of trauma center success has traditionally focused on mortality without directed measure of surgical subspecialization. However, survival alone may not be a sufficient marker of success with modern health care. The purpose of this study was to determine the number of trauma patients nationally who would benefit from subspecialized care by an orthopedic traumatologist., Methods: A list of musculoskeletal DRG International Classification of Diseases-9th Rev. codes representing injuries warranting care by subspecialized orthopedic traumatologists was generated by survey to each of two cohorts: one consisting of 10 subspecialized orthopedic traumatologists and one consisting of 10 nontraumatologists. The 2006 National Inpatient Sample data set was used to estimate the national volume of patients sustaining an orthopedic injury and the number requiring subspecialty orthopedic trauma care, as defined by the DRG International Classification of Diseases-9th Rev. lists generated by our survey., Results: Survey response rate was 100%. In 2006, 2,068,349 patients sustained a traumatic injury; 46.7% of these had an orthopedic injury. Our cohort of subspecialized orthopedic traumatologists identified 25.7% of all trauma patients as requiring an orthopedic traumatologist. Our cohort of general orthopedists identified 13.5% of all trauma patients as requiring an orthopedic traumatologist. Rates of polytrauma, injury severity, and treatment at trauma centers were similar between the two groups., Conclusion: Between 13.5% and 25.7% of all injured patients should, if resources permit, receive subspecialty orthopedic trauma care. The magnitude of this figure highlights the importance, from a public health perspective, of policy interventions aimed at better coordinating the field of orthopedic traumatology. Detailed outcome measures beyond mortality and triage guidelines suggesting which patients should receive subspecialty orthopedic trauma care should be developed. In addition, resources, including fellowship training, should be allocated in a methodical manner that matches supply to the national demand for this type of care., Level of Evidence: Economic/decision analysis, level IV.

Study Objectives: Many US cities have experienced population reductions, often blamed on crime and interpersonal injury. Yet the overall injury risk in urban areas compared with suburban and rural areas has not been fully described. We begin to investigate this evidence gap by looking specifically at injury-related mortality risk, determining the risk of all injury death across the rural-urban continuum., Methods: A cross-sectional time-series analysis of US injury deaths from 1999 to 2006 in counties classified according to the rural-urban continuum was conducted. Negative binomial generalized estimating equations and tests for trend were completed. Total injury deaths were the primary comparator, whereas differences by mechanism and age were also explored., Results: A total of 1,295,919 injury deaths in 3,141 US counties were analyzed. Injury mortality increased with increasing rurality. Urban counties demonstrated the lowest death rates, significantly less than rural counties (mean difference=24.0 per 100,000; 95% confidence interval 16.4 to 31.6 per 100,000). After adjustment, the risk of injury death was 1.22 times higher in the most rural counties compared with the most urban (95% confidence interval 1.07 to 1.39)., Conclusion: Using total injury death rate as an overall safety metric, US urban counties were safer than their rural counterparts, and injury death risk increased steadily as counties became more rural. Greater emphasis on elevated injury-related mortality risk outside of large cities, attention to locality-specific injury prevention priorities, and an increased focus on matching emergency care needs to emergency care resources are in order., (Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Objectives: The Institute of Medicine (IOM)'s "Future of Emergency Care" report recommended the categorization and regionalization of emergency care, but no uniform system to categorize hospital emergency care capabilities has been developed. The absence of such a system limits the ability to benchmark outcomes, to develop regional systems of care, and of patients to make informed decisions when seeking emergency care. The authors sought to pilot the deployment of an emergency care categorization system in two states., Methods: A five-tiered emergency department (ED) categorization system was designed, and a survey of all Pennsylvania and Wisconsin EDs was conducted. This 46-item survey described hospital staffing, characteristics, resources, and practice patterns. Based on responses, EDs were categorized as limited, basic, advanced, comprehensive, and pediatric critical care capable. Prehospital transport times were then used to determine population access to each level of care., Results: A total of 247 surveys were received from the two states (247 of 297, 83%). Of the facilities surveyed, roughly one-quarter of hospitals provided advanced care, 10.5% provided comprehensive care, and 1.6% provided pediatric critical care. Overall, 75.1% of the general population could reach an advanced or comprehensive ED within 60 minutes by ground transportation. Among the pediatric population (age 14 years and younger), 56.2% could reach a pediatric critical care or comprehensive ED, with another 19.5% being able to access an advanced ED within 60 minutes., Conclusions: Using this categorization system, fewer than half of all EDs provide advanced or comprehensive emergency care. While the majority of the population has access to advanced or comprehensive care within an hour, a significant portion (25%) does not. This article describes how an ED categorization scheme could be developed and deployed across the United States. There are implications for prehospital planning, patient decision-making, outcomes measurement, interfacility transfer coordination, and development of regional emergency care systems., (© 2013 by the Society for Academic Emergency Medicine.)

Objective: To apply systems optimization methods to simulate and compare the most effective locations for emergency care resources as measured by access to care., Study Design and Setting: This study was an optimization analysis of the locations of trauma centers (TCs), helicopter depots (HDs), and severely injured patients in need of time-critical care in select US states. Access was defined as the percentage of injured patients who could reach a level I/II TC within 45 or 60 minutes. Optimal locations were determined by a search algorithm that considered all candidate sites within a set of existing hospitals and airports in finding the best solutions that maximized access., Results: Across a dozen states, existing access to TCs within 60 minutes ranged from 31.1% to 95.6%, with a mean of 71.5%. Access increased from 0.8% to 35.0% after optimal addition of one or two TCs. Access increased from 1.0% to 15.3% after optimal addition of one or two HDs. Relocation of TCs and HDs (optimal removal followed by optimal addition) produced similar results., Conclusions: Optimal changes to TCs produced greater increases in access to care than optimal changes to HDs although these results varied across states. Systems optimization methods can be used to compare the impacts of different resource configurations and their possible effects on access to care. These methods to determine optimal resource allocation can be applied to many domains, including comparative effectiveness and patient-centered outcomes research., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background and Purpose: Evaluation at primary stroke centers (PSCs) has the potential to improve outcomes for patients with stroke. We looked for differences in evaluation at Joint Commission certified PSCs by race, education, income, and geography (urban versus nonurban; Southeastern Stroke Belt versus non-Stroke Belt)., Methods: Community-dwelling, black and white participants from the national Reasons for Geographic And Racial Differences in Stroke (REGARDS) prospective population-based cohort were enrolled between January 2003 and October 2007. Participants were contacted at 6-month intervals for suspected stroke events. For suspected stroke events, it was determined whether the evaluating hospital was a certified PSC., Results: Of 1000 suspected strokes, 204 (20.4%) strokes were evaluated at a PSC. A smaller proportion of women than men (17.8% versus 23.0%; P=0.04), those with a previous stroke (15.1% versus 21.6%; P=0.04), those living in the Stroke Belt (14.7% versus 27.3%; P<0.001), and those in a nonurban area (9.1% versus 23.1%; P<0.001) were evaluated at a PSC. There were no differences by race, education, or income. In multivariable analysis, subjects were less likely to be evaluated at a PSC if they lived in a nonurban area (odds ratio, 0.39; 95% confidence interval, 0.22-0.67) or lived in the Stroke Belt (odds ratio, 0.54; 95% confidence interval, 0.38-0.77) or had a previous stroke (odds ratio, 0.46; 95% confidence interval, 0.27-0.78)., Conclusions: Disparities in evaluation by PSCs are predominately related to geographic factors but not to race, education, or low income. Despite an increased burden of cerebrovascular disease in the Stroke Belt, subjects there were less likely to be evaluated at certified hospitals.

Background: In 1992, the first consensus definition of severe sepsis was published. Subsequent epidemiologic estimates were collected using administrative data, but ongoing discrepancies in the definition of severe sepsis produced large differences in estimates., Objectives: We seek to describe the variations in incidence and mortality of severe sepsis in the United States using four methods of database abstraction. We hypothesized that different methodologies of capturing cases of severe sepsis would result in disparate estimates of incidence and mortality., Design, Setting, Participants: Using a nationally representative sample, four previously published methods (Angus et al, Martin et al, Dombrovskiy et al, and Wang et al) were used to gather cases of severe sepsis over a 6-year period (2004-2009). In addition, the use of new International Statistical Classification of Diseases, 9th Edition (ICD-9), sepsis codes was compared with previous methods., Measurements: Annual national incidence and in-hospital mortality of severe sepsis., Results: The average annual incidence varied by as much as 3.5-fold depending on method used and ranged from 894,013 (300/100,000 population) to 3,110,630 (1,031/100,000) using the methods of Dombrovskiy et al and Wang et al, respectively. Average annual increase in the incidence of severe sepsis was similar (13.0% to 13.3%) across all methods. In-hospital mortality ranged from 14.7% to 29.9% using abstraction methods of Wang et al and Dombrovskiy et al. Using all methods, there was a decrease in in-hospital mortality across the 6-year period (35.2% to 25.6% [Dombrovskiy et al] and 17.8% to 12.1% [Wang et al]). Use of ICD-9 sepsis codes more than doubled over the 6-year period (158,722 - 489,632 [995.92 severe sepsis], 131,719 - 303,615 [785.52 septic shock])., Conclusion: There is substantial variability in incidence and mortality of severe sepsis depending on the method of database abstraction used. A uniform, consistent method is needed for use in national registries to facilitate accurate assessment of clinical interventions and outcome comparisons between hospitals and regions.

Background: The Joint Commission began certifying primary stroke centers (PSCs) in December 2003 and provides a standardized definition of stroke center care. It is unknown if PSCs outperform noncertified hospitals. We hypothesized that PSCs would use more recombinant tissue plasminogen activator (rt-PA) for ischemic stroke than would non-PSCs., Methods and Results: Data were obtained from the Nationwide Inpatient Sample from 2004 to 2009. The analysis was limited to states that publicly reported hospital identity. All patients ≥18 years with a primary diagnosis of acute ischemic stroke were included. Subjects were excluded if the treating hospital was not identified, if it was not possible to determine the temporal relationship between certification and admission, and/or if admitted as a transfer. Rt-PA was defined by ICD9 procedure code 99.10. All eligibility criteria were met by 323 228 discharges from 26 states. There were 63 145 (19.5%) at certified PSCs. Intravenous rt-PA was administered to 3.1% overall: 2.2% at non-PSCs and 6.7% at PSCs. Between 2004 and 2009, rt-PA administration increased from 1.4% to 3.3% at non-PSCs and from 6.0% to 7.6% at PSCs. In a multivariable model incorporating year, age, sex, race, insurance, income, comorbidities, DRG-based disease severity, and hospital characteristics, evaluation at a PSC was significantly associated with rt-PA utilization (OR, 1.87; 95% CI, 1.61 to 2.16)., Conclusions: Subjects evaluated at PSCs were more likely to receive rt-PA than those evaluated at non-PSCs. This association was significant after adjustment for patient and hospital-level variables. Systems of care are necessary to ensure stroke patients have rapid access to PSCs throughout the United States.

Object: A positive correlation between outcomes and the volume of patients seen by a provider has been supported by numerous studies. Volume-outcome relationships (VORs) have been well documented in the setting of both neurosurgery and trauma care and have shaped regionalization policies to optimize patient outcomes. Several authors have also investigated the correlation between patient volume and cost of care, known as the volume-cost relationship (VCR), with mixed results. The purpose of the present study was to investigate VORs and VCRs in the treatment of common intracranial injuries by testing the hypotheses that outcomes suffer at small-volume centers and costs rise at large-volume centers., Methods: The authors performed a cross-sectional cohort study of patients with neurological trauma using the 2006 Nationwide Inpatient Sample, the largest nationally representative all-payer data set. Patients were identified using ICD-9 codes for subdural, subarachnoid, and extradural hemorrhage following injury. Transfers were excluded from the study. In the primary analysis the association between a facility's neurotrauma patient volume and patient survival was tested. Secondary analyses focused on the relationships between patient volume and discharge status as well as between patient volume and cost. Analyses were performed using logistic regression., Results: In-hospital mortality in the overall cohort was 9.9%. In-hospital mortality was 14.9% in the group with the smallest volume of patients, that is, fewer than 6 cases annually. At facilities treating 6-11, 12-23, 24-59, and 60+ patients annually, mortality was 8.0%, 8.3%, 9.5%, and 10.0%, respectively. For these groups there was a significantly reduced risk of in-hospital mortality as compared with the group with fewer than 6 annual patients; the adjusted ORs (and corresponding 95% CIs) were 0.45 (0.29-0.68), 0.56 (0.38-0.81), 0.63 (0.44-0.90), and 0.59 (0.41-0.87), respectively. For these same groups (once again using < 6 cases/year as the reference), there were no statistically significant differences in either estimated actual cost or duration of hospital stay., Conclusions: A VOR exists in the treatment of neurotrauma, and a meaningful threshold for significantly improved mortality is 6 cases per year. Emergency and interfacility transport policies based on this threshold might improve national outcomes. Cost of care does not differ significantly with patient volume.

Background: Sudden cardiac arrest (SCA) is a leading cause of death in the US. Recent innovations in post-arrest care have been demonstrated to increase survival. However, little is known about the impact of emergency department (ED) and hospital characteristics on survival to hospital admission and ultimate outcome., Objective: We sought to describe the incidence of SCA presenting to the ED and to identify ED and hospital characteristics associated with survival to hospital admission., Methods: We identified patients with diagnoses of atraumatic cardiac arrest or ventricular fibrillation (ICD-9 427.5 or 427.41) in the 2007 Nationwide Emergency Department Sample (NEDS), a nationally representative estimate of all ED admissions in the United States. We defined SCA as cardiac arrest in the out-of-hospital or ED settings. We used the NEDS sample design to generate nationally representative estimates of the incidence of SCA that presents to EDs. We performed unadjusted and adjusted analyses to examine the relation between patient, ED, and hospital characteristics and outcome using logistic regression. Our primary outcome was survival to hospital admission. Survival to hospital discharge was a secondary outcome. Data are presented as odds ratios (OR) with 95% confidence intervals (CI)., Results: Of the 966 hospitals in the NEDS, 933 (96.6%) reported at least one SCA and were included in the analysis. We identified 38,593 cases of cardiac arrest representing an estimated 174,982 cases nationally. Overall ED SCA survival to hospital admission was 26.2% and survival to discharge was 15.7%. Greater survival to admission was seen in teaching hospitals (OR 1.3 95% CI 1.1-1.5, p=0.001), hospitals with ≥20,000 annual ED visits (OR 1.3 95% CI 1.1-1.6, p=0.003), and hospitals with percutaneous coronary intervention capability (OR 1.6 95% CI 1.4-1.8, p<0.001). Higher SCA volume (>40 annually) was associated with lower survival overall (OR 0.7 95% 0.6-0.9, p=0.010), but not when transferred patients were excluded from the analysis (OR 0.8 95% CI 0.6-1.1, p=0.116)., Conclusions: An estimated 175,000 cases of SCA present to or occur in US EDs each year. Percutaneous coronary intervention capability, ED volume, and teaching status were associated with higher survival to hospital admission. Emergency departments with higher annual SCA volume had lower survival rates, possibly because they transfer fewer patients. An improved understanding of the contribution of ED care to survival following SCA may be useful in advancing our understanding of how best to organize a system of care to ensure optimal outcomes for patients with SCA., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: Previous studies have demonstrated lower mortality among patients transported to single urban trauma centers by private vehicle (PV) compared with Emergency Medical Services (EMS). We sought to describe the characteristics and outcomes of injured patients transported by PV in a state trauma system compared to patients transported by EMS., Methods: We performed a retrospective cohort study of state trauma registry data for patients admitted to all Pennsylvania trauma centers over 5 years (1/2003 to 12/2007). Our primary exposure of interest was prehospital mode of transport and our primary outcome of interest was in-hospital mortality. Unadjusted analyses were performed as were adjusted analyses controlling for injury severity. Data are presented as percents, odds ratios (ORs), and 95% confidence intervals., Results: Of the 91132 patients analyzed, 9.6% were transported to the emergency department by PV and 90.4% by EMS. Overall Injury Severity Score (ISS) was 13.3 ± 11.0 (ISS for EMS 13.7 ± 11.3, PV 9.2 ± 7.1, P < .001), and 6.6% of patients died (EMS 7.1%, PV 1.5%, P < .001). After adjusting for injury severity, patients transported by EMS were more likely to die than PV patients (OR 1.9 [95% CI 1.5-2.4]). This effect persisted in blunt, penetrating, advanced life support, and basic life support subgroups, but not in the severely injured (ISS >15, ISS >25) subgroups., Conclusions: Nearly 10% of injured patients arrive at trauma centers by private vehicle. Transport of injured patients by EMS was associated with higher mortality than PV transport. This may reflect the effects of prehospital time, prehospital interventions, or other confounders., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Importance: Current efforts to improve health care focus on hospital readmission rates as a marker of quality and on the effectiveness of transitions in care during the period after acute care is received. Emergency department (ED) visits are also a marker of hospital-based acute care following discharge but little is known about ED use during this period., Objectives: To determine the degree to which ED visits and hospital readmissions contribute to overall use of acute care services within 30 days of discharge from acute care hospitals, to describe the reasons patients return for ED visits, and to describe these patterns among Medicare beneficiaries and those not covered by Medicare insurance., Design, Setting, and Participants: Prospective study of patients aged 18 years or older (mean age: 53.4 years) who were discharged between July 1, 2008, and September 31, 2009, from acute care hospitals in 3 large, geographically diverse states (California, Florida, and Nebraska) with data recorded in the Healthcare Cost and Utilization Project state inpatient and ED databases., Main Outcome Measures: The 3 primary outcomes during the 30-day period after hospital discharge were ED visits not resulting in admission (treat-and-release encounters), hospital readmissions from any source, and a combined measure of ED visits and hospital readmissions termed hospital-based acute care., Results: The final cohort included 5,032,254 index hospitalizations among 4,028,555 unique patients. In the 30 days following discharge, 17.9% (95% CI, 17.9%-18.0%) of hospitalizations resulted in at least 1 acute care encounter. Of these 1,233,402 postdischarge acute care encounters, ED visits comprised 39.8% (95% CI, 39.7%-39.9%). For every 1000 discharges, there were 97.5 (95% CI, 97.2-97.8) ED treat-and-release visits and 147.6 (95% CI, 147.3-147.9) hospital readmissions in the 30 days following discharge. The number of ED treat-and-release visits ranged from a low of 22.4 (95% CI, 4.6-65.4) encounters per 1000 discharges for breast malignancy to a high of 282.5 (95% CI, 209.7-372.4) encounters per 1000 discharges for uncomplicated benign prostatic hypertrophy. Among the highest volume discharges, the most common reason patients returned to the ED was always related to their index hospitalization., Conclusions and Relevance: After discharge from acute care hospitals in 3 states, ED visits within 30 days were common among adults and accounted for 39.8% of postdischarge hospital-based acute care visits. Improving care transitions should focus not only on decreasing readmissions but also on ED visits.

Background: Unintentional injuries are one of the leading causes of death in the United States. Many of these injuries are preventable, and unintentional firearm injuries, in particular, may be responsive to prevention efforts. We investigated the relationship between unintentional firearm death and urbanicity among adults., Methods: This study was a retrospective analysis of national death certificate data. Unintentional adult firearm deaths in the United States from 1999 to 2006 were identified using the Multiple Cause of Death Data files from the National Center for Health Statistics. Decedents were assigned to a county of death and classified along an urban-rural continuum defined by population density and proximity to metropolitan areas. Total unintentional firearm death rates by county were analyzed in adjusted analyses using negative binomial regression., Results: A total of 4,595 unintentional firearm injury deaths of adults occurred in the United States during the study period (a mean of 574.4 per year). Adjusted rates of unintentional firearm death showed increases from urban to rural counties. Americans in the most rural counties were significantly more likely to die of unintentional firearm deaths than those in the most urban counties (relative rate, 2.16; 95% confidence interval, 1.44-3.21, p = 0.002)., Conclusion: Rates of unintentional firearm death are significantly higher in rural counties than in urban counties. Prevention strategies should be tailored to account for both geographic location and manner of firearm injury., Level of Evidence: Epidemiologic study, level III.

Federal legislation placed comparative effectiveness research and patient-centered outcomes research at the center of current and future national investments in health care research. The role of this research in emergency care has not been well described. This article proposes an agenda for researchers and health care providers to consider comparative effectiveness research and patient-centered outcomes research methods and results to improve the care for patients who seek, use, and require emergency care. This objective will be accomplished by (1) exploring the definitions, frameworks, and nomenclature for comparative effectiveness research and patient-centered outcomes research; (2) describing a conceptual model for comparative effectiveness research in emergency care; (3) identifying specific opportunities and examples of emergency care-related comparative effectiveness research; and (4) categorizing current and planned funding for comparative effectiveness research and patient-centered outcomes research that can include emergency care delivery., (Copyright © 2012. Published by Mosby, Inc.)

Urgent coronary angiography following cardiac arrest is an important consideration as part of a therapeutic hypothermia/postresuscitation care bundle. Few data exist to guide the selection of patients who should receive postarrest angiography. This investigation sought to evaluate patient-level variables on initial postarrest presentation and their association with significant coronary lesions on subsequent angiography. Clinical and angiographic data were collected on consecutive postarrest patients from July 2007 to April 2012 who underwent coronary angiography during hospitalization. Univariate and multivariable analyses were performed to determine the relationship between patient characteristics, clinical data, and the outcome measure, defined as the presence of at least one coronary lesion with >75% stenosis. Of 527 cardiac arrest patients, 267 achieved return of spontaneous circulation; 106 of these initial survivors received coronary angiography. This cohort had a mean age of 58.1±13.5 years and a survival to discharge of 73/106 (69%), with therapeutic hypothermia utilized in 79/106 (75%) patients. Significant coronary lesions were found on angiography in 68/106 (64%) patients. Multivariable adjusted analysis demonstrated that significant lesions were associated with a prior known history of coronary disease and/or prior myocardial infarction (odds ratio [OR] 6.2, 95% confidence interval [CI] 1.6-24.4, p=0.009), and with initial rhythm of ventricular fibrillation/ventricular tachycardia (OR 2.9, 95% CI 1.1-7.7, p=0.033), but not with hypertension, tobacco use, age, or initial troponin measurements. Prior known history of coronary disease and a shockable arrest rhythm were associated with significant coronary lesions on subsequent angiography. Normal initial troponin values and younger age did not exclude clinically relevant lesions postarrest.

Background: Neurocritical care provides multidisciplinary, specialized care to critically ill neurological patients, yet an understanding of the proportion of the population able to rapidly access specialized Neurocritical Care Units (NCUs) in the United States is currently unknown. We sought to quantify geographic access to NCUs by state, division, region, and for the US as a whole. In addition, we examined how mode of transportation (ground or air ambulance), and prehospital transport times affected population access to NCUs., Methods: Data were obtained from the Neurocritical Care Society (NCS), US Census Bureau and the Atlas and Database of Air Medical Services. Empirically derived prehospital time intervals and validated models estimating prehospital ground and air travel times were used to calculate total prehospital times. A discrete total prehospital time interval was calculated for each small unit of geographic analysis (block group) and block group populations were summed to determine the proportion of Americans able to reach a NCU within discrete time intervals (45, 60, 75, and 90 min). Results are presented for different geographies and for different modes of prehospital transport (ground or air ambulance)., Results: There are 73 NCUs in the US using ground transportation alone, 12.8, 20.5, 27.4, and 32.6% of the US population are within 45, 60, 75, and 90 min of an NCU, respectively. Use of air ambulances increases access to 36.8, 50.4, 60, and 67.3 within 45, 60, 75, and 90 min, respectively. The Northeast has the highest access rates in the US using ground ambulances and for 45, 60, and 75 min transport times with the addition of air ambulances. At 90 min, the West has the highest access rate. The Southern region has the lowest ground and air access to NCUs access rates for all transport times., Conclusions: Using NCUs registered with the NCS, current geographic access to NCUs is limited in the US, and geographic disparities in access to care exist. While additional NCUs may exist beyond those identified by the NCS database, we identify geographies with limited access to NCUs and offer a population-based planning perspective on the further development of the US neurocritical care system.

Background: It is unknown how in-hospital cardiac arrest (IHCA) rates vary across hospitals and predictors of variability., Objectives: Measure variability in IHCA across hospitals and determine if hospital-level factors predict differences in case-mix adjusted event rates., Research Design: Get with the Guidelines Resuscitation (GWTG-R) (n=433 hospitals) was used to identify IHCA events between 2003 and 2007. The American Hospital Association survey, Medicare, and US Census were used to obtain detailed information about GWTG-R hospitals., Participants: Adult patients with IHCA., Measures: Case-mix-adjusted predicted IHCA rates were calculated for each hospital and variability across hospitals was compared. A regression model was used to predict case-mix adjusted event rates using hospital measures of volume, nurse-to-bed ratio, percent intensive care unit beds, palliative care services, urban designation, volume of black patients, income, trauma designation, academic designation, cardiac surgery capability, and a patient risk score., Results: We evaluated 103,117 adult IHCAs at 433 US hospitals. The case-mix adjusted IHCA event rate was highly variable across hospitals, median 1/1000 bed days (interquartile range: 0.7 to 1.3 events/1000 bed days). In a multivariable regression model, case-mix adjusted IHCA event rates were highest in urban hospitals [rate ratio (RR), 1.1; 95% confidence interval (CI), 1.0-1.3; P=0.03] and hospitals with higher proportions of black patients (RR, 1.2; 95% CI, 1.0-1.3; P=0.01) and lower in larger hospitals (RR, 0.54; 95% CI, 0.45-0.66; P<0.0001)., Conclusions: Case-mix adjusted IHCA event rates varied considerably across hospitals. Several hospital factors associated with higher IHCA event rates were consistent with factors often linked with lower hospital quality of care.

Background: Trauma system planners use patient home address as a proxy for injury location, although this proxy has not been validated. We sought to determine the precision of this proxy by evaluating the relationship between the location of injury death and the location of residence., Methods: This national descriptive analysis used the Multiple Cause of Death data files from 1999 to 2006 to determine the proportion of subjects in which county of residence (RC) matched county of death for all US injury deaths. Subgroup analyses were completed by age and injury intentionality using two sample tests of proportions. χ(2) tests were used to evaluate differences in concordance over time and by size of the RC., Results: Analysis included 3,141 US counties and 1,255,881 subjects. A total of 73.4% of subjects died in the RC and 87.7% died in the RC or a contiguous county. Intentional injury deaths were more likely than unintentional to happen within a decedent's RC (85.1% vs. 68.1%, p < 0.001) and within the RC or contiguous county (93.4% vs. 85.2%, p < 0.001). Adult injury deaths were more likely than pediatric to happen within a decedent's RC (73.6% vs. 68.4%, p < 0.001) and within the RC or contiguous county (87.9% vs. 84.2%, p < 0.001). Subjects from larger counties were more likely to die within the RC or a contiguous county (same p < 0.001, same or adjacent p < 0.001)., Conclusion: The preponderance of fatal injury deaths occur close to home. This supports the practice of trauma system's planning using home location available in administrative data to proxy injury location.

Objective: The incidence and incidence over time of cardiac arrest in hospitalized patients is unknown. We sought to estimate the event rate and temporal trends of adult inhospital cardiac arrest treated with a resuscitation response., Design: Three approaches were used to estimate the inhospital cardiac arrest event rate. First approach: calculate the inhospital cardiac arrest event rate at hospitals (n = 433) in the Get With The Guidelines-Resuscitation registry, years 2003-2007, and multiply this by U.S. annual bed days. Second approach: use the Get With The Guidelines-Resuscitation inhospital cardiac arrest event rate to develop a regression model (including hospital demographic, geographic, and organizational factors), and use the model coefficients to calculate predicted event rates for acute care hospitals (n = 5445) responding to the American Hospital Association survey. Third approach: classify acute care hospitals into groups based on academic, urban, and bed size characteristics, and determine the average event rate for Get With The Guidelines-Resuscitation hospitals in each group, and use weighted averages to calculate the national inhospital cardiac arrest rate. Annual event rates were calculated to estimate temporal trends., Setting: Get With The Guidelines-Resuscitation registry., Patients: Adult inhospital cardiac arrest with a resuscitation response., Measurements and Main Results: The mean adult treated inhospital cardiac arrest event rate at Get With The Guidelines-Resuscitation hospitals was 0.92/1000 bed days (interquartile range 0.58 to 1.2/1000). In hospitals (n = 150) contributing data for all years of the study period, the event rate increased from 2003 to 2007. With 2.09 million annual U.S. bed days, we estimated 192,000 inhospital cardiac arrests throughout the United States annually. Based on the regression model, extrapolating Get With The Guidelines-Resuscitation hospitals to hospitals participating in the American Hospital Association survey projected 211,000 annual inhospital cardiac arrests. Using weighted averages projected 209,000 annual U.S. inhospital cardiac arrests., Conclusions: There are approximately 200,000 treated cardiac arrests among U.S. hospitalized patients annually, and this rate may be increasing. This is important for understanding the burden of inhospital cardiac arrest and developing strategies to improve care for hospitalized patients.

Background: Necrotizing fasciitis (NF) is a rapidly progressive disease that requires urgent surgical debridement for survival. Interhospital transfer (IT) may be associated with delay to operation, which could increase mortality. We hypothesized that mortality would be higher in patients undergoing surgical debridement for necrotizing fasciitis after IT compared to Emergency Department (ED) admission., Methods: We performed a retrospective cohort analysis from 2000-2006 using the Nationwide Inpatient Sample. Inclusion criteria were age >18 years, primary diagnosis of NF, and surgical therapy within 72 hours of admission. Logistic regression was used to assess the relationship between admission source, patient and hospital variables, and mortality., Results: We identified 9,958 cases over the study period. Patients in the ED group were more likely to be nonwhite and of lower income when compared with patients in the IT group. Unadjusted mortality was higher in the IT group than ED group (15.5% vs 8.7%, P < .001). After adjusting for potential confounders, odds of mortality were still greater in the IT (OR 2.04, CI 95% 1.60-2.59, P < .001)., Conclusion: Interhospital transfer is associated with increased risk of in-hospital mortality after surgical therapy for NF, a finding which persists after controlling for patient and hospital level variables., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Objective: To evaluate whether mortality and clinical outcomes vary for injured patients in a mature trauma system on weeknights and weekends compared with weekdays., Design: Retrospective cohort study., Setting: Pennsylvania trauma system., Patients: A total of 90,461 patients over 5 years., Intervention: Treatment at a level I, II, or III trauma center., Main Outcome Measures: In-hospital mortality, time to procedures, and length of stay., Results: In adjusted analyses, patients presenting on weeknights were no more likely to die than patients presenting during weekdays, and patients presenting on weekends were less likely to die than patients presenting on weekdays (odds ratio = 0.89; 95% confidence interval, 0.81-0.97). Presenting on weeknights was associated with longer intensive care unit stay (incidence rate ratio = 1.06; 95% confidence interval, 1.02-1.10) and longer hospital stay (incidence rate ratio = 1.02; 95% confidence interval, 1.00-1.04). Presenting on weekends was associated with longer intensive care unit stay (incidence rate ratio = 1.04; 95% confidence interval, 1.02-1.10) but not longer hospital stay. Delays to laparotomy or craniotomy were not seen in either group., Conclusions: We demonstrate comparable mortality among injured patients presenting on weeknights vs weekdays and lower mortality among injured patients on weekends vs weekdays. Systems-based solutions of the trauma model are protective against the weekend effect and inform care for other emergency care-sensitive conditions.

Non-enteric salmonella infections in immunocompetent adults are exceedingly rare in the United States, and meningitis is one of the least common extra-intestinal sites. In addition, it is very unusual for a patient with bacterial meningitis to present with classic meningitis signs and symptoms of > 72 h duration. The objective of this work is to describe a rare case of salmonella meningitis in an immunocompetent adult and, in the context of previously published case reports, describe the frequently atypical clinical course of salmonella meningitis along with the potential pitfalls encountered during its evaluation and treatment. An otherwise healthy 45-year-old man presented to our Emergency Department with frontal headache, fever, and stiff neck of 7 days duration. He was alert and oriented in triage, where he was noted to be afebrile, mildly tachycardic, with a normal blood pressure and respiratory rate; shortly after triage he developed a high fever, severe tachycardia, hypotension, and a change in mental status. He was resuscitated according to our severe sepsis protocol and treated empirically for bacterial meningitis. Blood and cerebrospinal fluid cultures grew group D Salmonella berta. An evaluation for underlying immunodeficiency was unrevealing. The patient was discharged home on hospital day 7 in good condition. Salmonella meningitis can present with an indolent course and can mimic, in many misleading ways, the less serious diagnosis of aseptic meningitis. This case highlights the need for an unbiased clinical assessment, aggressive management of critical illness, and point-for-point correspondence between clinical data and assigned diagnosis., (Copyright © 2011. Published by Elsevier Inc.)

Background: More than a decade ago, the city of Philadelphia began allowing police transport of penetrating trauma patients., Objectives:   The objective was to determine the relation between prehospital mode of transport (police department [PD] vs. Philadelphia Fire Department (PFD) emergency medical services [EMS]) and survival in subjects with proximal penetrating trauma., Methods: The authors performed a retrospective cohort study of prospectively collected trauma registry data. All subjects who sustained proximal penetrating trauma and who presented to a Level I urban trauma center over a 5-year period (January 1, 2003, to December 31, 2007) were included. Mortality for subjects presenting by EMS was compared to that of those who arrived by PD transport in unadjusted and adjusted analyses. Unadjusted analyses were performed using the chi-square test, Wilcoxon rank sum test, and Student's t-test. Adjusted analyses were performed using logistic regression using the Trauma Injury Severity Score (TRISS) methodology. Data are presented as percentages, odds ratios (ORs), and 95% confidence intervals (CIs). Total hospital length of stay was examined as a secondary outcome., Results: Of the 2,127 subjects, 26.8% were transported to the emergency department (ED) by PD, and 73.2% by EMS. The mean(±standard deviation [SD]) age of PD subjects was 26.3 (±9.1) years and 92% were male versus EMS subjects whose mean (±SD) age was 31.5 (±11.8) years and of whom 87% were male. Overall, 70.8% sustained a gunshot wound (GSW), and 29.2% sustained a stab wound (SW). Overall Injury Severity Score (ISS) was 11.21 (ISS for PD, 14.2±17.5; for EMS, 10.1±14.5; p<0.001), and 16.6% of the subjects died (PD, 21.4±0.41%; EMS, 14.8±0.36%; p<0.001). In unadjusted analyses, PD subjects were more likely to die than EMS subjects (OR=1.6, 95% CI=1.2 to 2.0; p<0.001). When adjusting for injury severity using TRISS, there was no difference in survival between PD and EMS subjects (OR=1.01, 95% CI=0.63 to 1.61). Median length of hospital stay was 1 day and did not differ according to mode of prehospital transport (p=0.159)., Conclusions: Although unadjusted mortality appears to be higher in PD subjects, these findings are explained by the more severely injured population transported by PD. The current practice of permitting police officers to transport penetrating trauma patients should be continued., (© 2010 by the Society for Academic Emergency Medicine.)

The 2010 Academic Emergency Medicine consensus conference on regionalization in emergency care began with an update on the Institute of Medicine (IOM) reports on the Future of Emergency Care. This was followed by two presentations from federal officials, focusing on regionalization from the perspective of the White House National Security Staff and the Emergency Care Coordination Center. This article summarizes the content of these presentations. It should be noted that this summary is the perspective of the authors and does not represent the official policy of the U.S. government., (2010 by the Society for Academic Emergency Medicine.)

The 2010 Academic Emergency Medicine (AEM) consensus conference "Beyond Regionalization" aimed to place the design of a 21st century emergency care delivery system at the center of emergency medicine's (EM's) health policy research agenda. To examine the lessons learned from existing regional systems, consensus conference organizers convened a panel discussion made up of experts from the fields of acute care surgery, interventional cardiology, acute ischemic stroke, cardiac arrest, critical care medicine, pediatric EM, and medical toxicology. The organizers asked that each member provide insight into the barriers that slowed network creation and the solutions that allowed them to overcome barriers. For ST-segment elevation myocardial infarction (STEMI) management, the American Heart Association's (AHA's) Mission: Lifeline aims to increase compliance with existing guidelines through improvements in the chain of survival, including emergency medical services (EMS) protocols. Increasing use of therapeutic hypothermia post-cardiac arrest through a network of hospitals in Virginia has led to dramatic improvements in outcome. A regionalized network of acute stroke management in Cincinnati was discussed, in addition to the effect of pediatric referral centers on pediatric capabilities of surrounding facilities. The growing importance of telemedicine to a variety of emergencies, including trauma and critical care, was presented. Finally, the importance of establishing a robust reimbursement mechanism was illustrated by the threatened closure of poison control centers nationwide. The panel discussion added valuable insight into the possibilities of maximizing patient outcomes through regionalized systems of emergency care. A primary challenge remaining is for EM to help to integrate the existing and developing disease-based systems of care into a more comprehensive emergency care system., (2010 by the Society for Academic Emergency Medicine.)

ST-segment elevation myocardial infarction (STEMI), cardiac arrest, and ischemic stroke are a diverse group of cardiovascular illnesses linked by the necessity for timely intervention in order to maximize patient outcomes. Despite the known efficacies of therapies, such as emergent percutaneous coronary intervention (PCI), rapid administration of tissue plasminogen activator, and induction of therapeutic hypothermia after cardiac arrest, translating these discoveries into standard practice nationwide has proven difficult to achieve. Significant regional variations in practice are commonplace, and facilities with higher patient volumes of STEMI, cardiac arrest, and ischemic stroke consistently have better outcomes compared with lower-volume facilities. Such disparities in emergency care led the Institute of Medicine in 2006 to describe the existing emergency care system as "at the breaking point," and to call for "coordinated, regionalized, and accountable" systems of care. An effective and equitable regionalized emergency care system would resemble the existing US trauma system in some respects, with transparent and standard triage guidelines, cooperation between local and regional emergency medical service systems, and an integrated network of referring and receiving facilities. Emerging technologies, such as telemedicine, will likely play a significant role. Regionalized referral systems, such as designated PCI centers and designated stroke centers, are in existence, but have largely been reactive and local, and no mechanism is in place to ensure equitable distribution of such facilities across all geographic regions. As scientific advances in the treatment of these conditions continue to evolve, so too must the system of care that provides these therapies. Evidence suggests that regionalized systems of care for acute cardiovascular events may increase compliance with existing life-saving guidelines and improve patient outcomes.

Background: Occurrence on weekends or at night has been associated with poor outcomes for time-sensitive conditions including ST elevation myocardial infarction, stroke, and cardiac arrest. We sought to determine whether the "weekend effect" exists for injured patients at our trauma center., Methods: We performed a retrospective cohort study at a Level I trauma center (2006-2008). The relative risks of mortality associated with weekend or night arrival were estimated using unadjusted and adjusted analyses., Results: Four thousand three hundred eighty-two patients were included. One-third of patients (34.0%) arrived on weekends, and 23.3% of patients arrived at night (12:00 midnight to 6:00 am). Average age was 43.2 years (44.2 weekdays vs. 41.4 weekends, p < 0.001 and 45.1 days vs. 37.5 nights, p < 0.001), 72.3% were men (72.6 weekdays vs. 71.8 weekends, p = not significant (NS) and 71.0% days vs. 76.8% nights, p < 0.001), overall Injury Severity Score was 13.7 (13.7 weekdays vs. 13.6 weekends, p = NS and 13.7 days vs. 13.3 nights, p = NS), and overall Glasgow Coma Scale score was 13.6 (13.5 weekdays vs. 13.6 weekends, p = NS and 13.7 days vs. 13.4 nights, p < 0.05). In unadjusted analyses, no survival difference was detected for patients presenting on weekends (5.2% vs. 5.3%; odds ratio [OR], 0.98; and 95% confidence interval [CI], 0.75-1.28) or at night (4.4% vs. 5.5%; OR, 0.81; and 95% CI, 0.58-1.11). In adjusted analyses controlling for age, sex, Injury Severity Score, Glasgow Coma Scale score, and arrival hypotension, no survival difference was detected on weekends (OR, 1.03 and 95% CI, 0.71-1.51) or at night (OR, 0.79 and 95% CI, 0.49-1.25)., Conclusion: Differential mortality on off-hours is not seen at our Level I trauma center. Outcomes that are independent of time of day and day of week may be because of the explicit requirements for trauma centers to be fully staffed and operational at all times. There are implications for staffing and systems solutions for other time-sensitive disease including ST elevation myocardial infarction, stroke, and cardiac arrest. Interventions may include the development of a categorization system based on emergency care capabilities, development of explicit staffing requirements, and requiring an emergency care-specific quality improvement program.

Background: Boarding of admitted patients in the Emergency Department (ED) is common and is associated with poor patient outcomes., Objectives: We sought to estimate the magnitude of and trends for ED boarding in the US., Methods: We used the 2003-2005 National Hospital Ambulatory Medical Care Survey to estimate the time patients spent boarding in EDs in the US. We used fixed and imputed times required to evaluate, treat, and decide to admit each patient using the number of medications and diagnostic tests received. We calculated the absolute and relative patient-care hours spent boarding in US EDs over the 3-year period., Results: Total patient-hours spent in US EDs increased from 209 million to 217 million between 2003 and 2005. Overall admission rates decreased between 2003 and 2005 (13.9% in 2003, 12.3% in 2005), whereas intensive care unit admission rates increased (1.3% in 2003, 2.0% in 2005). Mean ED length of stay decreased (5.4 h in 2003, 4.6 h in 2005). The proportion of patient-hours accounted for by ED boarding decreased over the study period (11.3-17.1% in 2003, 5.9-15.3% in 2004, and 2.8-12.0% 2005)., Conclusions: Boarding of admitted patients in the ED accounts for a substantial portion of ED patient-care hours. Overall boarding time decreased over the 3 years., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Objectives: Our primary objective was to determine the proportion of the population able to achieve acute cerebrovascular care in emergency stroke systems (ACCESS) in the United States. In addition, we examined how policy changes, including allowing ground ambulances to cross state lines and allowing air ambulances to transport patients from the prehospital setting to primary stroke centers (PSCs), would affect population access to stroke care., Design: Data were obtained via the US Census Bureau, The Joint Commission, and the Atlas and Database of Air Medical Services. Driving distances, ambulance driving speeds, and prehospital times were estimated using validated models and adjusted for population density. Access was determined by summing the population that could reach a PSC within the specified time intervals., Setting/ Participants: US population., Main Outcome Measures: Thirty-, 45-, and 60-minute access by ground and air ambulance to PSCs., Results: Fewer than 1 in 4 Americans (22.3%) have access to a PSC within 30 minutes, less than half (43.2%) have access within 45 minutes, and just over half (55.4%) have access within 60 minutes. The use of air ambulances to deliver patients to PSCs would increase access from 22.3% to 26.0% for 30 minutes, 43.2% to 65.5% for 45 minutes, and from 55.4% to 79.3% for 60 minutes. The combination of prehospital regionalization and air ambulance transport of patients with acute stroke would reduce the 135.7 million Americans without 60-minute access to a PSC by half, to 62.9 million., Conclusions: About half of the US population has timely access to a PSC. The use of air ambulances to triage patients with ischemic stroke to a PSC would increase the percentage of the US population with prompt access to stroke care. These data have implications for the ongoing design of the US stroke system.

Objectives: In the United States, injury is a leading cause of alcohol-related death, and alcohol use is the leading risk factor for injury. We reviewed state and federal legislation regulating the intersection of alcohol and firearms., Methods: We examined the current criminal codes of all 50 states and the District of Columbia using the databases Westlaw and LexisNexis to review restrictions on firearm use while intoxicated., Results: We found three types of laws in 26 states that restrict firearm use by intoxicated people: sales or transfers are restricted in six states, carrying of concealed weapons is restricted in four states, and possession or discharge of a firearm while intoxicated is restricted in 20 states., Conclusions: Regulation of the carrying and use of firearms by acutely intoxicated individuals may represent a public health opportunity to reduce firearm-related injury.

Purpose of Review: Injury is a leading cause of pediatric death and disability. Although adult trauma care in the United States has been celebrated as a model system of emergency care, it is not clear that pediatric trauma care is as well organized. We seek to describe in this review the current state of pediatric trauma care and suggest next steps required to ensure the efficient delivery of pediatric trauma care., Recent Findings: Eighty-four percent of adults in the United States have access to a level 1 or 2 trauma center within an hour, and 71.5% of pediatric patients have access to a verified pediatric trauma center within an hour assuming ground and air transport. These results are variable depending on state, region, and population density. An estimated 17.4 million children do not have access to a pediatric trauma center within 60 min., Summary: Trauma centers improve outcome for injured patients with care at pediatric-focused centers superior to that provided at nonpediatric centers. However, access to high-level trauma care varies geographically and is not available to all children in a timely fashion. Future studies should correlate access to outcome and guide policy makers to optimize trauma systems for children.

Objective: We examined whether firearm mortality rates among children varied across US counties along a rural-urban continuum., Methods: US vital statistics data were accessed for all pediatric (age: 0-19 years) firearm deaths from 1999 through 2006. Deaths were analyzed according to a modified rural-urban continuum code (based on population size and proximity to metropolitan areas) assigned to each county (3141 counties)., Results: In the 8-year study period, there were 23649 pediatric firearm deaths (15190 homicides, 7082 suicides, and 1377 unintentional deaths). Pediatric nonfirearm mortality rates were significantly higher in the most-rural counties (adjusted rate ratio: 1.36 [95% confidence interval [CI]: 1.13-1.64]), compared with the most-urban counties. The most-rural counties demonstrated virtually identical pediatric firearm mortality rates (adjusted rate ratio: 0.91 [95% CI: 0.63-1.32]), compared with the most-urban counties. The most-rural counties had higher rates of pediatric firearm suicide (adjusted rate ratio: 2.01 [95% CI: 1.43-2.83]) and unintentional firearm death (adjusted rate ratio: 2.19 [95% CI: 1.27-3.77]), compared with the most-urban counties. Pediatric firearm homicides rates were significantly higher in the most-urban counties (adjusted rate ratio: 3.69 [95% CI: 2.00-6.80]), compared with the most-rural counties., Conclusions: Children in the most-rural US counties had firearm mortality rates that were statistically indistinguishable from those for children in the most-urban counties. This finding reflects a greater homicide rate in urban counties counterbalanced by greater suicide and unintentional firearm death rates in rural counties. Nonfirearm mortality rates were significantly greater outside the most-urban US counties.

Introduction: Survival after out-of-hospital cardiac arrest (OHCA) remains unacceptably low. Therapeutic hypothermia (TH) is the most efficacious treatment option available for comatose survivors of cardiac arrest. However, clearly delineated instructions for how to induce, maintain, and conclude TH have not been published in a codified format., Objective: We assembled 11 clinicians from the University of Pennsylvania Schools of Medicine and Nursing for a day-long moderated discussion to review our institution's TH protocol and reach consensus on a step-by-step management plan of the comatose survivor of OHCA. We attempted to systematically work our way through the existing University of Pennsylvania TH protocol. The goal was to address critical decisions at each stage of care of the post-arrest patient, including whom to cool, how to cool, how long to cool, how to rewarm, neuroprognostication, and other fundamental aspects of patient management. We made every effort to include relevant scientific evidence with appropriate citations. However, given the paucity of data in certain areas, we have relied heavily on expert opinion., Summary: We present a step-by-step management plan for incorporation of TH in the care of the comatose survivor of OHCA, which can be adapted to a variety of clinical settings with diverse resources. This article is intended to supplement current care provided by health care providers and should be adopted in concert with current standards of post-arrest and intensive care unit care.

Study Objective: Rapid access to emergency services is essential for emergency care-sensitive conditions such as acute myocardial infarction, stroke, sepsis, and major trauma. We seek to determine US population access to an emergency department (ED)., Methods: The National Emergency Department Inventories-USA was used to identify the location, annual visit volume, and teaching status of all EDs in the United States. EDs were categorized as any ED, by patient volume, and by teaching status. Driving distances, driving speeds, and out-of-hospital times were estimated with validated models and adjusted for population density. Access was determined by summing the population that could reach an ED within the specified intervals., Results: Overall, 71% of the US population has access to an ED within 30 minutes, and 98% has access within 60 minutes. Access to teaching hospitals was more limited, with 16% having access within 30 minutes and 44% within 60 minutes. Rural states had lower access to all types of EDs., Conclusion: Although the majority of the US population has access to an ED, there are regional disparities in ED access, especially by rurality. Future efforts should measure the relationship between access to emergency services and outcomes for emergency care-sensitive conditions. The development of a regionalized emergency care delivery system should be explored.

Objectives: To catalog trauma center resources and estimate access to age-specific trauma care for children younger than 15 years in the United States., Design: Cross-sectional study collating information from national, state, and local trauma systems authorities to create a catalog of verified pediatric trauma centers (PTCs) and self-designated "candidate" trauma centers. Access-to-care calculations were estimated using all US block groups and prior validated methods., Setting: United States., Patients: Children in the US younger than 15 years., Main Outcome Measures: The PTC statuses of hospitals in the United States. Percentages of pediatric populations (by state and population density) having access (by ground or air) within 60 minutes to a PTC., Results: A total of 170 verified PTCs were identified in 41 states (including the District of Columbia). An estimated 71.5% of pediatric patients were within 60 minutes of a verified PTC by air or ground transport, 43% if ground transportation only was considered. An estimated 17.4 million children did not have access to a PTC within 60 minutes. Access ranged from 22.9% of the population in the most rural areas of the United States to 93.5% in the most urban. The addition of 24 candidate centers increased coverage to 77.4% of the pediatric population being within 60 minutes of a PTC., Conclusions: Current pediatric trauma resources vary greatly by state and population density, with many children, particularly in rural areas, underserved. A thorough standardized catalog of verified PTCs is necessary to accurately assess pediatric trauma needs now and to optimize future trauma system planning for children.

Background: Comatose survivors of out-of-hospital cardiac arrest (OHCA) have high in-hospital mortality due to a complex pathophysiology that includes cardiovascular dysfunction, inflammation, coagulopathy, brain injury and persistence of the precipitating pathology. Therapeutic hypothermia (TH) is the only intervention that has been shown to improve outcomes in this patient population. Due to the similarities between the post-cardiac arrest state and severe sepsis, it has been postulated that early goal-directed hemodyamic optimization (EGDHO) combined with TH would improve outcome of comatose cardiac arrest survivors., Objective: We examined the feasibility of establishing an integrated post-cardiac arrest resuscitation (PCAR) algorithm combining TH and EGDHO within 6h of emergency department (ED) presentation., Methods: In May, 2005 we began prospectively identifying comatose (Glasgow Motor Score<6) survivors of OHCA treated with our PCAR protocol. The PCAR patients were compared to matched historic controls from a cardiac arrest database maintained at our institution., Results: Between May, 2005 and January, 2008, 18/20 (90%) eligible patients were enrolled in the PCAR protocol. They were compared to historic controls from 2001 to 2005, during which time 18 patients met inclusion criteria for the PCAR protocol. Mean time from initiation of TH to target temperature (33 degrees C) was 2.8h (range 0.8-23.2; SD=h); 78% (14/18) had interventions based upon EGDHO parameters; 72% (13/18) of patients achieved their EGDHO goals within 6h of return of spontaneous circulation (ROSC). Mortality for historic controls who qualified for the PCAR protocol was 78% (14/18); mortality for those treated with the PCAR protocol was 50% (9/18) (p=0.15)., Conclusions: In patients with ROSC after OHCA, EGDHO and TH can be implemented simultaneously.

As national health care reform advances, increasing attention is being paid to the adequacy of existing resources to meet health care needs. Do we have the right mix of providers and facilities? Are they located and organized efficiently? These persistent questions are especially relevant to the provision of emergency care, in which timely access can save lives. This Issue Brief describes the first national study of population access to emergency care, taking into account the locations of emergency departments (EDs), people, and transportation.

Purpose: We sought to generate national estimates for post-cardiac arrest mortality, to assess trends, and to identify hospital factors associated with survival., Methods: We used a national sample of US hospitals to identify patients resuscitated after cardiac arrest from 2000 to 2004 to describe the association between hospital factors (teaching status, location, size) and mortality, length of stay, and hospital charges. Analyses were performed using logistic regression., Results: A total of 109,739 patients were identified. In-hospital mortality was 70.6%. A 2% decrease in unadjusted mortality from 71.6% in 2000 to 69.6% in 2004 (OR 0.96, P < 0.001) was observed. Mortality was lower at teaching hospitals (OR 0.58, P = 0.001), urban hospitals (OR 0.63, P = 0.004), and large hospitals (OR 0.55, P < 0.001)., Conclusion: Mortality after in-hospital cardiac arrest decreased over 5 years. Mortality was lower at urban, teaching, and large hospitals. There are implications for dissemination of best practices or regionalization of post-cardiac arrest care.

Aim: A growing body of evidence suggests that variability in post-cardiac arrest care contributes to differential outcomes of patients with initial return of spontaneous circulation after cardiac arrest. We examined hospital-level variation in mortality of patients admitted to United States intensive care units (ICUs) with a diagnosis of cardiac arrest., Methods: Patients with a primary ICU admission diagnosis of cardiac arrest were identified in the 2002--2005 Acute Physiology and Chronic Health Evaluation (APACHE) IV dataset, a multicenter clinical registry of ICU patients., Results: We identified 4674 patients from 39 hospitals. The median number of annual patients was 33 per hospital (range: 12-116). Mean APACHE score was 94 (+/-38), and overall mortality was 56.8%. Age, severity of illness (acute physiology score), and admission Glasgow Coma Scale were all associated with increased mortality (p<0.001). There was no survival difference for patients admitted from the emergency department vs. the inpatient floor. Among institutions, unadjusted in-hospital mortality ranged from 41% to 81%. After adjusting for age and severity of illness, institutional mortality ranged from 46% to 68%. Patients treated at higher volume centers were significantly less likely to die in the hospital., Conclusions: We demonstrate hospital-level variation in severity adjusted mortality among patients admitted to the ICU after cardiac arrest. We identify a volume-outcome relationship showing lower mortality among patients admitted to ICUs that treat a high volume of post-cardiac arrest patients. Prospective studies should identify hospital-level and patient care factors that contribute to post-cardiac arrest survival.

Background: Indications for immediate cardiac catheterization in cardiac arrest survivors without ST elevation myocardial infarction (STEMI) are uncertain as electrocardiographic and clinical criteria may be challenging to interpret in this population. We sought to evaluate rates of early catheterization after in-hospital ventricular fibrillation (VF) arrest and the association with survival., Methods: Using a billing database we retrospectively identified cases with an ICD-9 code of cardiac arrest (427.5) or VF (427.41). Discharge summaries were reviewed to identify in-hospital VF arrests. Rates of catheterization on the day of arrest were determined by identifying billing charges. Unadjusted analyses were performed using Chi-square, and adjusted analyses were performed using logistic regression., Results: One hundred and ten in-hospital VF arrest survivors were included in the analysis. Cardiac catheterization was performed immediately or within 1 day of arrest in 27% (30/110) of patients and of these patients, 57% (17/30) successfully received percutaneous coronary intervention. Of those who received cardiac catheterization the indication for the procedure was STEMI or new left bundle branch block (LBBB) in 43% (13/30). Therefore, in the absence of standard ECG data suggesting acute myocardial infarction, 57% (17/30) received angiography. Patients receiving cardiac catheterization were more likely to survive than those who did not receive catheterization (80% vs. 54%, p<.05)., Conclusion: In patients receiving cardiac catheterization, more than half received this procedure for indications other than STEMI or new LBBB. Cardiac catheterization was associated with improved survival. Future recommendations need to be established to guide clinicians on which arrest survivors might benefit from immediate catheterization.

Background: Blunt cervical spine injury (CSI) is rare in the pediatric population. The objective of this study was to better characterize the incidence and type of CSI in young children (age <3 years) using a large, trauma center-based data set., Methods: The National Trauma Data Bank (NTDB) was reviewed for the period January 2001 to December 2005 for patients younger than 3 years of age with a blunt CSI (International Classification of Diseases, Ninth Revision, 805x, 806x, 952x). Demographic, injury, and outcome information were reviewed. Data management was performed using SAS (SAS, Cary, NC) and Stata (Stata Corp, College Station, TX). Patients with CSI were compared to patients without CSI of similar age. Means were compared with the Wilcoxon rank sum test, medians were compared with a nonparametric test, and count data were compared with the chi(2) test, with significance set at <.05., Results: For the period of review, 95,654 young children (age <3 years) with blunt trauma were identified in the NTDB. The overall population had a median Injury Severity Score (ISS) of 4, and most patients (77.01%) had a Glasgow Coma Score (GCS) of 15. There were 1523 (1.59%) patients with a CSI (spinal cord and/or column), including 366 patients (0.38%) with a spinal cord injury (with or without column injury) and 182 (0.19%) with an isolated spinal cord injury (SCIWORA). The CSI and non-CSI populations did not differ regarding median GCS (15 for both groups), but the CSI population had a significantly higher median ISS (14 vs 4, respectively; P < .001). Compared to patients without CSI, the CSI population was more likely to die in the emergency department (2.04% vs 1.25%; P = .007) or be admitted to the intensive care unit (45.3% vs 16.9%; P < .001). Nearly half of all cervical spine fractures (48%) and more than half of cervical spinal cord injuries (53%) were in the lower cervical spine (C5-7). MVCs were the most common injury mechanism (66%) followed by falls (15%). A CSI was observed in 3.2% of all motor vehicle crashes (MVCs)., Conclusions: In this trauma center population, these findings confirm the infrequency of blunt CSI in the youngest (age <3 years) trauma patients. The frequency of injuries to the lower cervical spine is higher than previously appreciated. MVCs are the most likely injury mechanism for this potentially devastating injury.

Vital statistics are widely used to evaluate trends in health and illness, inform policy, and allocate resources among health priorities. Literature comparing autopsies to clinical death certification has shown that the clinical "cause of death" certification is inaccurate or incomplete in many cases. Short of increasing autopsies, however, these studies have proposed few improvements. Using the case of death certification in the emergency department (ED), the authors analyzed the current approach to death certification. The authors propose the following to improve the quality of data: 1) acceptance of the declaration "manner of death, natural; cause of death, uncertain"; 2) training for physicians in the selection of appropriate underlying causes of death and "chains of causation"; and 3) participation of physicians with ongoing relationships to the patient in the certification process.

Objectives: The prehospital management of trauma patients remains controversial. Little is known about the time each procedure contributes to the on-scene duration, and this information would be helpful in prioritizing which procedures to perform in the prehospital setting. We sought to estimate the contribution of procedures to on-scene duration focusing on intubation and establishment of intravenous (IV) access., Methods: Data were provided by the Office of Emergency Planning and Response at the Mississippi Department of Health. Real-time prehospital patient-level data are collected by emergency medical services (EMS) providers for all 9-1-1 calls statewide. Linear regression was performed to determine the overall additional time for an average procedure and to calculate marginal increases in on-scene time associated with the establishment of IV access and with endotracheal intubation. Analyses were performed using Stata 9., Results: During 2001-2005, 192,055 prehospital runs were made for trauma patients. 121,495 (63%) included prehospital procedures. Average on-scene duration for those runs was 15:24 (minutes:seconds). On average, each procedure was associated with an addition of 1 minute to the on-scene duration (95% confidence interval [CI]: 58-62 seconds). A scene involving the establishment of IV access was 5:04 longer, while one involving tracheal intubation was 2:36 longer., Conclusions: We estimate the marginal increase in on-scene duration associated with the performance of an average procedure, establishment of IV access, and endotracheal intubation. There are policy and planning implications for the time trade-off of prehospital procedures, especially discretionary ones.

Objective: A goal in intimate partner violence (IPV) research is to identify victims when they are treated in a hospital Emergency Department (ED) and predict which patients will sustain abuse again after discharge, so interventions can be targeted. Following patients to determine those prognostic factors is difficult, however, especially to study IPV given the risk to be assaulted if their partner learns of their participation. We assessed the feasibility of an automated telephone survey and a wireless incentive delivery system to follow ED patients after discharge, enabling detection of IPV recurrence., Methods: A four-week prospective cohort pilot study was conducted at an urban academic medical center ED in the U.S. Thirty patient subjects (24 women, 6 men; 18-54 years) who had sustained IPV in the past six months, 12 of whom presented for an acute IPV-related condition, were interviewed in the ED and were asked to report weekly for four weeks after discharge to a toll-free, password protected telephone survey, and answer recorded questions using the telephone keypad. A $10 convenience store debit card was provided as an incentive, and was electronically recharged with $10 for each weekly report, with a $20 bonus for making all four reports., Results: Twenty-two of 30 subjects (73.3%) made at least one report to the telephone survey during the four weeks following discharge; 14 of the 30 subjects (46.7%) made all four weekly reports. Each time the telephone survey was accessed, the subject completed all questions (i.e., no mid-survey break-offs). Eight months after follow-up ended, almost all debit cards (86.7%) had been used to make purchases., Conclusion: Approximately three of every four subjects participated in follow-up after ED discharge, and approximately two of every four subjects completed all follow-up reports, suggesting the method of an automated telephone survey and wireless incentive delivery system makes it feasible to study IPV prospectively among discharged patients. That finding, along with evidence that IPV recurrence risk is high, suggests the protocol tested is warranted for use conducting full-scale studies of IPV. The protocol could benefit efforts to study other outcomes, especially when patient confidentiality is paramount for their safety.

Objectives: Firearm wounding patterns have changed, and patients more commonly present with multiple gunshot wounds (GSWs). We hypothesized that multiple GSW are associated with increased mortality risk and increased hospital length of stay (LOS)., Methods: Medical charts were abstracted for patients with GSW during a 4-month period. GSW to each of six anatomic regions were quantified. Proportions, medians, and trends were compared, and relative risks of death were computed., Results: Among 111 patients, GSW per patient ranged from 1 to 12. Most (62%) patients sustained GSW to a single region. The median number of regions involved increased with the number of GSW (p < 0.01). Patients with multiple regions injured were more likely to die in the emergency department (16% vs. 12%, p < 0.05) or be admitted (72% vs. 52%, p < 0.01). Intensive care unit and hospital LOS increased (p < 0.05) with the number of regions involved., Conclusions: Multiple GSW are associated with higher mortality, more intensive care unit days, and longer LOS. Changing wounding patterns seem to have increased morbidity and mortality associated with firearm injuries. These data have associated health policy implications.