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Introduction At the request of then-Assistant Secretary of Defense for Health Affairs, Dr. Jonathan Woodson, Defense Health Horizons (DHH) examined options for shaping Graduate Medical Education (GME) in the Military Health System (MHS) in order to achieve the goals of a medically ready force and a ready medical force. Materials and Methods The DHH interviewed service GME directors, key designated institutional officials, and subject-matter experts on GME in the military and civilian health care systems. Results This report proposes numerous short- and long-term courses of action in three areas: 1. Balancing the allocation of GME resources to suit the needs of active duty and garrisoned troops. We recommend developing a clear, tri-service mission and vision for GME in the MHS and expanding collaborations with outside institutions in order to prepare an optimal mix of physicians and ensure that trainees meet requirements for clinical experience. 2. Improving the recruitment and tracking of GME students, as well as the management of accessions. We recommend several measures to improve the quality of incoming students, to track the performance of students and medical schools, and to foster a tri-service approach to accessions. 3. Aligning MHS with the tenets of the Clinical Learning Environment Review to advance a culture of safety and to help the MHS become a high reliability organization (HRO). We recommend several actions to strengthen patient care and residency training and to develop a systematic approach to MHS management and leadership. Conclusion Graduate Medical Education (GME) is vital to produce the future physician workforce and medical leadership of the MHS. It also provides the MHS with clinically skilled manpower. Graduate Medical Education (GME) research sows the seeds for future discoveries to improve combat casualty care and other priority objectives of the MHS. Although readiness is the MHS’s top mission, GME is also vital to meeting the other three components of the quadruple aim (better health, better care, and lower costs). Properly managed and adequately resourced GME can accelerate the transformation of the MHS into an HRO. Based on our analysis, DHH believes that there are numerous opportunities for MHS leadership to strengthen GME so it is more integrated, jointly coordinated, efficient, and productive. All physicians emerging from military GME should understand and embrace team-based practice, patient safety, and a systems-oriented focus. This will ensure that those we prepare to be the military physicians of the future are prepared to meet the needs of the line, to protect the health and safety of deployed warfighters, and to provide expert and compassionate care to garrisoned service members, families, and military retirees.

The Military Health System (MHS) has a medical research program aimed at a wide range of health-, disease-, and injury-related topic areas that works with civilian academic institutions and the biomedical industry to accomplish its goals. There are many opportunities for civilian academic institutions and the biomedical industry to engage with this program, but its unique features are important to understand to optimize the chances for successful partnerships. Unlike the National Institutes of Health, which uses an "investigator-initiated" approach, the Department of Defense (DoD) aligns its funding with specific needs, also referred to as requirements; thus, DoD research is often described as "requirements-driven" research. At the highest level, requirements are aligned with the National Security Strategy and National Defense Strategy, though requirements documents list specific areas in medicine with unmet needs. Military labs and the Uniformed Services University of the Health Sciences, which can also receive DoD appropriations to conduct medical research, serve as hubs that interface with civilian academic institutions and the biomedical industry and organize and track the overall progress of DoD investments. As a mechanism to propel findings from "bench to bedside," the military budgets funds for the various phases of research and development for a given topic area. Research programs are most effective when they are integrated into the MHS learning health system, which allows MHS clinical communities to inform and track research investments and evaluate the utility of research products in real clinical practice settings. This Perspective provides introductory information and a basic framework for those interested in performing DoD-funded medical research or collaborating with researchers in military labs. It is hoped that as academic institutions and the biomedical industry look to increase efficiency in medical research, they will find ways to engage with DoD research opportunities and consider elements of the military's approach useful.

Author(s): El Sayed, Mazen J; Hitti, Eveline A.; Cheaito, Mohamad Ali; Davis, Tim; Kazzi, Amin A. | Abstract: The first article in this series (Part I) discussed the abundant exposure of our emergency department (ED) to mass casualty incidents (MCIs), particularly over the past 14 years. This experience led us to define practical strategies that emergency departments can use to develop their own MCI response plans. In the first part, our main focus was to highlight the abrupt nature of MCIs and the subsequent need to use disaster drills. Additionally, we discussed the importance of having a tiered response and activation as well as other lessons learned from our experience to maximize the preparedness of the emergency department to receive mass casualty.In this article, we discuss the optimal way to triage patients. In addition, we will tackle the best methods for documentation and communication, which are vital yet overlooked during mass casualty incidents. We will also elaborate on what we learned from dealing with outbursts of anger and violence in the ED during MCIs and how to ensure the safety of the ED staff.

OBJECTIVE: The objective was to determine whether brief, Web‐based instruction several weeks prior to tourniquet application improves layperson success compared to utilizing just‐in‐time (JiT) instructions alone. BACKGROUND: Stop the Bleed is a campaign to educate laypeople to stop life‐threatening hemorrhage. It is based on U.S. military experience with lifesaving tourniquet use. While previous research shows simple JiT instructions boost laypeople's success with tourniquet application, the optimal approach to educate the public is not yet known. METHODS: This is a prospective, nonblinded, randomized study. Layperson participants from the Washington, DC, area were randomized into: 1) an experimental group that received preexposure education using a website and 2) a control group that did not receive preexposure education. Both groups received JiT instructions. The primary outcome was the proportion of subjects that successfully applied a tourniquet to a simulated amputation. Secondary outcomes included mean time to application, mean placement position, ability to distinguish bleeding requiring a tourniquet from bleeding requiring direct pressure only, and self‐reported comfort and willingness to apply a tourniquet. RESULTS: Participants in the preexposure group applied tourniquets successfully 75% of the time compared to 50% success for participants with JiT alone (p

To understand the long-term economic implications of key pathways for financing a medical school education.The authors calculated the net present value (NPV) of cash flow over a 30-year career for a 2013 matriculant associated with (1) self-financing, (2) federally guaranteed loans, (3) the Public Service Loan Forgiveness program, (4) the National Health Service Corps, (5) the Armed Forces Health Professions Scholarship Program, and (6) matriculation at the Uniformed Services University of the Health Sciences. They calculated the NPV for students pursuing one of four specialties in two cities with divergent tax policies. Borrowers were assumed to have a median level of debt ($180,000), and conservative projections of inflation, discount rates, and income growth were employed. Sensitivity analyses examined different discount and income growth rates, alternative repayment strategies, and various lengths of public-sector service by scholarship recipients.For those wealthy enough to pay cash or fortunate enough to secure a no-strings scholarship, self-financing produced the highest NPV in almost every scenario. Borrowers start practice $300,000 to $400,000 behind their peers who secure a national service scholarship, but those who enter a highly paid specialty, such as orthopedic surgery, overtake their national service counterparts 4 to 11 years after residency. Those in lower-paid specialties take much longer. Borrowers who enter primary care never close the gap.Over time, the value of a medical degree offsets the high up-front cost. Debt avoidance confers substantial economic benefits, particularly for students interested in primary care.

The article discusses health protection in the U.S., focusing upon how military concepts can be applied to the "civilian world." Particular focus is given to how military medicine has advanced trauma and emergency care in the U.S. Additional topics discussed include disease prevention during the American Civil War, the clear evidence that healthy populations are more productive and prosperous than those who are not, and how public health can be improved in the US. by holding leaders accountable.

Background Although the survivability of military extremity hemorrhage is well documented, equivalent civilian data are limited. We analyzed statewide autopsy records in Maryland to determine the number of hemorrhagic deaths that might have been potentially survivable with prompt hemorrhage control. Similar analyses of battlefield deaths led to life-saving changes in military medical practice. Study Design This is a retrospective study of decedent records. The objective is to estimate the number of hemorrhagic deaths that might have been prevented by prompt placement of an extremity tourniquet. Maryland autopsy records from 2002 to 2016 were selected using the following search terms: amputation, arm/arms, avulsion, exsanguination, extremity/extremities, leg/legs. The records were analyzed by applying a checklist of previously developed military criteria to characterize deaths as potentially survivable or nonsurvivable with prompt use of a tourniquet. Suicides and decedents less than 18 years old were excluded. The study did not use information about living participants. Two expert reviewers independently evaluated and scored the death records. Deaths were classified as either potentially survivable or nonsurvivable. A third reviewer broke any ties. Results There were 288 full autopsy records included in the final analysis. Of the eligible decedents reviewed during the 14-year period, 124 of 288 had potentially survivable wounds; 164 had nonsurvivable wounds. Conclusions Over the 14-year study interval, 124 Maryland decedents—an average of 9 per year—might have been saved with prompt placement of a tourniquet. If extrapolated, approximately 480 people in the US might be saved per year. These results provide evidence to support educating and equipping the public to provide bleeding control.

Background— Despite intensive efforts over many years, the United States has made limited progress in improving rates of survival from out-of-hospital cardiac arrest. Recently, national organizations, such as the American Heart Association, have focused on promoting bystander cardiopulmonary resuscitation, use of automated external defibrillators, and other performance improvement efforts. Methods and Results— Using the Cardiac Arrest Registry to Enhance Survival (CARES), a prospective clinical registry, we identified 70 027 U.S. patients who experienced an out-of-hospital cardiac arrest between October 2005 and December 2012. Using multilevel Poisson regression, we examined temporal trends in risk-adjusted survival. After adjusting for patient and cardiac arrest characteristics, risk-adjusted rates of out-of-hospital cardiac arrest survival increased from 5.7% in the reference period of 2005 to 2006 to 7.2% in 2008 (adjusted risk ratio, 1.27; 95% confidence interval, 1.12–1.43; P P P for interaction=0.22) and was also accompanied by better neurological outcomes among survivors ( P for trend=0.01). Improved survival was attributable to both higher rates of prehospital survival, where risk-adjusted rates increased from 14.3% in 2005 to 2006 to 20.8% in 2012 ( P for trendP for trend=0.015). Rates of bystander cardiopulmonary resuscitation and automated external defibrillator use modestly increased during the study period and partly accounted for prehospital survival trends. Conclusions— Data drawn from a large subset of U.S communities suggest that rates of survival from out-of-hospital cardiac arrest have improved among sites participating in a performance improvement registry.

Some Medicare beneficiaries who place 911 calls to request an ambulance might safely be cared for in settings other than the emergency department (ED) at lower cost. Using 2005-09 Medicare claims data and a validated algorithm, we estimated that 12.9-16.2 percent of Medicare-covered 911 emergency medical services (EMS) transports involved conditions that were probably nonemergent or primary care treatable. Among beneficiaries not admitted to the hospital, about 34.5 percent had a low-acuity diagnosis that might have been managed outside the ED. Annual Medicare EMS and ED payments for these patients were approximately $1 billion per year. If Medicare had the flexibility to reimburse EMS for managing selected 911 calls in ways other than transport to an ED, we estimate that the federal government could save $283-$560 million or more per year, while improving the continuity of patient care. If private insurance companies followed suit, overall societal savings could be twice as large.

Efforts to close the primary care workforce gap typically employ one of three basic strategies: train more primary care physicians; boost the supply of nurse practitioners or physician assistants, or both; or use community health workers to extend the reach of primary care physicians. In this article we briefly review each strategy and the barriers to its success. We then propose a new approach adapted from the widely accepted model of emergency medical services. Translating this model to primary care and leveraging the capabilities of modern health information technology, it should be possible to create primary care technicians who can dramatically expand the impact and reach of patient-centered medical homes by providing basic preventive, minor illness, and stable chronic disease care in rural and resource-deprived communities.

The Affordable Care Act (ACA) established nationwide eligibility for young adults 19 to 25 years of age to retain coverage under their parents' private health plans. We conducted a study to determine how the implementation of this provision changed rates of insurance coverage for young adults seeking medical care for major emergencies.We evaluated more than 480,000 nondiscretionary visits made to emergency departments from 2009 through 2011, as recorded in a large, geographically diverse data set of hospital claims, to estimate how the ACA provision affected private insurance coverage of such visits by young adults (19 to 25 years of age). To adjust for underlying trends in insurance coverage, we compared changes in the target age group with changes among adults 26 to 31 years of age, who were unaffected by the provision (control group).After the ACA provision took effect, private coverage of nondiscretionary visits to emergency departments by young adults increased by 3.1 percentage points (95% confidence interval [CI], 2.3 to 3.9; relative increase, 5.2%; P0.001), as compared with similar visits in the control group. The percentage of visits by uninsured young adults also fell significantly (-1.7 percentage points; 95% CI, -2.8 to -0.7; relative decrease, 9.1%; P0.001). The rates of nondiscretionary visits that were covered by Medicaid or other nonprivate insurers remained relatively steady throughout the study period. The coverage expansion led to an estimated 22,072 visits to emergency departments by newly insured young adults and $147 million in associated costs that were covered by private insurance plans during a 1-year period.Enactment of the dependent-coverage provision was associated with a significant increase in the proportion of young adults who were protected from the financial consequences of a serious medical emergency. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services.).

A team of RAND Corporation researchers projected in 2005 that rapid adoption of health information technology (IT) could save the United States more than $81 billion annually. Seven years later the empirical data on the technology's impact on health care efficiency and safety are mixed, and annual health care expenditures in the United States have grown by $800 billion. In our view, the disappointing performance of health IT to date can be largely attributed to several factors: sluggish adoption of health IT systems, coupled with the choice of systems that are neither interoperable nor easy to use; and the failure of health care providers and institutions to reengineer care processes to reap the full benefits of health IT. We believe that the original promise of health IT can be met if the systems are redesigned to address these flaws by creating more-standardized systems that are easier to use, are truly interoperable, and afford patients more access to and control over their health data. Providers must do their part by reengineering care processes to take full advantage of efficiencies offered by health IT, in the context of redesigned payment models that favor value over volume.

INTRODUCTION Over the past 150 years, military medical research has made significant contributions to American health care. In the past decade alone, military medicine has achieved significant advances in combat casualty care by demonstrating the value of tourniquets, damage control resuscitation and surgery, new infection management guidelines, transcontinental critical care transport, advanced prosthetics, and new techniques in rehabilitation. This pioneering research cannot occur in a vacuum. As in civilian settings, medical research must be nested in an academic architecture. In the Military Health System (MHS) the foundation for cuttingedge research is built at the Uniformed Services University of the Health Sciences and through military Graduate Medical Education (GME).

To assess whether differences in readmission rates between safety-net hospitals (SNH) and non-SNHs are due to differences in hospital quality, and to compare the results of hospital profiling with and without SES adjustment.In response to concerns that quality measures unfairly penalizes SNH, NQF recently recommended that performance measures adjust for socioeconomic status (SES) when SES is a risk factor for poor patient outcomes.Multivariate regression was used to examine the association between SNH status and 30-day readmission after major surgery. The results of hospital profiling with and without SES adjustment were compared using the CMS Hospital Compare and the Hospital Readmissions Reduction Program (HRRP) methodologies.Adjusting for patient risk and SES, patients admitted to SNHs were not more likely to be readmitted compared with patients in in non-SNHs (AOR 1.08; 95% CI:0.95-1.23; P = 0.23). The results of hospital profiling based on Hospital Compare were nearly identical with and without SES adjustment (ICC 0.99, κ 0.96). Using the HRRP threshold approach, 61% of SNHs were assigned to the penalty group versus 50% of non-SNHs. After adjusting for SES, 51% of SNHs were assigned to the penalty group.Differences in surgery readmissions between SNHs and non-SNHs are due to differences in the patient case mix of low-SES patients, and not due to differences in quality. Adjusting readmission measures for SES leads to changes in hospital ranking using the HRRP threshold approach, but not using the CMS Hospital Compare methodology. CMS should consider either adjusting for the effects of SES when calculating readmission thresholds for HRRP, or replace it with the approach used in Hospital Compare.

The federal government plays a critical role in achieving national health security by providing strategic guidance and funding research to help prevent, respond to, mitigate, and recover from disasters, epidemics, and acts of terrorism. In this article we describe the first-ever inventory of nonclassified national health security-related research funded by civilian agencies of the federal government. Our analysis revealed that the US government's portfolio of health security research is currently weighted toward bioterrorism and emerging biological threats, laboratory methods, and development of biological countermeasures. Eight of ten other priorities identified in the Department of Health and Human Services' National Health Security Strategy-such as developing and maintaining a national health security workforce or incorporating recovery into planning and response-receive scant attention. We offer recommendations to better align federal spending with health security research priorities, including the creation of an interagency working group charged with minimizing research redundancy and filling persistent gaps in knowledge.

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

US government programs and communications regarding citizen preparedness for disasters rest on several untested, and therefore unverified, assumptions. We explore the assumptions related to citizen preparedness promotion and argue that in spite of extensive messaging about the importance of citizen preparedness and countless household surveys purporting to track the preparedness activities of individuals and households, the role individual Americans are being asked to play is largely based on conventional wisdom. Recommendations for conceptualizing and measuring citizen preparedness are discussed.(Disaster Med Public Health Preparedness. 2012;6:170–173)

Although a median-income US family of four with employer-based health insurance saw its gross annual income increase from $76,000 in 1999 to $99,000 in 2009 (in current dollars), this gain was largely offset by increased spending to pay for health care. Monthly spending increases occurred in the family's health insurance premiums (from $490 to $1,115), out-of-pocket health spending (from $135 to $235), and taxes devoted to health care (from $345 to $440). After accounting for price increases in other goods and services, the family had $95 more in monthly income to devote to nonhealth spending in 2009 than in 1999. By contrast, had the rate of health care cost growth not exceeded general inflation, the family would have had $545 more per month instead of $95-a difference of nearly $5,400 per year. Even the $95 gain was artificial, because tax collections in 2009 were insufficient to cover actual increases in federal health spending. As a result, we argue, the burdens imposed on all payers by steadily rising health care spending can no longer be ignored.

Historically, general practitioners provided first-contact care in the United States. Today, however, only 42 percent of the 354 million annual visits for acute care--treatment for newly arising health problems--are made to patients' personal physicians. The rest are made to emergency departments (28 percent), specialists (20 percent), or outpatient departments (7 percent). Although fewer than 5 percent of doctors are emergency physicians, they handle a quarter of all acute care encounters and more than half of such visits by the uninsured. Health reform provisions in the Patient Protection and Affordable Care Act that advance patient-centered medical homes and accountable care organizations are intended to improve access to acute care. The challenge for reform will be to succeed in the current, complex acute care landscape.

The American Heart Association's (AHA's) Advanced Cardiac Life Support guidelines act as the national standards for termination of resuscitation (TOR) in cases of refractory out-of-hospital cardiac arrest. However, local emergency medical services (EMS) implementation of these guidelines has been nonuniform.To identify the operational issues within local EMS systems that may serve as barriers or facilitators to full acceptance of national guidelines for prehospital TOR in appropriate circumstances. Methods. We conducted three focus groups at the January 2008 National Association of EMS Physicians (NAEMSP) annual meeting. Snowball sampling was used to recruit 19 physicians, two EMS providers, one research director, one nurse, and one medical student attending the conference. Two reviewers analyzed the data in an iterative process to identify recurrent and unifying themes.We identified three distinct stakeholder groups whose current beliefs and practices may influence local implementation of TOR: EMS providers with variations in education and work culture; EMS medical directors with responsibility but little authority; and online medical control physicians who do not communicate effectively with the other groups. Our focus group participants suggested that national organizations, such as the AHA and the American College of Emergency Physicians, may serve a role in overcoming the overarching barriers of communication, standardized educational requirements, and coordination of local services.We have identified operational barriers that may impede implementation of TOR guidelines. Three influential stakeholder groups will need to work with national organizations to overcome these local barriers.

Background— Prior studies have identified key predictors of out-of-hospital cardiac arrest (OHCA), but differences exist in the magnitude of these findings. In this meta-analysis, we evaluated the strength of associations between OHCA and key factors (event witnessed by a bystander or emergency medical services [EMS], provision of bystander cardiopulmonary resuscitation [CPR], initial cardiac rhythm, or the return of spontaneous circulation). We also examined trends in OHCA survival over time. Methods and Results— An electronic search of PubMed, EMBASE, Web of Science, CINAHL, Cochrane DSR, DARE, ACP Journal Club, and CCTR was conducted (January 1, 1950 to August 21, 2008) for studies reporting OHCA of presumed cardiac etiology in adults. Data were extracted from 79 studies involving 142 740 patients. The pooled survival rate to hospital admission was 23.8% (95% CI, 21.1 to 26.6) and to hospital discharge was 7.6% (95% CI, 6.7 to 8.4). Stratified by baseline rates, survival to hospital discharge was more likely among those: witnessed by a bystander (6.4% to 13.5%), witnessed by EMS (4.9% to 18.2%), who received bystander CPR (3.9% to 16.1%), were found in ventricular fibrillation/ventricular tachycardia (14.8% to 23.0%), or achieved return of spontaneous circulation (15.5% to 33.6%). Although 53% (95% CI, 45.0% to 59.9%) of events were witnessed by a bystander, only 32% (95% CI, 26.7% to 37.8%) received bystander CPR. The number needed to treat to save 1 life ranged from 16 to 23 for EMS-witnessed arrests, 17 to 71 for bystander-witnessed, and 24 to 36 for those receiving bystander CPR, depending on baseline survival rates. The aggregate survival rate of OHCA (7.6%) has not significantly changed in almost 3 decades. Conclusions— Overall survival from OHCA has been stable for almost 30 years, as have the strong associations between key predictors and survival. Because most OHCA events are witnessed, efforts to improve survival should focus on prompt delivery of interventions of known effectiveness by those who witness the event.

The 2008 election brought sweeping political change to Washington, DC. For a variety of reasons, there is also substantial political momentum for reform of our health care system. At the 2008 Association of American Medical Colleges meeting in San Antonio, Texas, the Association of Academic Chairs of Emergency Medicine, meeting in conjunction with the Society for Academic Emergency Medicine, chose to examine the topic of "advocacy and political influence." This article summarizes comments made at the meeting and develops the argument that expertise in health policy and political advocacy are valuable skills that should be considered legitimate components of scholarly activity in academic emergency medicine. Strategies for effective advocacy of issues relevant to emergency medicine and emergency patient care are also discussed.

Background— Despite the existence of national American Heart Association guidelines and 2 termination-of-resuscitation (TOR) rules for ceasing efforts in refractory out-of-hospital cardiac arrest, many emergency medical services agencies in the United States have adopted their own local protocols. Public policies and local perceptions may serve as barriers or facilitators to implementing national TOR guidelines at the local level. Methods and Results— Three focus groups, lasting 90 to 120 minutes, were conducted at the National Association of Emergency Medical Services Physicians meeting in January 2008. Snowball sampling was used to recruit participants. Two reviewers analyzed the data in an iterative process to identify recurrent and unifying themes. We identified 3 distinct groups whose current policies or perceptions may impede efforts to adopt national TOR guidelines: payers who incentivize transport; legislators who create state mandates for transport and allow only narrow use of do-not-resuscitate orders; and communities where cultural norms are perceived to impede termination of resuscitation. Our participants suggested that national organizations, such as the American Heart Association and American College of Emergency Physicians, may serve as potential facilitators in addressing these barriers by taking the lead in asking payers to change reimbursement structures; encouraging legislators to revise laws to reflect the best available medical evidence; and educating the public that rapid transport to the hospital cannot substitute for optimal provision of prehospital care. Conclusion— We have identified 3 influential groups who will need to work with national organizations to overcome current policies or prevailing perceptions that may impede implementing national TOR guidelines.

In this article, we review published preclinical and epidemiologic studies that examine progesterone's role in the central nervous system. Its effects on the reproductive and endocrine systems are well known, but a large and growing body of evidence, including a recently published pilot clinical trial, indicates that the hormone also exerts neuroprotective effects on the central nervous system. We now know that it is produced in the brain, for the brain, by neurons and glial cells in the central and peripheral nervous system of both male and female individuals. Laboratories around the world have reported that administering relatively large doses of progesterone during the first few hours to days after injury significantly limits central nervous system damage, reduces loss of neural tissue, and improves functional recovery. Although the research published to date has focused primarily on progesterone's effects on blunt traumatic brain injury, there is evidence that the hormone affords protection from several forms of acute central nervous system injury, including penetrating brain trauma, stroke, anoxic brain injury, and spinal cord injury. Progesterone appears to exert its protective effects by protecting or rebuilding the blood-brain barrier, decreasing development of cerebral edema, down-regulating the inflammatory cascade, and limiting cellular necrosis and apoptosis. All are plausible mechanisms of neuroprotection.

Objective Emergency Departments (EDs) offer an opportunity to improve the care of patients with at-risk and dependent drinking by teaching staff to screen, perform brief intervention and refer to treatment (SBIRT). We describe here the implementation at 14 Academic EDs of a structured SBIRT curriculum to determine if this learning experience improves provider beliefs and practices. Methods ED faculty, residents, nurses, physician extenders, social workers, and Emergency Medical Technicians (EMTs) were surveyed prior to participating in either a two hour interactive workshops with case simulations, or a web-based program ( www.ed.bmc.org/sbirt ). A pre-post repeated measures design assessed changes in provider beliefs and practices at three and 12 months post-exposure. Results Among 402 ED providers, 74% reported Conclusions ED providers respond favorably to SBIRT. Changes in utilization were substantial at three months post-exposure to a standardized curriculum, but less apparent after 12 months. Booster sessions, trained assistants and infrastructure supports may be needed to sustain changes over the longer term.

One of every 150 hospitalized patients experiences a lethal adverse event; nearly half of these events involves surgical patients. Although variations in surgeon performance and quality have been reported in the literature, less is known about the influence of anesthesiologists on outcomes after major surgery. Our goal of this study was to determine whether there is significant variation in outcomes between anesthesiologists after controlling for patient case mix and hospital quality.Using clinical data from the New York State Cardiac Surgery Reporting System, we conducted a retrospective observational study of 7920 patients undergoing isolated coronary artery bypass graft surgery. Multivariable logistic regression modeling was used to examine the variation in death or major complications (Q-wave myocardial infarction, renal failure, stroke) across anesthesiologists, controlling for patient demographics, severity of disease, comorbidities, and hospital quality.Anesthesiologist performance was quantified using fixed-effects modeling. The variability across anesthesiologists was highly significant (P0.001). Patients managed by low-performance anesthesiologists (corresponding to the 25th percentile of the distribution of anesthesiologist risk-adjusted outcomes) experienced nearly twice the rate of death or serious complications (adjusted rate 3.33%; 95% confidence interval [CI], 3.09%-3.58%) as patients managed by high-performance anesthesiologists (corresponding to the 75th percentile) (adjusted rate 1.82%; 95% CI, 1.58%-2.10%). This performance gap was observed across all patient risk groups.The rate of death or major complications among patients undergoing coronary artery bypass graft surgery varies markedly across anesthesiologists. These findings suggest that there may be opportunities to improve perioperative management to improve outcomes among high-risk surgical patients.

Smoking is the leading cause of preventable death and illness in the United States. National practice guidelines call for all health care providers to "ask" all patients about tobacco use, and to "advise, assess, assist, arrange" when smokers want to quit smoking (the "5 As"). Emergency departments (EDs) have not been an important locus of tobacco control efforts, although ED patients typically smoke at rates exceeding that of the general population, are interested in quitting, and often have limited access to primary care. To address the role of emergency medicine in tobacco control, the American College of Emergency Physicians convened a task force of representatives of major emergency medicine professional organizations. Funded by the Robert Wood Johnson Foundation, the group met in 2004 and 2005. This article represents a summary of the task force's recommendations for tobacco control practice, training, and research. We call on emergency care providers to routinely assess patients' smoking status, offer brief advice to quit, and refer patients to the national smokers' Quitline (800-QUIT-NOW) or a locally available program. Given the global burden of tobacco-related illness, the task force considers it essential for emergency physicians to conduct research into the efficacy of ED-based interventions and to place tobacco control into the training curriculum for emergency medicine residencies. Tobacco control fits within the traditions of other ED-based public health practices, such as injury control. ED-based tobacco control would allow the specialty to help fulfill the Healthy People 2010 mandate to reduce the prevalence of smoking among US citizens.

The power and sophistication of terrorist bombings have increased dramatically, but America's emergency and trauma care system has deteriorated to an alarming degree. Dr. Arthur Kellermann writes that strengthening disaster response is a key priority.

Injuries, whether caused by unintentional or intentional events, area significant public health problem. The burden of injury is greatest in low-and middle-income countries and among individuals of low socioeconomic status living in high-income countries. Most of these injuries are prevent-able. Emergency physicians can play an important role in reducing the global burden of injuries by providing expert care and by identifying, implementing, and evaluating population-based countermeasures to prevent and control injuries. The strategy used in a particular country depends in large part on the nature of the local problem, the concerns of the population, the availability of resources, and competing demands. Even simple countermeasures may have a big impact in reducing the global burden of death and disability due to injury.

A proposed rule for reducing disproportionate-share-hospital payments encourages states to focus DSH funds on the hospitals that need it most. But if states not expanding Medicaid don't reallocate their DSH funds, safety-net hospitals and their patients will suffer.

Objectives: To determine whether households that generate several 911 calls differ in important ways from those that make a single call and to determine whether households that generate repeat 911 calls for intimate partner violence (IPV) experience more severe violence than those that do not. Methods: All cases of police-documented IPV were reviewed and linked with their respective 911 calls. Each incident report was reviewed to determine the relationship between the offender and victim, demographic characteristics of the offender and victim, weapon and substance involvement, prior incidents of IPV, and violence severity. Results: Of the 1,505 IPV addresses identified during the 12-month study interval, 1,010 (67.1%) placed more than one phone call to report IPV. Sixty-nine percent of African American victims, 50.6% of white victims, and 36.8% of Hispanic victims were repeat callers (p < 0.001). There were no differences between addresses that generated repeat calls versus single calls with respect to offender alcohol or drug involvement, presence of children, victim age, or offender age. Sixty-seven percent of households with severe violence and 66.9% of households with minor violence generated repeat 911 calls (p = 0.98). Conclusions: Ethnic differences in 911 use for IPV exist between African Americans, whites, and Hispanics. However, unknown societal, economic, or cultural issues could have influenced this finding. Households that repeatedly contacted 911 during the study interval to report IPV were not more likely to experience severe violence than those that placed a single 911 call.

Glenn Melnick and colleagues' analysis of emergency department (ED) capacity and access in California is fatally flawed because the authors do not consider the operational constraints tha...

To date, severe acute respiratory syndrome (SARS) has sickened at least 8,400 individuals and killed more than 820 worldwide. Before public health officials in China recognized the significance of the initial outbreak of this new disease, infected travelers had sparked secondary outbreaks in several Asian nations and in Toronto, Ontario, Canada. The severity of the ensuing illness and its ready transmissibility severely challenged the medical care systems of affected countries.1-4 Although much has been learned about SARS since the disease was first identified, many questions are unanswered. It is not yet known, for example, if the disease is seasonal, how it may be transmitted, and why certain individuals are “superspreaders” of infection.5,6 SARS is characterized by a high degree of infectivity among close personal contacts, including treating health care workers.7,8 To date, SARS infection has not produced a random pattern of contagious spread.1-3,9,10 The virus can contaminate buildings, fixtures, and patient care areas, but details of how contamination takes place and the persistence of infectious material are unknown.4 As yet, no antimicrobial agent (alone or in combination with other drugs such as corticosteroids) has been established as effective. Worse yet, the disease is highly virulent. Despite widespread provision of intensive care, including endotracheal intubation and mechanical ventilation, the disease produced a case-fatality rate among hospitalized patients of 10% to 15%.11-13 Aggressive respiratory care increased the risk of disease transmission to treating health care workers.7,8,14,15 The combination of ready transmissibility and virulence makes SARS a particularly dangerous disease, one that resembles the Class A bioterrorism agents (Table). Because the first outbreaks of SARS and deaths occurred outside the United States, public concern in this country was intense, but short-lived. When the worldwide incidence of SARS declined this past spring, officials quickly declared victory. The June 18, 2003 edition of USA Today announced, “Experts: SARS Is Stopped.”5 This statement may be regretfully premature. It is extremely difficult to predict the course of a new epidemic disease, particularly one that is still being characterized. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, offered a cautionary note. “We still have the same conditions in China that led to the emergence of this epidemic, so there’s no reason to believe it’s not going to happen again,” he observed. “We’re just one case from the disease reappearing.”5 There are also historical reasons to worry. The influenza pandemic of 1918 to 1919 was a global disaster. First identified in Spain in February 1918, the disease was named “Spanish flu” or “La Grippe.” The initial outbreak in the United States occurred at a Kansas army camp in March 1918. Like many viral respiratory diseases, Spanish flu subsided with the onset of summer. Only isolated cases were identified over the next few months. The disease reemerged with explosive force in the autumn of 1918. The first major outbreaks in the United States occurred in Boston, MA, and Philadelphia, PA. By the time the Spanish flu ran its course, more than 25% of the US population had fallen ill, and 675,000 Americans had died. Worldwide, Spanish flu I N F E C T I O U S D I S E A S E / E D I T O R I A L

Study objective: 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. Methods: 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. Results: 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%. Conclusion: 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.

In Williamsburg, VA, April 17 to 20, 1994, the Josiah Macy, Jr. Foundation sponsored a conference entitled "The Role of Emergency Medicine in the Future of American Medical Care," a report on which was published in Annals in 1995. This report promulgated recommendations for the development and enhancement of academic departments of emergency medicine and a conference to develop an agenda for research in emergency medicine. The American College of Emergency Physicians' Research Committee, along with several ad hoc members, presents updates in several of the areas addressed by the Macy Report and subsequent conferences, as a status report for the development of emergency medicine research as a whole, as of late 2002. [ Ann Emerg Med. 2003;42:66-80.]

Study objective: We determine the proportion of unintended shootings that might be prevented by promoting safe storage, safe handling, and/or safer firearm designs. Methods: A regional firearm injury surveillance system was used to identify fatal and nonfatal unintentional shootings in a 5-county metropolitan area. Case reports were reviewed, and the causes of each shooting were independently classified by 4 members of the research team. A consensus conference was held to resolve disagreements. Results: Between May 1, 1996, and June 30, 2000, 216 cases of unintentional firearm injury were identified, 3.8% of the shootings documented during the study period. Six (2.8%) were fatal. The majority of victims were between 15 and 34 years of age. One fourth (54) of the shootings involved victims younger than 18 years. Handguns were involved in 87% of the incidents. Enough information was available to characterize the incident in 122 (57%) cases. All but 6 fell into 1 or more of 3 broad categories of causation: Child access (14%), mishandling (74%), and/or deficiencies in firearm design (32%). Conclusion: Many unintentional shootings could be prevented by promoting safe storage of guns in the home, promoting safe handling of firearms, and requiring that all new handguns incorporate basic safety features. [ Ann Emerg Med. 2003;41:10-17.]

Many state governments are seeking ways to cut Medicaid spending. Washington State has proposed to reduce beneficiaries' overuse of emergency departments by refusing to pay for “unnecessary” visits. However, primary care is often unavailable to these patients.