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Intimate partner violence (IPV) is a serious public health issue. This study aims to characterize IPV-related injuries in trauma patients presenting to emergency departments (ED) who required hospitalization.Trauma registries of two Level 1 trauma centers were searched for assault-related ED visits by adults reporting "abuse" over 3 and 5 years to identify IPV victims. Imaging and electronic medical records were reviewed for demographics, injury type, hospital stay, and previous or subsequent presentations for presumed IPV.Twenty-nine of 18,465 (0.2%) individuals seen on the trauma service had reported IPV. Majority were women (90%, mean age 37) and Caucasian (69%), over 50% had psychiatric or substance use comorbidities, and 45% reported prior IPV. Blunt trauma (22/29) was more common than penetrating trauma. Soft tissue injuries dominated when including both radiologic and non-radiologic findings. Excluding two patients who were not imaged, most frequent injuries identified on imaging were to the head/face (14/27), followed by the chest (9/27; mainly rib fractures), upper extremity and abdomen (7/27 each). All spinal fractures involved the upper lumbar spine. Synchronous injuries to multiple body regions were common, particularly craniofacial and upper extremity. Twenty-eight of 29 patients scored a grade 3-4 on the IPV severity grading scale. Eight (28%) patients required intensive care unit -level care. One patient passed. Four (14%) patients had prior IPV-related ED presentations.While craniofacial and soft tissue injuries dominate, IPV can also result in serious thoracoabdominal, extremity and spinal injuries, even death. Multisystem injuries are common with synchronous craniofacial and upper extremity injuries being the most common combination.

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Emergency department boarding and crowding lead to worse patient outcomes and patient satisfaction.We describe the implementation of a program to transfer patients requiring medical admission from an academic emergency department to a community hospital's medical floor and analyze its effects on patient outcomes.A prospective cohort study was performed. Data was collected on patient flow through the transfer program. Patient characteristics, boarding time in the emergency department, and hospital-based outcome measures were compared between patients in the transfer program who were successfully transferred to the community hospital and patients who were admitted to the academic medical center.79 patients were successfully transferred to the community hospital between November 23, 2020 and August 5, 2021, resulting in 279 bed days in the community hospital. Successfully transferred patients experienced a statistically shorter ED boarding time (5.7 vs. 10.9 h, p0.0001), ED length of stay (10.5 vs 16.1 h, p0.0001), and hospital length of stay (3.5 vs 5.7 days, p0.0001) compared to patients initially referred to the transfer program who were admitted to the academic medical center. There were no reported adverse events during transfer, upgrades to the ICU within 24 h of admission, or inpatient deaths for patients who were transferred.We implemented an academic emergency department to partner community hospital transfer program that safely level-loads medical patients in a healthcare system.

Objective: Sporting events often constitute mass gatherings (MGs) featuring large crowds of spectators and participants. Our objective is to understand the current state of emergency preparedness for sporting events by examining past MG sporting events to evaluate mitigation, preparedness, response, and recovery against chemical, biological, radiological, nuclear, and explosive (CBRNE) events.Methods: In accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, a systematic literature review was carried out among 10 literature databases. The quality and risk of bias in each reviewed publication was assessed using the Mixed Methods Appraisal Tool.Results: A total of 5,597 publications were identified. Of these, 81 papers were selected for full text reads and 25 publications were accepted. The included articles documented sporting events worldwide, ranging from incidents occurring from 1972 to 2020. Cross-cutting themes found in best practices and recommendations were strategic communication, surveillance, planning and preparedness, and training and response.Conclusion: More evidence-based guidelines are needed to ensure best practices in response and recovery for CBRNE incidents at sporting events. Public health risks as well as implementation barriers and opportunities to prepare for potential CBRNE threats at sporting event MGs require further investigation.

ImportanceThe absence of reliable hospital discharge data regarding the intent of firearm injuries (ie, whether caused by assault, accident, self-harm, legal intervention, or an act of unknown intent) has been characterized as a glaring gap in the US firearms data infrastructure.ObjectiveTo use incident-level information to assess the accuracy of intent coding in hospital data used for firearm injury surveillance.Design, Setting, and ParticipantsThis cross-sectional retrospective medical review study was conducted using case-level data from 3 level I US trauma centers (for 2008-2019) for patients presenting to the emergency department with an incident firearm injury of any severity.ExposuresClassification of firearm injury intent.Main Outcomes and MeasuresResearchers reviewed electronic health records for all firearm injuries and compared intent adjudicated by team members (the gold standard) with International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM) codes for firearm injury intent assigned by medical records coders (in discharge data) and by trauma registrars. Accuracy was assessed using intent-specific sensitivity and positive predictive value (PPV).ResultsOf the 1227 cases of firearm injury incidents seen during the ICD-10-CM study period (October 1, 2015, to December 31, 2019), the majority of patients (1090 [88.8%]) were male and 547 (44.6%) were White. The research team adjudicated 837 (68.2%) to be assaults. Of these assault incidents, 234 (28.0%) were ICD coded as unintentional injuries in hospital discharge data. These miscoded patient cases largely accounted for why discharge data had low sensitivity for assaults (66.3%) and low PPV for unintentional injuries (34.3%). Misclassification was substantial even for patient cases described explicitly as assaults in clinical notes (sensitivity of 74.3%), as well as in the ICD-9-CM study period (sensitivity of 77.0% for assaults and PPV of 38.0% for unintentional firearm injuries). By contrast, intent coded by trauma registrars differed minimally from researcher-adjudicated intent (eg, sensitivity for assault of 96.0% and PPV for unintentional firearm injury of 93.0%).Conclusions and RelevanceThe findings of this cross-sectional study underscore questions raised by prior work using aggregate count data regarding the accuracy of ICD-coded discharge data as a source of firearm injury intent. Based on our observations, researchers and policy makers should be aware that databases drawn from hospital discharge data (most notably, the Nationwide Emergency Department Sample) cannot be used to reliably count or characterize intent-specific firearm injuries.

Mass vaccination campaigns have been used effectively to limit the impact of communicable disease on public health. However, the scale of the coronavirus disease (COVID-19) vaccination campaign is unprecedented. Mass vaccination sites consolidate resources and experience into a single entity and are essential to achieving community (“herd”) immunity rapidly, efficiently, and equitably. Health care systems, local and regional public health entities, emergency medical services, and private organizations can rapidly come together to solve problems and achieve success. As medical directors at several mass vaccination sites across the United States, we describe key mass vaccination site concepts, including site selection, operational models, patient flow, inventory management, staffing, technology, reporting, medical oversight, communication, and equity. Lessons learned from experience operating a diverse group of mass vaccination sites will help inform not only sites operating during the current pandemic, but also may serve as a blueprint for future outbreaks of highly infectious communicable disease.

Although the Stop the Bleed campaign's impact is encouraging, gaps remain. These gaps include rapid skill decay, a lack of easy-to-use tourniquets for the untrained public, and training barriers that prevent scalability. A team of academic and industry partners developed the Layperson Audiovisual Assist Tourniquet (LAVA TQ)-the first audiovisual-enabled tourniquet for public use. LAVA TQ addresses known tourniquet application challenges and is novel in its design and technology.This study is a prospective, randomized, superiority trial comparing the ability of the untrained public to apply LAVA TQ to a simulated leg vs their ability to apply a Combat Application Tourniquet (CAT). The study team enrolled participants in Boston, MA; Frederick, MD; and Linköping, Sweden in 2022. The primary outcome was the proportion of successful applications of each tourniquet. Secondary outcomes included: mean time to application, placement position, reasons for failed application, and comfort with the devices.Participants applied the novel LAVA TQ successfully 93% (n = 66 of 71) of the time compared with 22% (n = 16 of 73) success applying CAT (relative risk 4.24 [95% CI 2.74 to 6.57]; p0.001). Participants applied LAVA TQ faster (74.1 seconds) than CAT (126 seconds ; p0.001) and experienced a greater gain in comfort using LAVA TQ than CAT.The untrained public is 4 times more likely to apply LAVA TQ correctly than CAT. The public also applies LAVA TQ faster than CAT and has more favorable opinions about its usability. LAVA TQ's highly intuitive design and built-in audiovisual guidance solve known problems of layperson education and skill retention and could improve public bleeding control.

Introduction Super-utilizers (patients with 4 or more emergency department [ED] visits a year) account for 10% to 26% of all ED visits and are responsible for a growing proportion of healthcare expenditures. Patients recognize the ED as a reliable provider of acute care, as well as a timely resource for diagnosis and treatment. The value of ED care is indisputable in critical and emergent conditions, but in the case of non-urgent conditions, ED utilization may represent an inefficiency in the healthcare system. We sought to identify patient and clinical characteristics associated with ED super-utilization in a universally insured population. Material and Methods We performed a retrospective cohort study using TRICARE claims data from the Military Health System Data Repository (2011-2015). We reviewed the claims data of all adult patients (aged 18-64 years) who had at least one encounter at the ED for any cause. Multivariable logistic regression was used to determine independent factors associated with ED super-utilization. Results Factors associated with increased odds of ED super-utilization included Charlson Score ≥2 (adjusted odds ratio [aOR] 1.98, 95% confidence interval [CI]: 1.90-2.06), being eligible for Medicare (aOR 1.95, 95% CI: 1.90-2.01), and female sex (aOR 1.35, 95% CI: 1.33-1.37). Active duty service members (aOR 0.69, 95% CI 0.68-0.72) and beneficiaries with higher sponsor-rank (Officers: aOR 0.50, 95% CI: 0.55-0.57; Senior enlisted: aOR 0.82, 95% CI: 0.81-0.83) had lower odds of ED super-utilization. The most common primary diagnoses for ED visits among super-utilizers were abdominal pain, headache and migraine, chest pain, urinary tract infection, nausea and vomiting, and low back pain. Conclusions Risk of ED super-utilization appears to increase with age and diminished health status. Patient demographic and clinical characteristics of ED super-utilization identified in this study can be used to formulate healthcare policies addressing gaps in primary care in diagnoses associated with ED super-utilization and develop interventions to address modifiable risk factors of ED utilization.

This study describes the detection, mitigation, and analysis of a large cluster of SARS-CoV-2 infections in an acute care hospital with mature infection control policies and discusses insights that may inform additional measures to protect patients and staff., Visual Abstract. SARS-CoV-2 Cluster in an Acute Care Hospital This study describes the detection, mitigation, and analysis of a large cluster of SARS-CoV-2 infections in an acute care hospital with mature infection control policies and discusses insights that may inform additional measures to protect patients and staff. Visual Abstract. SARS-CoV-2 Cluster in an Acute Care Hospital This study describes the detection, mitigation, and analysis of a large cluster of SARS-CoV-2 infections in an acute care hospital with mature infection control policies and discusses insights that may inform additional measures to protect patients and staff., Background: Little is known about clusters of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in acute care hospitals. Objective: To describe the detection, mitigation, and analysis of a large cluster of SARS-CoV-2 infections in an acute care hospital with mature infection control policies. Design: Descriptive study. Setting: Brigham and Women's Hospital, Boston, Massachusetts. Participants: Patients and staff with cluster-related SARS-CoV-2 infections. Intervention: Close contacts of infected patients and staff were identified and tested every 3 days, patients on affected units were preemptively isolated and repeatedly tested, affected units were cleaned, room ventilation was measured, and specimens were sent for whole-genome sequencing. A case–control study was done to compare clinical interactions, personal protective equipment use, and breakroom and workroom practices in SARS-CoV-2–positive versus negative staff. Measurements: Description of the cluster, mitigation activities, and risk factor analysis. Results: Fourteen patients and 38 staff members were included in the cluster per whole-genome sequencing and epidemiologic associations. The index case was a symptomatic patient in whom isolation was discontinued after 2 negative results on nasopharyngeal polymerase chain reaction testing. The patient subsequently infected multiple roommates and staff, who then infected others. Seven of 52 (13%) secondary infections were detected only on second or subsequent tests. Eight of 9 (89%) patients who shared rooms with potentially contagious patients became infected. Potential contributing factors included high viral loads, nebulization, and positive pressure in the index patient's room. Risk factors for transmission to staff included presence during nebulization, caring for patients with dyspnea or cough, lack of eye protection, at least 15 minutes of exposure to case patients, and interactions with SARS-CoV-2–positive staff in clinical areas. Whole-genome sequencing confirmed that 2 staff members were infected despite wearing surgical masks and eye protection. Limitation: Findings may not be generalizable. Conclusion: SARS-CoV-2 clusters can occur in hospitals despite robust infection control policies. Insights from this cluster may inform additional measures to protect patients and staff. Primary Funding Source: None.

In the late 1980s, the hospital emergency incident command system (now HICS) was developed to align with the National Interagency Incident Management System, the federal plan for improving coordination among agencies in a broad range of large-scale emergencies 2 As HICS have been deployed over recent decades, we have deepened our understanding of the strengths and weaknesses of their structure for addressing the needs of diverse populations Recurrent experiences with large-scale disasters, including the COVID-19 pandemic and Hurricanes Katrina, Maria, Harvey, and Sandy, have underscored the ways in which health care responses, emergency preparedness, and broader social determinants of health lead to preventable morbidity and mortality in marginalized communities 3 Here we share the case for embedding an equity element in HICS, our institutional experiences in operationalizing equity, and our recommendation for a structural change in the national HICS guidelines: including a defined equity officer (EO) and subject matter experts in health care equity to ensure that actions are taken to improve outcomes for diverse groups during public health emergencies or disasters The absence of equity as an emergency management principle in responses to COVID-19 has resulted in a slow and incomplete hospital response to the disproportionate mortality and morbidity in several historically marginalized populations 4 For example, hospitals have access to detailed information on the demographic composition of their inpatient populations, the ability to screen patients for social needs, and the opportunity to conduct coordinated community outreach to address the needs of communities of color through HICS infrastructure An after-action review is a structured process developed by the US Army to identify strengths and weaknesses in event response 10 This concept has been adapted as a critical step after public health emergencies to gather information on quantitative and qualitative issues to improve preparedness, mitigation, response, and recovery for future incidents 11 Our institution has conducted several after-action reviews within the past decade after local events including the Boston Marathon bombings and an active shooter incident in our hospital 1214 We have also facilitated reviews in the wake of other large-scale events such as the urban terror attacks in Paris and Brussels 15 Since our initial patient surge in Boston, Massachusetts, in April 2020 (and given the concern for future surges), we have conducted several debriefings with more than 150 staff members across an academic medical center and community hospital within our larger multihospital health care system

Introduction Total hip arthroplasty and total knee arthroplasty account for over 1 million procedures annually. Opioids are the mainstay of postoperative pain management for these patients. In this context, the objective of this study was to determine patterns of use and factors associated with early discontinuation of opioids after total joint arthroplasty (TJA). Methods TRICARE claims data (2006-2014) were queried for adult (18-64 years) patients who underwent total hip arthroplasty or total knee arthroplasty. Prescription opioid use was identified from 6 months before and 6 months after surgical intervention. Prior opioid use was categorized as naïve, exposed (with non-sustained use), and sustained (6 month continuous use before surgery). Cox proportional-hazards models were used to identify factors associated with opioid discontinuation following TJA. Results Among the 29,767 patients included in the study, 15,271 (51.3%) had prior opioid exposure and 3,740 (12.5%) were sustained opioid users. At 6 months after the surgical intervention, 3,171 (10.6%) continued opioid use, 3.3% were among opioid naïve, 10.2% among exposed, and 33.3% among sustained users. In risk-adjusted models, prior opioid exposure (hazards ratio: 0.65, 95% CI: 0.62-0.67) and sustained prior use (hazards ratio: 0.33, 95% CI: 0.31-0.35) were the strongest predictors of lower likelihood of opioid discontinuation. Lower socio-economic status, depression, and anxiety were also strong predictors. Conclusion Prior opioid exposure was strongly associated with continued opioid dependence after TJA. Although one-third of prior sustained users continued use after surgery, approximately 10% of previously exposed patients became sustained users, making them the prime candidates for targeted interventions to reduce the likelihood of sustained opioid use after TJA.

Background Traditional, instructor led, in-person training of CPR skills has become more challenging due to COVID-19 pandemic. We compared the learning outcomes of standard in-person CPR training (ST) with alternative methods of training such as hybrid or online-only training (AT) on CPR performance, quality, and knowledge among laypersons with no previous CPR training. Methods We searched PubMed and Google Scholar for relevant articles from January 1995 to May 2020. Covidence was used to review articles by two independent researchers. Effective Public Health Practice Project (EPHPP) Quality Assessment Tool was used to assess quality of the manuscripts. Results Of the 978 articles screened, twenty met the final inclusion criteria. All included studies had an experimental design and moderate to strong global quality rating. The trainees in ST group performed better on calling 911, time to initiate chest compressions, hand placement and chest compression depth. Trainees in AT group performed better in assessing scene safety, calling for help, response time including initiating first rescue breathing, adequate ventilation volume, compression rates, shorter hands-off time, confidence, willingness to perform CPR, ability to follow CPR algorithm, and equivalent or better knowledge retention than standard teaching methodology. Conclusion AT methods of CPR training provide an effective alternative to the standard in-person CPR for large scale public training.

ImportanceInternational Classification of Diseases–coded hospital discharge data do not accurately reflect whether firearm injuries were caused by assault, unintentional injury, self-harm, legal intervention, or were of undetermined intent. Applying natural language processing (NLP) and machine learning (ML) techniques to electronic health record (EHR) narrative text could be associated with improved accuracy of firearm injury intent data.ObjectiveTo assess the accuracy with which an ML model identified firearm injury intent.Design, Setting, and ParticipantsA cross-sectional retrospective EHR review was conducted at 3 level I trauma centers, 2 from health care institutions in Boston, Massachusetts, and 1 from Seattle, Washington, between January 1, 2000, and December 31, 2019; data analysis was performed from January 18, 2021, to August 22, 2022. A total of 1915 incident cases of firearm injury in patients presenting to emergency departments at the model development institution and 769 from the external validation institution with a firearm injury code assigned according to International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification (ICD-10-CM), in discharge data were included.ExposuresClassification of firearm injury intent.Main Outcomes and MeasuresIntent classification accuracy by the NLP model was compared with ICD codes assigned by medical record coders in discharge data. The NLP model extracted intent-relevant features from narrative text that were then used by a gradient-boosting classifier to determine the intent of each firearm injury. Classification accuracy was evaluated against intent assigned by the research team. The model was further validated using an external data set.ResultsThe NLP model was evaluated in 381 patients presenting with firearm injury at the model development site (mean [SD] age, 39.2 [13.0] years; 348 [91.3%] men) and 304 patients at the external development site (mean [SD] age, 31.8 [14.8] years; 263 [86.5%] men). The model proved more accurate than medical record coders in assigning intent to firearm injuries at the model development site (accident F-score, 0.78 vs 0.40; assault F-score, 0.90 vs 0.78). The model maintained this improvement on an external validation set from a second institution (accident F-score, 0.64 vs 0.58; assault F-score, 0.88 vs 0.81). While the model showed some degradation between institutions, retraining the model using data from the second institution further improved performance on that site’s records (accident F-score, 0.75; assault F-score, 0.92).Conclusions and RelevanceThe findings of this study suggest that NLP ML can be used to improve the accuracy of firearm injury intent classification compared with ICD-coded discharge data, particularly for cases of accident and assault intents (the most prevalent and commonly misclassified intent types). Future research could refine this model using larger and more diverse data sets.

Rib fractures are painful injuries that are treated with aggressive analgesia, which can include opioids. We sought to evaluate the patterns and predictors of opioid prescription and sustained use for rib fracture patients to identify opportunities for opiate reduction.We used TRICARE claims data (2006-2014) to identify adult (18-64 years) patients presenting to the emergency department with rib fracture(s) and isolated chest trauma. We used logistic regression and Cox proportional hazards model to identify factors associated with opioid prescription and duration of use.We identified 29,943 patients meeting inclusion criteria, and 2,542 (9%) patients were prescribed opioids. When prescribed, the median duration opioid use was 16 days (interquartile range 6-31) for opioid naïve patients, compared with 36 days (interquartile range 15-134) for those with prior opioid exposure. Increased number of ribs fractured (6+ fractures) (odds ratio 2.96 [95% confidence interval 2.23-3.94], P.001) and prior opioid exposure (odds ratio 32.95 [29.36-36.99], P.001) were significant predictors of initial opioid prescription. Patients with prior opioid exposure (hazard ratio 0.47 [0.43-0.52], P.001) had lower likelihood of opioid discontinuation. Injury characteristics did not significantly predict discontinuation.Prior opioid exposure was the strongest predictor of sustained opioid use after rib fractures, while the severity of injury did not predict the duration of use.

Background Low hospital volume for emergency general surgery (EGS) procedures is associated with worse patient outcomes within the civilian health care system. The military maintains treatment facilities (MTFs) in remote locations to provide access to service members and their families. We sought to determine if patients treated at low-volume MTFs for EGS conditions experience worse outcomes compared with high-volume centers. Materials and methods We analyzed TRICARE data from 2006 to 2014. Patients were identified using an established coding algorithm for EGS admission. MTFs were divided into quartiles based on annual EGS volume. Outcomes included 30-d mortality, complications, and readmissions. Logistic regression models adjusting for clinical and sociodemographic differences in case-mix including EGS condition, surgical intervention, and comorbidities were used to determine the influence of hospital volume on outcomes. Results We identified 106,915 patients treated for an EGS condition at 79 MTFs. The overall mortality rate was 0.21%, with complications occurring in 8.55% and readmissions in 4.45%. After risk adjustment, lowest-volume MTFs did not demonstrate significantly higher odds of mortality (OR: 2.02, CI: 0.45-9.06) or readmissions (OR: 0.77, CI: 0.54-1.11) compared with the highest-volume centers. Lowest-volume facilities exhibited a lower likelihood of complications (OR: 0.76, CI: 0.59-0.98). Conclusions EGS patients treated at low-volume MTFs did not experience worse clinical outcomes when compared with high-volume centers. Remote MTFs appear to provide care for EGS conditions comparable with that of high-volume facilities. Our findings speak against the need to reduce services at small, critical access facilities within the military health care system.

To inform research on developing or adopting leadership competency frameworks for use in U.S. undergraduate medical education (UME), this scoping review describes the content of U.S. UME leadership curricula, associated competency frameworks, and content delivery.The authors searched PubMed, Embase, and ERIC databases on June 22, 2020. They included English-language studies that described U.S. UME curricula in which the primary end goal was leadership development. They excluded studies published before January 1, 2000. Data were extracted on leadership competency frameworks and curricular content, audience, duration, electivity, selectivity, learning pedagogies, and outcome measures. The curricular content was coded and categorized within the Medical Leadership Competency Framework (MLCF) using the constant comparative method. A repeated search of the literature on May 14, 2021, did not yield any additional studies.Of 1,094 unique studies, 25 studies reporting on 25 curricula met inclusion criteria. The course content of the curricula was organized into 91 distinct themes, most of which could be organized into the first 2 competencies of the MLCF: Demonstrating Personal Qualities and Working With Others. Thirteen curricula (52%) aligned with leadership competency frameworks, and 12 (48%) did not appear to use a framework. Number of participants and target learner level varied widely, as did curricula duration, with fewer than half (n = 12, 48%) spanning more than 1 semester. Most curricula (n = 14, 56%) were elective, and many (n = 16, 64%) offered experiential learning. Most studies (n = 16, 64%) reported outcomes as student perception data.The authors found wide variation in content of U.S. UME leadership development curricula, and few curricula aligned with an established leadership competency framework. The lack of professional consensus on the scope of medical leadership and how it should be taught thwarts effective incorporation of medical leadership training within UME.

Despite concerns about long-term dependence, opioids remain the mainstay of treatment for acute pain from traumatic injuries. Additionally, early pain management has been associated with improved long-term outcomes in injured patients. We sought to identify the patterns of prehospital pain management across the United States.We used 2019 national emergency medical services (EMS) data to identify the use of pain management for acutely injured patients. Opioid specific dosing was calculated in morphine milligram equivalents (MME). The effects of opioids as well as adverse events were identified through objective patient data and structured provider documentation.We identified a total of 3,831,768 injured patients, 85% of whom were treated by an advanced life support (ALS) unit. There were 269,281 (7.0%) patients treated with opioids, including a small number of patients intubated by EMS (n = 1537; 0.6%). The median opioid dose was 10 MME [IQR 5-10] and fentanyl was the most commonly used opioid (88.2%). Patients treated with opioids had higher initial pain scores documented by EMS than those not receiving opioids (median: 9 vs 4, p0.001), and had a median reduction in pain score of 3 points (IQR 1-5) based on the final prehospital pain score. Adverse events associated with opioid administration, including episodes of altered mental status (n = 453; 0.2%) and respiratory compromise (n = 252; 0.1%), were rare. For patients with severe pain (≥8/10), 27.3% of patients with major injuries (ISS ≥15) were treated with opioids, compared with 24.8% of those with moderate injuries (ISS 9-14), and 21.4% of those with minor (ISS 1-8) injuries (p0.001).The use of opioids in the prehospital setting significantly reduced pain among injured patients with few adverse events. Despite its efficacy and safety, the majority of patients with major injuries and severe pain do not receive opioid analgesia in the prehospital setting.

This Viewpoint discusses the potential for use of nonconventional warfare threats (chemical, biological, radiological, nuclear, and explosives) in the conflict in Ukraine and how health care professionals need to recognize and respond to these threats.

BACKGROUND The National Academies of Sciences, Engineering, and Medicine 2016 trauma system report recommended a National Trauma Research Action Plan (NTRAP) to strengthen and guide future trauma research. To address this recommendation, 11 expert panels completed a Delphi survey process to create a comprehensive research agenda, spanning the continuum of trauma care. We describe the gap analysis and high priority research questions generated from the NTRAP panel on prehospital and mass casualty trauma care. METHODS We recruited interdisciplinary national experts to identify gaps in the prehospital and mass casualty trauma evidence base and generate prioritized research questions using a consensus-driven Delphi survey approach. We included military and civilian representatives. Panelists were encouraged to use the PICO (Patient/Population, Intervention, Compare/Control, and Outcome) format to generate research questions. We conducted four Delphi rounds in which participants generated key research questions and then prioritized the questions on a 9-point Likert scale to low, medium, and high priority items. We defined consensus as ≥60% agreement on the priority category and coded research questions using a taxonomy of 118 research concepts in 9 categories. RESULTS 31 interdisciplinary subject matter experts generated 490 research questions, of which 433 (88%) reached consensus on priority. The rankings of the 433 questions were: 81 (19%) high priority, 339 (78%) medium priority, and 13 (3%) low priority. Among the 81 high priority questions, there were 46 taxonomy concepts, including: health systems of care (36 questions), interventional clinical trials and comparative effectiveness (32 questions), mortality as an outcome (30 questions); prehospital time/transport mode/level of responder (24 questions), system benchmarks (17 questions), and fluid/blood product resuscitation (17 questions).Conclusions This Delphi gap analysis of prehospital and mass casualty care identified 81 high priority research questions to guide investigators and funding agencies for future trauma research. LEVEL OF EVIDENCE not applicable.

In the US, racial disparities in outcomes following coronary artery bypass grafting (CABG) are well documented. TRICARE insurance data represent a large population with universal insurance that allows for the robust assessment of the impact of such insurance on disparities in health care. This study examined racial differences in specific aspects of surgical care quality following CABG, using metrics endorsed by the National Quality Forum that included the prescription of beta-blockers and statins at discharge and thirty-day readmissions. There were no risk-adjusted differences in outcomes between African American and white patients insured through TRICARE. Our study provides a window into the potential impacts of universal insurance and an equal-access health care system on racial disparities in surgical care quality following CABG.

Background Index length of stay (LOS) and readmissions are viewed as important quality measures. However, these metrics represent competing demands as an inordinate reduction in LOS may lead to unplanned readmissions. We sought to assess the optimal LOS associated with the lowest 90-d readmission rate following discharge after common surgical procedures. Materials and methods This was a retrospective study relying on Tricare claims. We identified all eligible adult patients (18-64 y) receiving a series of common surgical procedures between 2006 and 2014. We used a generalized additive model with spline regression to determine the optimal LOS associated with the lowest 90-d risk of readmission. Results Ninety-day readmission rates varied from 6.03% to 34.69%. Most procedures exhibited a logit linear relationship, with the lowest risk of readmission evident on postoperative day-1 and increasing thereafter. Among the more invasive procedures (e.g., esophagectomy and radical cystectomy), a U-shaped relationship was realized, indicating that expedited discharge would increase the potential for readmission as would any extended hospital LOS. For these procedures, the ideal index LOS appeared to be 6-7 d for radical cystectomy and 12-13 d for esophagectomy. Conclusions Our results support the practice of discharging patients as soon as clinically feasible after hip and knee arthroplasty, lumbar spine surgery, hernia repair, appendectomy, nephrectomy, and colectomy. Among esophagectomy or radical cystectomy, there is a well-defined optimal index admission period and discharge outside this window appears to be detrimental. Our results suggest that invasive procedures appear to possess a unique “signature” when it comes to optimal LOS.

Objective:The Society of Academic Emergency Medicine Disaster Medicine Interest Group, the Office of the Assistant Secretary for Preparedness and Response – Technical Resources, Assistance Center, and Information Exchange (ASPR TRACIE) team, and the National Institutes of Health Library searched disaster medicine peer-reviewed and gray literature to identify, review, and disseminate the most important new research in this field for academics and practitioners.Methods:MEDLINE/PubMed and Scopus databases were searched with key words. Additional gray literature and focused hand search were performed. A Level I review of titles and abstracts with inclusion criteria of disaster medicine, health care system, and disaster type concepts was performed. Eight reviewers performed Level II full-text review and formal scoring for overall quality, impact, clarity, and importance, with scoring ranging from 0 to 20. Reviewers summarized and critiqued articles scoring 16.5 and above.Results:Articles totaling 1176 were identified, and 347 were screened in a Level II review. Of these, 193 (56%) were Original Research, 117 (34%) Case Report or other, and 37 (11%) were Review/Meta-Analysis. The average final score after a Level II review was 11.34. Eighteen articles scored 16.5 or higher. Of the 18 articles, 9 (50%) were Case Report or other, 7 (39%) were Original Research, and 2 (11%) were Review/Meta-Analysis.Conclusions:This first review highlighted the breadth of disaster medicine, including emerging infectious disease outbreaks, terror attacks, and natural disasters. We hope this review becomes an annual source of actionable, pertinent literature for the emerging field of disaster medicine.

In a decade, the US military reduced deaths from uncontrolled bleeding on the battlefield by 67%. This success, coupled with an increased incidence of mass shootings in the US, has led to multiple initiatives intent on translating hemorrhage-control readiness to the civilian sector. However, the best method to achieve widespread population-level hemorrhage-control readiness for civilians has not yet been elucidated. This study evaluates the implementation of American College of Surgeons Bleeding Control training at a National Football League stadium as a prospective model for general mass gathering site implementation.The American College of Surgeons' Bleeding Control Basic layperson hemorrhage-control training was implemented at Gillette Stadium in Massachusetts. The five domains are as follows: reach (demographics of study participants), effectiveness (correct tourniquet application after intervention), adoption (investigator, leadership, and participant efforts for sustainability of intervention), implementation (course details), and maintenance (correct tourniquet application at retention testing at 3 to 9 months).A total of 562 employees were included in the study. Of those included employees, 58.7% reported having taken first-aid training and 17.3% reported having taken hemorrhage-control training. There was an increased mean likelihood to help (4.39 vs 4.09, P.01) and comfort level to control hemorrhage (4.26 vs 3.60, P.01) after training compared with before training, on a Likert scale (1-5). The stadium operations team located hemorrhage control kits with automatic external defibrillators, integrated layperson immediate-response awareness into its Web site, and developed a public safety announcement. The training, performed by physicians, nurses, and emergency medical technicians, consisted of a 30-minute lecture and a 30-minute hands-on skills-training course, with a class size of 24. The total number of sessions was 24.Achieving initial hemorrhage-control readiness and maintenance at a mass gathering site through American College of Surgeons Bleeding Control training is feasible but requires significant commitment from training staff, site leadership, and financial resources.

In response to increasing violent attacks, the Stop the Bleed campaign recommends that everyone have access to both personal and public bleeding-control kits. There are currently no guidelines about how many bleeding victims public sites should be equipped to treat during a mass casualty incident. We conducted a retrospective review of intentional mass casualty incidents, including shootings, stabbings, vehicle attacks, and bombings, to determine the typical number of people who might benefit from immediate hemorrhage control by a bystander before professional medical help arrives. On the basis of our analysis, we recommend that planners at public venues consider equipping their sites with supplies to treat a minimum of 20 bleeding victims during an intentional mass casualty incident.

Application of extremity tourniquets is a central tenet of multiple national initiatives to empower laypersons to provide hemorrhage control (HC). However, the efficacy of the general population who self-report prior first-aid (FA) or HC training on individual's ability to control bleeding with a tourniquet remains unknown. Therefore, the objective of this study was to assess the effectiveness of laypeople with self-reported prior FA or HC training to control bleeding with a tourniquet.Employees of a stadium were assessed via simulation in their ability to apply a Combat Application Tourniquet. As a subgroup analysis of a larger study, participants who self-reported: 1) No prior training, 2) FA training only or 2) FA + HC training were compared. Logistic regression adjusting for age, gender, education, willingness-to-assist, and comfort level in HC was performed.317 participants were included. Compared to participants with no prior training (14.4%,n = 16/111), those with FA training only (25.2%,n = 35/139) had a 2.12-higher odds (95%CI:1.07-4.18) of correct tourniquet application while those with FA + HC (35.8%,n = 24/67) had a 3.50-higher odds (95%CI:1.59-7.72) of correct application. Participants with prior FA + HC were more willing-to-assist and comfortable performing HC than those without prior training (p 0.05). However, reporting being very willing-to-assist [OR0.83,95%CI:0.43-1.60] or very comfortable [OR1.11,95%CI:0.55-2.25] was not associated with correct tourniquet application.Self-reported prior FA + HC training, while associated with increased likelihood to correctly apply a tourniquet, results in only 1/3 of individuals correctly performing the skill. As work continues in empowering and training laypeople to act as immediate responders, these findings highlight the importance of effective layperson education techniques.

Background Reports published directly after terrorist mass casualty incidents frequently fail to capture difficulties that may have been encountered. An anonymised consensus-based platform may enable discussion and collaboration on the challenges faced. Our aim was to identify where to focus improvement for future responses. Methods We conducted a mixed methods study by email of clinicians' experiences of leading during terrorist mass casualty incidents. An initial survey identified features that worked well, or failed to, during terrorist mass casualty incidents plus ongoing challenges and changes that were implemented as a result. A follow-up, quantitative survey measured agreement between responses within each of the themes using a Likert scale. Results Thirty-three participants responded from 22 hospitals that had received casualties from a terrorist incident, representing 17 cities in low-middle, middle and high income countries. The first survey identified themes of sufficient (sometimes abundant) human resource, although coordination of staff was a challenge. Difficulties highlighted were communication, security, and management of blast injuries. The most frequently implemented changes were education on specific injuries, revising future plans and preparatory exercises. Persisting challenges were lack of time allocated to training and psychological well-being. The follow-up survey recorded highest agreement amongst correspondents on the need for re-triage at hospital (90% agreement), coordination roles (85% agreement), flexibility (100% agreement), and large-scale exercises (95% agreement). Conclusion This survey collates international experience gained from clinicians managing terrorist mass casualty incidents. The organisation of human response, rather than consumption of physical supplies, emerged as the main finding. NHSH Clinical Effectiveness Unit project registration number: 2020/21–036.

Emergency department (ED) crowding is recognized as a critical threat to patient safety, while sub‐optimal ED patient flow also contributes to reduced patient satisfaction and efficiency of care. Provider in triage (PIT) programs—which typically involve, at a minimum, a physician or advanced practice provider conducting an initial screening exam and potentially initiating treatment and diagnostic testing at the time of triage—are frequently endorsed as a mechanism to reduce ED length of stay (LOS) and therefore mitigate crowding, improve patient satisfaction, and improve ED operational and financial performance. However, the peer‐reviewed evidence regarding the impact of PIT programs on measures including ED LOS, wait times, and costs (as variously defined) is mixed. Mechanistically, PIT programs exert their effects by initiating diagnostic work‐ups earlier and, sometimes, by equipping triage providers to directly disposition patients. However, depending on local contextual factors—including the co‐existence of other front‐end interventions and delays in ED throughput not addressed by PIT—we demonstrate how these features may or may not ultimately translate into reduced ED LOS in different settings. Consequently, site‐specific analysis of the root causes of excessive ED LOS, along with mechanistic assessment of potential countermeasures, is essential for appropriate deployment and successful design of PIT programs at individual EDs. Additional motivations for implementing PIT programs may include their potential to enhance patient safety, patient satisfaction, and team dynamics. In this conceptual article, we address a gap in the literature by demonstrating the mechanisms underlying PIT program results and providing a framework for ED decision‐makers to assess the local rationale for, operational feasibility of, and financial impact of PIT programs.

Summary: Many US states published crisis standards of care (CSC) guidelines for allocating scarce critical care resources during the COVID-19 pandemic. However, the performance of these guidelines in maximizing their population benefit has not been well tested. In 2,272 adults with COVID-19 requiring mechanical ventilation drawn from the Study of the Treatment and Outcomes in Critically Ill Patients with COVID-19 (STOP-COVID) multicenter cohort, we test the following three approaches to CSC algorithms: Sequential Organ Failure Assessment (SOFA) scores grouped into ranges, SOFA score ranges plus comorbidities, and a hypothetical approach using raw SOFA scores not grouped into ranges. We find that area under receiver operating characteristic (AUROC) curves for all three algorithms demonstrate only modest discrimination for 28-day mortality. Adding comorbidity scoring modestly improves algorithm performance over SOFA scores alone. The algorithm incorporating comorbidities has modestly worse predictive performance for Black compared to white patients. CSC algorithms should be empirically examined to refine approaches to the allocation of scarce resources during pandemics and to avoid potential exacerbation of racial inequities.

Mass-Vaccination Sites Covid-19 vaccination poses challenges that complicate the traditional reliance on primary care delivery. Mass-vaccination sites offer a logical solution, and early adopters h...

Disasters have many deleterious effects and are becoming more frequent. From a health-care perspective, disasters may cause periods of stress for hospitals and health-care systems. Telemedicine is a rapidly growing technology that has been used to improve access to health-care during disasters. Telemedicine applied in disasters is referred to as disaster telemedicine. Our objective was to conduct a scoping literature review on current use of disaster telemedicine to develop recommendations addressing the most common barriers to implementation of a telemedicine system for regional disaster health response in the United States. Publications on telemedicine in disasters were collected from online databases. This included both publications in English and those translated into English. Predesigned inclusion/exclusion criteria and a PRISMA flow diagram were applied. The PRISMA flow diagram was used on the basis that it would help streamline the available literature. Literature that met the criteria was scored by 2 reviewers who rated relevance to commonly identified disaster telemedicine implementation barriers, as well as how disaster telemedicine systems were implemented. We also identified other frequently mentioned themes and briefly summarized recommendations for those topics. Literature scoring resulted in the following topics: telemedicine usage (42 publications), system design and operating models (43 publications), as well as difficulties with credentialing (5 publications), licensure (6 publications), liability (4 publications), reimbursement (5 publications), and technology (24 publications). Recommendations from each category were qualitatively summarized.

Current mass casualty incident (MCI) response in the United States calls for rapid deployment of first responders, such as law enforcement, fire, and emergency medical services personnel, to the incident and simultaneous activation of trauma center disaster protocols. Past investigations demonstrated that the incorporation of advanced trauma-trained physicians and paramedics into prehospital teams resulted in improved mortality during routine emergency medical care in Europe and in the combat setting. To date, limited research exists on the incorporation of advanced trauma-trained physicians and paramedics into prehospital teams for civilian MCIs. We proposed the concept of Special Medical Response Teams, which would rapidly deploy advanced trauma-trained physicians and paramedics to deliver a higher level of medical and surgical care in the prehospital setting during civilian mass casualty incidents.

Purpose Management of an acute shortage of parenteral opioid products at a large hospital through prescribing interventions and other guideline-recommended actions is described. Summary In early 2018, many hospitals were faced with a shortage of parenteral opioids that was predicted to last an entire year. The American Society of Health-System Pharmacists (ASHP) has published guidelines on managing drug product shortages. This article describes the application of these guidelines to manage the parenteral opioid shortage and the impact on opioid dispensing that occurred in 2018. Our approach paralleled that recommended in the ASHP guidelines. Daily dispensing reports generated from automated dispensing cabinets and from the electronic health record were used to capture dispenses of opioid medications. Opioid prescribing and utilization data were converted to morphine milligram equivalents (MME) to allow clinical leaders and hospital administrators to quickly evaluate opioid inventories and consumption. Action steps included utilization of substitute opioid therapies and conversion of opioid patient-controlled analgesia (PCA) and opioid infusions to intravenous bolus dose administration. Parenteral opioid supplies were successfully rationed so that surgical and elective procedures were not canceled or delayed. During the shortage, opioid dispensing decreased in the inpatient care areas from approximately 2.0 million MME to 1.4 million MME and in the operating rooms from 0.56 MME to 0.29 million MME. The combination of electronic health record alerts, increased utilization of intravenous acetaminophen and liposomal bupivacaine, and pharmacist interventions resulted in a 67% decline in PCA use and a 65% decline in opioid infusions. Conclusion A multidisciplinary response is necessary for effective management of drug shortages through implementation of strategies and practices for notifying clinicians of shortages and identifying optimal alternative therapies.

Background Nearly four million Americans present to hospitals with conditions requiring emergency general surgery annually, facing significant morbidity and mortality. Unlike elective surgery and trauma, there is no dedicated national quality improvement program to improve Emergency General Surgery (EGS) outcomes. Our objective is to estimate the number of excess deaths that could potentially be averted through EGS quality improvement in the United States. Methods Adults with the American Association for the Surgery of Trauma-defined EGS diagnoses were identified in the Nationwide Emergency Department Sample 2006-2014. Hierarchical logistic regression was performed to benchmark treating hospitals into reliability adjusted mortality quintiles. Weighted generalized linear modeling was used to calculate the relative-risk of mortality at each hospital quintile, relative to best-performing quintile. We then calculated the number of excess deaths at each hospital quintile versus the best-performing quintile using techniques previously used to quantify potentially preventable trauma deaths. Results Twenty six million EGS patients were admitted and 6.5 million (25%) underwent an operation. In-hospital mortality varied from 0.3% to 4.1% across the treating hospitals. Relative to the best performing hospital quintile, an estimated 158,177 (153,509-162-736) excess EGS deaths occurred at lower-performing hospital quintiles. Overall, 47% of excess deaths occurred at the worst-performing hospitals, while 27% of all excess deaths occurred among the operative cohort.Conclusion:Nearly 200,000 excess EGS deaths occur across the US each decade. A national initiative to enable structures and processes-of-care associated with optimal EGS outcomes is urgently needed to achieve "Zero Preventable Deaths after Emergency General Surgery." Level of evidence III, epidemiological.

Introduction Emergency department (ED) utilization represents an expensive and growing means of accessing care for a variety of conditions. Prior studies have characterized ED utilization in the general population. We aim to identify the clinical conditions that drive ED utilization in a universally insured population and the impacts of care setting on ED use and admissions in the U.S. Military Health System. Methods We queried TRICARE claims data from October 1, 2012, to September 30, 2015, to identify all ED visits for adult patients (age 18-64). The primary presenting diagnoses of all ED visits and those leading to admission are presented with descriptive statistics. Logistic regression was used to identify clinical and sociodemographic factors associated with admission from the ED. Results A total of 4,687,205 ED visits were identified, of which 46% took place in the DoD healthcare facilities (direct care). The most common diagnoses across all ED visits were abdominal pain, chest pain, headache, nausea and vomiting, and urinary tract infection. A total of 270,127 (5.8%) ED visits led to inpatient admission. The most common diagnoses leading to admission were chest pain, abdominal pain, depression, conditions relating to acute psychological stress, and pneumonia. For patients presenting with 1 of the 10 most common ED diagnoses, those who were seen at a civilian ED were significantly less likely to be admitted (3.4%) compared to direct care facilities (4.1%) in an adjusted logistic regression model (Adjusted Odds Ratio 0.40 [95% CI: 0.40-0.41], P Conclusions Ultimately, we show that abdominal pain and chest pain are the most common reasons for presentation to the ED in the Military Health System and the most common presenting diagnoses for admission from the ED. Among patients presenting with the most common ED conditions, direct care EDs were significantly more likely to admit patients than civilian facilities.