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Bacong AM, Chu R, Le A, Bui V, Wang NE, Palaniappan LP. Increased COVID-19 mortality among immigrants compared with US-born individuals: a cross-sectional analysis of 2020 mortality data. Public Health 2024; 231:173-178. [PMID: 38703491 DOI: 10.1016/j.puhe.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/28/2024] [Accepted: 03/20/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVE Multiple studies have shown that racially minoritized groups had disproportionate COVID-19 mortality relative to non-Hispanic White individuals. However, there is little known regarding mortality by immigrant status nationally in the United States, despite being another vulnerable population. STUDY DESIGN This was an observational cross-sectional study using mortality vital statistics system data to calculate proportionate mortality ratios (PMRs) and mortality rates due to COVID-19 as the underlying cause. METHODS Rates were compared by decedents' identified race, ethnicity (Hispanic vs non-Hispanic), and immigrant (immigrants vs US born) status. Asian race was further disaggregated into "Asian Indian," "Chinese," "Filipino," "Japanese," "Korean," and "Vietnamese." RESULTS Of the over 3.4 million people who died in 2020, 10.4% of all deaths were attributed to COVID-19 as the underlying cause (n = 351,530). More than double (18.9%, n = 81,815) the percentage of immigrants who died of COVID-19 compared with US-born decedents (9.1%, n = 269,715). PMRs due to COVID-19 were higher among immigrants compared with US-born individuals for non-Hispanic White, non-Hispanic Black, Hispanic, and most disaggregated Asian groups. Among disaggregated Asian immigrants, age- and sex-adjusted PMR due to COVID-19 ranged from 1.58 times greater mortality among Filipino immigrants (95% confidence interval [CI]: 1.53, 1.64) to 0.77 times greater mortality among Japanese immigrants (95% CI: 0.68, 0.86). Age-adjusted mortality rates were also higher among immigrant individuals compared with US-born people. CONCLUSIONS Immigrant individuals experienced greater mortality due to COVID-19 compared with their US-born counterparts. As COVID-19 becomes more endemic, greater clinical and public health efforts are needed to reduce disparities in mortality among immigrants compared with their US-born counterparts.
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Affiliation(s)
- A M Bacong
- Stanford University School of Medicine, Department of Medicine, Division of Cardiovascular Medicine, Stanford, CA, USA; Stanford University Center for Asian Health Research and Education, Stanford, CA, USA.
| | - R Chu
- Stanford University Center for Asian Health Research and Education, Stanford, CA, USA; University of California, Los Angeles Fielding School of Public Health, Department of Community Health Sciences, Los Angeles, CA, USA; Asian American Studies Department, University of California, Los Angeles, Los Angeles, CA, USA
| | - A Le
- University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - V Bui
- University of California, Berkeley School of Public Health, Berkeley, CA, USA
| | - N E Wang
- Stanford University Center for Asian Health Research and Education, Stanford, CA, USA; Stanford University School of Medicine, Department of Medicine, Division of Emergency Medicine, Stanford, CA, USA
| | - L P Palaniappan
- Stanford University School of Medicine, Department of Medicine, Division of Cardiovascular Medicine, Stanford, CA, USA; Stanford University Center for Asian Health Research and Education, Stanford, CA, USA
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Schertzer K, Wang NE, Khanna K, Lee MO. Implementation of a pediatric in situ, train-the-trainer simulation program in general emergency departments. AEM Educ Train 2023; 7:e10843. [PMID: 36743260 PMCID: PMC9887404 DOI: 10.1002/aet2.10843] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 12/13/2022] [Accepted: 12/26/2022] [Indexed: 06/18/2023]
Abstract
Background Most children receive emergency care in general emergency departments (EDs). Pediatric resuscitations require specific equipment and weight-based dosing that may be less familiar to general ED healthcare professionals. In situ simulation (ISS) improves teamwork and problem solving, and it may identify latent safety threats. This innovative program brought academic faculty to participating hospitals and taught simulation principles in a small-group environment. This format removed many of the barriers to implementing simulations for general EDs and was intended to teach principles for utilizing simulation to meet unique departmental needs. Methods Using the Consolidated Framework for Implementation Research (CFIR) framework, ED teams at eight hospitals participated in a train-the-trainer program from 2016 to 2020 intended to help them implement their own ISSs. Training covered benefits of ISS, use of simulation for identifying latent safety threats, debriefing principles, and potential safety risks of ISS. Faculty also provided on-site mentoring during the implementation phase. We identified factors and barriers that contributed to the successful adoption of an ISS program. Results Most hospitals continued their ISS program after the study ended. Several themes emerged as pearls and pitfalls to implementing a train-the-trainer program. Successful teams had strong nursing and physician leadership participation, and team members had positive working relationships with early positive feedback which encouraged future ISS implementation. Barriers to simulation included high staff turnover of nurses and physicians as well as social distancing protocols related to infection control. Conclusions Academic EDs can partner with general EDs to implement a train-the-trainer simulation program. We describe facilitators and barriers to implementing a train-the-trainer ISS program in general EDs to improve emergency care for high-risk, low-frequency events.
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Affiliation(s)
- Kimberly Schertzer
- Department of Emergency MedicineStanford University School of MedicinePalo AltoCaliforniaUSA
| | - N. Ewen Wang
- Department of Emergency MedicineStanford University School of MedicinePalo AltoCaliforniaUSA
| | - Kajal Khanna
- Department of Emergency MedicineStanford University School of MedicinePalo AltoCaliforniaUSA
| | - Moon O. Lee
- Department of Emergency MedicineStanford University School of MedicinePalo AltoCaliforniaUSA
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Lee MO, Wall J, Saynina O, Camargo CA, Wang NE. Characteristics of Pediatric Patient Transfers From General Emergency Departments in California From 2005 to 2018. Pediatr Emerg Care 2023; 39:20-27. [PMID: 36440988 DOI: 10.1097/pec.0000000000002885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Each year, approximately 300,000 pediatric patients are transferred out of emergency departments (EDs). Emergency department transfers may not only provide a higher level of care but also incur increased resource use and cost. Our objective was to identify hospital characteristics and patient demographics and conditions associated with ED transfer as well as the trend of transfers over time. METHODS This was a retrospective cohort study of pediatric visits to EDs in California using the California Office of Statewide Health Planning and Development ED data set (2005-2018). Hospitals were categorized based on inpatient pediatric capabilities. Patients were characterized by demographics and Clinical Classifications Software diagnostic categories. Regression models were created to analyze likelihood of outcome of transfer compared with admission. RESULTS Over the 14-year period, there were 38,117,422 pediatric visits to 364 EDs in California with a transfer rate of 1% to 2%. During this time, the overall proportion of pediatric transfers increased, whereas pediatric admissions decreased for all hospital types. Transfers were more likely in general hospitals without licensed pediatric beds (odds ratio [OR], 16.26; 95% confidence interval [CI], 15.87-16.67) and in general hospitals with licensed pediatric beds (OR, 3.54; 95% CI, 3.46-3.62) than in general hospitals with pediatric intensive care unit beds. Mental illness (OR, 61.00; 95% CI, 57.90-63.20), poisoning (OR, 11.78; 95% CI, 11.30-12.30), diseases of the circulatory system (OR, 6.13; 95% CI, 5.84-6.43), diseases of the nervous system (OR, 4.61; 95% CI, 4.46-4.76), and diseases of the blood and blood-forming organs (OR, 3.21; 95% CI, 3.62; 95% CI, 3.45-3.79) had increased odds of transfer. CONCLUSION Emergency departments in general hospitals without pediatric intensive care units and patients' Clinical Classifications Software category were associated with increased likelihood of transfer. A higher proportion of patients with complex conditions are transferred than those with common conditions. General EDs may benefit from developing transfer processes and protocols for patients with complex medical conditions.
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Affiliation(s)
- Moon O Lee
- From the Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jessica Wall
- Department of Pediatrics and Emergency Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Emergency Department, Seattle, WA
| | - Olga Saynina
- Stanford Center for Policy, Outcomes and Prevention, Stanford, CA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - N Ewen Wang
- From the Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA
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Hampton K, Mishori R, Griffin M, Hillier C, Pirrotta E, Wang NE. Clinicians' perceptions of the health status of formerly detained immigrants. BMC Public Health 2022; 22:575. [PMID: 35321680 PMCID: PMC8941369 DOI: 10.1186/s12889-022-12967-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 03/08/2022] [Indexed: 11/23/2022] Open
Abstract
Background In the past decade, the U.S. immigration detention system regularly detained more than 30,000 people per day; in 2019 prior to the pandemic, the daily detention population exceeded 52,000 people. Inhumane detention conditions have been documented by internal government watchdogs, and news media and human rights groups who have observed over-crowding, poor hygiene and sanitation and poor and delayed medical care, as well as verbal, physical and sexual abuse. Methods This study surveyed health professionals across the United States who had provided care for immigrants who were recently released from immigration detention to assess clinician perceptions about the adverse health impact of immigration detention on migrant populations based on real-life clinical encounters. There were 150 survey responses, of which 85 clinicians observed medical conditions attributed to detention. Results These 85 clinicians reported seeing a combined estimate of 1300 patients with a medical issue related to their time in detention, including patients with delayed access to medical care or medicine in detention, patients with new or acute health conditions such as infection and injury attributed to detention, and patients with worsened chronic or special needs conditions. Clinicians also provided details regarding sentinel cases, categorized into the following themes: Pregnant women, Children, Mentally Ill, COVID-19, and Other serious health issue. Conclusions This is the first survey, to our knowledge, of health care professionals treating individuals upon release from detention. Due to the lack of transparency by federal entities and limited access to detainees, this survey serves as a source of credible information about conditions experienced within immigration detention facilities and is a means of corroborating immigrant testimonials and media reports. These findings can help inform policy discussions regarding systematic changes to the delivery of healthcare in detention, quality assurance and transparent reporting.
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Affiliation(s)
| | - Ranit Mishori
- Physicians for Human Rights, New York, NY, USA.,Department of Family Medicine, Georgetown University School of Medicine, Washington, DC, USA
| | - Marsha Griffin
- Department of Pediatrics, University of Texas Rio Grande Valley School of Medicine, Edinburg, TX, USA
| | - Claire Hillier
- Department of Human Biology, Stanford University, Stanford, California, USA
| | - Elizabeth Pirrotta
- Department of Emergency Medicine, Division of Population Health Research, Stanford University School of Medicine, Stanford, California, USA
| | - N Ewen Wang
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
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Shearer E, Wang NE. California Children Presenting to an Emergency Department for Mental Health Emergencies: Trajectories of Care. Pediatr Emerg Care 2022; 38:e1075-e1081. [PMID: 35015392 DOI: 10.1097/pec.0000000000002590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Pediatric emergency department (ED) mental health visits are increasing in the United States. At the same time, child/adolescent psychiatric services are limited. This study examines the trajectory of pediatric patients presenting with mental health emergencies to better understand availability of specialty care resources in regional networks. METHODS This retrospective cohort study used a California Office of Statewide Health Planning and Development linked ED and Inpatient Discharge Dataset (2005-2015) to study pediatric patients (5-17 years) who presented to an ED with a primary mental health diagnosis. Outcomes were disposition: discharge, admission, or transfer.Patients transferred were further analyzed for disposition. Regression models to identify characteristics associated with disposition were created. RESULTS There were 384,339 pediatric patients presented for a primary mental health emergency from 2005 to 2015; 287,997 were discharged, 17,564 were admitted, and 78,725 were transferred. Among those not discharged, patients with public (odds ratio [OR], 1.28; P < 0.01) or self-pay insurance (OR, 5.64; P < 0.01), Black (OR, 2.15; P < 0.01), or Native American race (OR, 2.32; P < 0.01), and who presented to rural EDs (OR, 3.10; P < 0.01), nonteaching hospitals (OR, 3.06; P < 0.01), or hospitals in counties without dedicated child/adolescent psychiatric beds (OR, 5.59; P < 0.01) had higher odds of transfer.Among those not discharged from the second hospital, Black patients (OR, 2.47; P < 0.03) and those who were transferred to a teaching hospital (OR, 1.9; P < 0.01) had higher odds of second transfer. CONCLUSIONS Pediatric patients with mental health emergencies experience different trajectories of care. Transfer protocols and regionalized networks may help streamline services and decrease inefficiencies in care.
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Affiliation(s)
| | - N Ewen Wang
- Stanford Department of Emergency Medicine, Stanford CA
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Affiliation(s)
- N Ewen Wang
- From the Department of Emergency Medicine (N.E.W.), and the Department of Psychiatry and Behavioral Sciences (R.M.), Stanford University School of Medicine, Stanford, CA; the Department of Pediatrics, Division of Academic General Pediatrics, Montefiore Medical Center; Albert Einstein College of Medicine; and Terra Firma: Healthcare and Justice for Immigrant Children - all in New York (A.S.)
| | - Ryan Matlow
- From the Department of Emergency Medicine (N.E.W.), and the Department of Psychiatry and Behavioral Sciences (R.M.), Stanford University School of Medicine, Stanford, CA; the Department of Pediatrics, Division of Academic General Pediatrics, Montefiore Medical Center; Albert Einstein College of Medicine; and Terra Firma: Healthcare and Justice for Immigrant Children - all in New York (A.S.)
| | - Alan Shapiro
- From the Department of Emergency Medicine (N.E.W.), and the Department of Psychiatry and Behavioral Sciences (R.M.), Stanford University School of Medicine, Stanford, CA; the Department of Pediatrics, Division of Academic General Pediatrics, Montefiore Medical Center; Albert Einstein College of Medicine; and Terra Firma: Healthcare and Justice for Immigrant Children - all in New York (A.S.)
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Lowe J, Brown I, Duriseti R, Gallegos M, Ribeira R, Pirrotta E, Wang NE. Emergency Department Access During COVID-19: Disparities in Utilization by Race/Ethnicity, Insurance, and Income. West J Emerg Med 2021; 22:552-560. [PMID: 34125026 PMCID: PMC8203020 DOI: 10.5811/westjem.2021.1.49279] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 01/14/2021] [Accepted: 01/19/2021] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION In March 2020, shelter-in-place orders were enacted to attenuate the spread of coronavirus 2019 (COVID-19). Emergency departments (EDs) experienced unexpected and dramatic decreases in patient volume, raising concerns about exacerbating health disparities. METHODS We queried our electronic health record to describe the overall change in visits to a two-ED healthcare system in Northern California from March-June 2020 compared to 2019. We compared weekly absolute numbers and proportional change in visits focusing on race/ethnicity, insurance, household income, and acuity. We calculated the z-score to identify whether there was a statistically significant difference in proportions between 2020 and 2019. RESULTS Overall ED volume declined 28% during the study period. The nadir of volume was 52% of 2019 levels and occurred five weeks after a shelter-in-place order was enacted. Patient demographics also shifted. By week 4 (April 5), the proportion of Hispanic patients decreased by 3.3 percentage points (pp) (P = 0.0053) compared to a 6.2 pp increase in White patients (P = 0.000005). The proportion of patients with commercial insurance increased by 11.6 pp, while Medicaid visits decreased by 9.5 pp (P < 0.00001) at the initiation of shelter-in-place orders. For patients from neighborhoods <300% federal poverty levels (FPL), visits were -3.8 pp (P = 0.000046) of baseline compared to +2.9 pp (P = 0.0044) for patients from ZIP codes at >400% FPL the week of the shelter-in-place order. Overall, 2020 evidenced a consistently elevated proportion of high-acuity Emergency Severity Index (ESI) level 1 patients compared to 2019. Increased acuity was also demonstrated by an increase in the admission rate, with a 10.8 pp increase from 2019. Although there was an increased proportion of high-acuity patients, the overall census was decreased. CONCLUSION Our results demonstrate changing ED utilization patterns circa the shelter-in-place orders. Those from historically vulnerable populations such as Hispanics, those from lower socioeconomic areas, and Medicaid users presented at disproportionately lower rates and numbers than other groups. As the pandemic continues, hospitals should use operations data to monitor utilization patterns by demographic, in addition to clinical indicators. Messaging about availability of emergency care and other services should include vulnerable populations to avoid exacerbating healthcare disparities.
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Affiliation(s)
- Jason Lowe
- Stanford University School of Medicine, Department of Emergency Medicine, Palo Alto, California
| | - Ian Brown
- Stanford University School of Medicine, Department of Emergency Medicine, Palo Alto, California
| | - Ram Duriseti
- Stanford University School of Medicine, Department of Emergency Medicine, Palo Alto, California
| | - Moises Gallegos
- Stanford University School of Medicine, Department of Emergency Medicine, Palo Alto, California
| | - Ryan Ribeira
- Stanford University School of Medicine, Department of Emergency Medicine, Palo Alto, California
| | - Elizabeth Pirrotta
- Stanford University School of Medicine, Department of Emergency Medicine, Palo Alto, California
| | - N Ewen Wang
- Stanford University School of Medicine, Department of Emergency Medicine, Palo Alto, California
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Lee MO, Schertzer K, Khanna K, Wang NE, Camargo CA, Sebok-Syer SS. Using In Situ Simulations to Improve Pediatric Patient Safety in Emergency Departments. Acad Med 2021; 96:395-398. [PMID: 33116057 DOI: 10.1097/acm.0000000000003807] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PROBLEM Given the complex interaction among patients, individual providers, health care teams, and the clinical environment, patient safety events with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments (EDs). With low-frequency, high-risk events such as pediatric resuscitations, health care teams working in EDs may not have the clinical opportunity to identify deficiencies, review and reinforce knowledge and skills, and problem solve in authentic clinical conditions. Without creating opportunities to safely practice, hospitals run the risk of having health care teams and environments that are not prepared to provide optimal patient care. APPROACH Researchers employed a case series design and used a train-the-trainer model for in situ simulation. They trained health care professionals (instructors) in 3 general, nonacademic EDs in the San Francisco Bay area of California to perform pediatric resuscitation in situ simulations in 2018-2019. In situ simulations occur in the clinical work environment with simulation participants (teams) who are health care professionals taking care of actual patients. OUTCOMES Teams made up of physicians, nurses, and ED technicians were evaluated for clinical performance, teamwork, and communication during in situ simulations conducted by instructors at baseline, 6 months, and 12 months. Debriefing after the simulations identified multiple latent safety threats (i.e., unidentified potential safety hazards) that were previously unknown. Each ED's pediatric readiness-its ability to provide emergency care for children-was evaluated at baseline and 12 months. NEXT STEPS The authors will continue to monitor and examine the impact and sustainability of the pediatric in situ simulation program on pediatric readiness scores and its possible translation to other high-risk clinical settings, as well as explore the relationship between in situ simulations and patient outcomes.
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Affiliation(s)
- Moon O Lee
- M.O. Lee is associate professor, Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
| | - Kimberly Schertzer
- K. Schertzer is assistant professor, Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
| | - Kajal Khanna
- K. Khanna is associate professor, Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
| | - N Ewen Wang
- N.E. Wang is professor, Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
| | - Carlos A Camargo
- C.A. Camargo Jr is professor, Departments of Emergency Medicine, Medicine, and Epidemiology, Harvard University, Boston, Massachusetts
| | - Stefanie S Sebok-Syer
- S.S. Sebok-Syer is instructor, Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
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Lee MO, Altamirano J, Garcia LC, Gisondi MA, Wang NE, Lippert S, Maldonado Y, Gharahbaghian L, Ribeira R, Fassiotto M. Patient Age, Race and Emergency Department Treatment Area Associated with "Topbox" Press Ganey Scores. West J Emerg Med 2020; 21:117-124. [PMID: 33207156 PMCID: PMC7673899 DOI: 10.5811/westjem.2020.8.47277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 08/06/2020] [Indexed: 12/30/2022] Open
Abstract
Introduction Hospitals commonly use Press Ganey (PG) patient satisfaction surveys for benchmarking physician performance. PG scores range from 1 to 5, with 5 being the highest, which is known as the “topbox” score. Our objective was to identify patient and physician factors associated with topbox PG scores in the emergency department (ED). Methods We looked at PG surveys from January 2015–December 2017 at an academic, urban hospital with 78,000 ED visits each year. Outcomes were topbox scores for the questions: “Likelihood of your recommending our ED to others”; and “Courtesy of the doctor.” We analyzed topbox scores using generalized estimating equation models clustered by physician and adjusted for patient and physician factors. Patient factors included age, gender, race, ethnicity, and ED area where patient was seen. The ED has four areas based on patient acuity: emergent; urgent; vertical (urgent but able to sit in a recliner rather than a gurney); and fast track (non-urgent). Physician factors included age, gender, race, ethnicity, and number of years at current institution. Results We analyzed a total of 3,038 surveys. For “Likelihood of your recommending our ED to others,” topbox scores were more likely with increasing patient age (odds ratio [OR] 1.07; 95% confidence interval [CI], 1.03–1.12); less likely among female compared to male patients (OR 0.81; 95% CI, 0.70–0.93); less likely among Asian compared to White patients (OR 0.71; 95% CI, 0.60–0.83); and less likely in the urgent (OR 0.71; 95% CI, 0.54–0.93) and vertical areas (OR 0.71; 95% CI 0.53–0.95) compared to fast track. For “Courtesy of the doctor,” topbox scores were more likely with increasing patient age (OR 1.1; CI, 1.06–1.14); less likely among Asian (OR 0.70; 95% CI, 0.58–0.84), Black (OR 0.66; 95% CI, 0.45–0.96), and Hispanic patients (OR 0.68; 95% CI, 0.55–0.83) compared to White patients; and less likely in urgent area (OR 0.69; 95% CI, 0.50–0.95) compared to fast track. Conclusion Increasing patient age was associated with increased likelihood of topbox scores, while Asian patients, and urgent and vertical areas had decreased likelihood of topbox scores. We encourage hospitals that use PG topbox scores as financial incentives to understand the contribution of non-service factors to these scores.
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Affiliation(s)
- Moon O Lee
- Stanford University School of Medicine, Department of Emergency Medicine, Stanford, California
| | - Jonathan Altamirano
- Stanford University School of Medicine, Office of Faculty Development and Diversity, Stanford, California
| | - Luis C Garcia
- Stanford University School of Medicine, Office of Faculty Development and Diversity, Stanford, California
| | - Michael A Gisondi
- Stanford University School of Medicine, Department of Emergency Medicine, Stanford, California
| | - N Ewen Wang
- Stanford University School of Medicine, Department of Emergency Medicine, Stanford, California
| | - Suzanne Lippert
- Kaiser-Permanente East Bay, Department of Emergency Medicine, Oakland, California
| | - Yvonne Maldonado
- Stanford University School of Medicine, Office of Faculty Development and Diversity, Stanford, California
| | - Laleh Gharahbaghian
- Stanford University School of Medicine, Department of Emergency Medicine, Stanford, California
| | - Ryan Ribeira
- Stanford University School of Medicine, Department of Emergency Medicine, Stanford, California
| | - Magali Fassiotto
- Stanford University School of Medicine, Office of Faculty Development and Diversity, Stanford, California
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Ijaz N, Strehlow M, Wang NE, Pirrotta E, Tariq A, Mahmood N, Mahadevan S. Correction to: Epidemiology of patients presenting to a pediatric emergency department in Karachi, Pakistan. BMC Emerg Med 2020; 20:66. [PMID: 32859173 PMCID: PMC7453707 DOI: 10.1186/s12873-020-00364-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Nadir Ijaz
- Department of Emergency Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Rm M121, Alway Building MC 5119, Stanford, CA, 94305, USA
| | - Matthew Strehlow
- Department of Emergency Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Rm M121, Alway Building MC 5119, Stanford, CA, 94305, USA.
| | - N Ewen Wang
- Department of Emergency Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Rm M121, Alway Building MC 5119, Stanford, CA, 94305, USA
| | - Elizabeth Pirrotta
- Department of Emergency Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Rm M121, Alway Building MC 5119, Stanford, CA, 94305, USA
| | - Areeba Tariq
- Honors Program in Medical Education, Northwestern University, Evanston, IL, USA
| | - Naseeruddin Mahmood
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Swaminatha Mahadevan
- Department of Emergency Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Rm M121, Alway Building MC 5119, Stanford, CA, 94305, USA
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Vongsachang H, Oshima S, Nguyen C, Gaulocher S, Wang NE. Undergraduate Premedical Student Perceptions of an Emergency Department-Based Social Needs Screening Program. Med Sci Educ 2020; 30:673-677. [PMID: 34457723 PMCID: PMC8368874 DOI: 10.1007/s40670-020-00936-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
BACKGROUND Medical school admission requirements increasingly encompass competencies beyond the traditional premedical curriculum, such as service orientation and knowledge of "social determinants of health." ACTIVITY The Stanford Help Desk is an undergraduate service-learning program that provides didactic and experiential exposure to the social determinants of health through screening for social and legal needs of emergency department (ED) patients. We assessed student perceptions of program impact through student applications, course evaluations, and an online program survey. RESULTS AND DISCUSSION This course strengthened students' understanding of their career aspirations in medicine. Students were resolved to incorporate consideration of social determinants of health in future practice.
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Affiliation(s)
| | - Sachi Oshima
- Duke University School of Medicine, Durham, NC USA
| | - Christine Nguyen
- University of Oklahoma College of Medicine, Oklahoma City, OK USA
| | - Suzanne Gaulocher
- Center for Healthy Communities at Plymouth State University, Plymouth, NH USA
| | - N. Ewen Wang
- Stanford University School of Medicine, 900 Welch Road, Palo Alto, CA 94304 USA
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Wang NE, Ewbank C, Newton CR, Spain DA, Pirrotta E, Thomas-Uribe M. Regionalization Patterns for Children with Serious Trauma in California (2005-2015): A Retrospective Cohort Study. PREHOSP EMERG CARE 2020; 25:103-116. [PMID: 32091292 DOI: 10.1080/10903127.2020.1733715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Trauma centers provide coordinated specialty care and have been demonstrated to save lives. Many states do not have a comprehensive statewide trauma system. Variable geography, resources, and population distributions present significant challenges to establishing an effective uniform system for pediatric trauma care. We aimed to identify patterns of primary (field) triage and transfer of serious pediatric trauma throughout California. We hypothesized that pediatric primary triage to trauma center care would be positively associated with younger age, increased injury severity, and local emergency medical service (EMS) regions with increased resources. We hypothesized that pediatric trauma transfer would be associated with younger age, increased injury severity, and rural regions with decreased resources. Methods: We conducted a retrospective cohort study of the California Office of Statewide Health Planning and Development emergency department and inpatient discharge data (2005-2015). All patients with serious injury, defined as Injury Severity Score (ISS) >9 were included. Demographic, injury, hospital, and regional characteristics such as distances between patient residence and destination hospitals were tabulated. Univariate and multinomial logit analyses were conducted to analyze individual, hospital, and regional characteristics associated with the outcomes of location of primary triage and transfer. Estimates were converted into predicted probabilities for ease of data interpretation. Results: Primary triage to was to either a pediatric trauma center (37.8%), adult level I/II trauma center (35.0%), adult level III/IV trauma center (1.9%), pediatric non-trauma hospital (3.4%), or an adult non-trauma hospital (21.9%).Younger age, private non-HMO insurance, motor vehicle mechanism, and rural areas were the major factors influencing primary triage to any trauma hospital. Younger age, private non-HMO insurance, higher ISS, fall mechanism, <200 bed hospital, and rural areas were the major factors influencing transfer from a non-trauma hospital to any trauma center. Conclusions: We demonstrate statewide primary triage and transfer patterns for pediatric trauma in a large and varied state. Specifically we identified previously unrecognized individual, hospital, and EMS system associations with pediatric trauma regionalization. Knowledge of these de facto trauma care access patterns has policy and process implications that could improve care for all injured children in need.
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Affiliation(s)
- N Ewen Wang
- Stanford University School of Medicine, Palo Alto, CA.
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Wang NE, Newton CR, Spain DA, Pirrotta E, Thomas-Uribe M. Patient, hospital and regional characteristics associated with undertriage of injured children in California (2005-2015): a retrospective cohort study. Trauma Surg Acute Care Open 2019; 4:e000317. [PMID: 31565676 PMCID: PMC6744082 DOI: 10.1136/tsaco-2019-000317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/31/2019] [Accepted: 06/20/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND/OBJECTIVE Trauma centers save lives, but they are scarce and concentrated in urban settings. The population of severely injured children in California who do not receive trauma center care (undertriage) is not well understood. METHODS Retrospective observational study of all children (0-17 years) hospitalized for severe trauma in California (2005-2015). We used the California Office of Statewide Health Planning and Development linked Emergency Department and Inpatient Discharge data sets. Logistic regression models were created to analyze characteristics associated with undertriage. The model was clustered on differential distance between distance from residence to primary triage hospital and distance from residence to nearest trauma center. We controlled for body part injured, injury type, intent and year. The a priori hypothesis was that uninsured and publicly insured children and hospitals and regions with limited resources would be associated with undertriage. RESULTS Twelve percent (1866/15 656) of children with severe injury experienced undertriage. Children aged >14 years compared with 0-13 years had more than 2.5 times the odds of undertriage (OR 2.58; 95% CI 2.1 to 3.16). Children with private Health Maintenance Organization (HMO) insurance compared with public insurance had 13 times the odds of undertriage (OR 12.62; 95% CI 8.95 to 17.79). Hospitals with >400 compared with <200 beds had more than three times the odds of undertriage (OR 3.64; 95% CI 2.6 to 5.11). Urban versus suburban residence had 1.3 times increased odds of undertriage (OR 1.31; 95% CI 1.02 to 1.67) Undertriage volume was largest in urban areas. CONCLUSION Undertriage is associated with private HMO insurance, primary triage to large hospitals and urban residence. Understanding the characteristics associated with undertriage can help improve trauma systems. LEVEL OF EVIDENCE Level III (non-experimental retrospective observational study).
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Affiliation(s)
- N. Ewen Wang
- Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Christopher R. Newton
- Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | | | - Elizabeth Pirrotta
- Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Monika Thomas-Uribe
- Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
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Ewbank C, Sheckter CC, Warstadt NM, Pirrotta EA, Curtin C, Newton C, Wang NE. Variations in access to specialty care for children with severe burns. Am J Emerg Med 2019; 38:1146-1152. [PMID: 31474377 DOI: 10.1016/j.ajem.2019.158401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/09/2019] [Accepted: 08/18/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Pediatric burns account for 120,000 emergency department visits and 10,000 hospitalizations annually. The American Burn Association has guidelines regarding referrals to burn centers; however there is variation in burn center distribution. We hypothesized that disparity in access would be related to burn center access. METHODS Using weighted discharge data from the Nationwide Inpatient Sample 2001-2011, we identified pediatric patients with International Classification of Diseases-9th Revision codes for burns that also met American Burn Association criteria. Key characteristics were compared between pediatric patients treated at burn centers and those that were not. RESULTS Of 54,529 patients meeting criteria, 82.0% (n = 44,632) were treated at burn centers. Patients treated at burn centers were younger (5.6 versus 6.7 years old; p < 0.0001) and more likely to have burn injuries on multiple body regions (88% versus 12%; p < 0.0001). In urban areas, 84% of care was provided at burn centers versus 0% in rural areas (p < 0.0001), a difference attributable to the lack of burn centers in rural areas. Both length of stay and number of procedures were significantly higher for patients treated at burn centers (7.3 versus 4.4 days, p < 0.0001 and 2.3 versus 1.1 procedures, p < 0.0001; respectively). There were no significant differences in mortality (0.7% versus 0.8%, p = 0.692). CONCLUSION The majority of children who met criteria were treated at burn centers. There was no significant difference between geographical regions. Of those who were treated at burn centers, more severe injury patterns were noted, but there was no significant mortality difference. Further study of optimal referral of pediatric burn patients is needed.
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Affiliation(s)
- Clifton Ewbank
- University of California San Francisco East Bay Department of Surgery, Oakland, CA, United States of America; University of California San Francisco Benioff Children's Hospital Oakland, Oakland, CA, United States of America.
| | - Clifford C Sheckter
- Stanford University Department of Surgery, Stanford, CA, United States of America
| | - Nicholus M Warstadt
- Stanford University School of Medicine, Stanford, CA, United States of America
| | | | - Catherine Curtin
- Stanford University Department of Surgery, Stanford, CA, United States of America
| | - Christopher Newton
- University of California San Francisco Benioff Children's Hospital Oakland, Oakland, CA, United States of America
| | - N Ewen Wang
- Stanford University Department of Emergency Medicine, Stanford, CA, United States of America
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Affiliation(s)
| | - Christopher Newton
- Department of Surgery, University of California-San Francisco Benioff Children's Hospital, Oakland, California
| | - Richard A Kline
- Department of Surgery, Regional Medical Center, San Jose, California
| | - David A Spain
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Elizabeth Pirrotta
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
| | - N Ewen Wang
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
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Gordon AJ, Sebok‐Syer SS, Dohn AM, Smith‐Coggins R, Ewen Wang N, Williams SR, Gisondi MA. The Birth of a Return to work Policy for New Resident Parents in Emergency Medicine. Acad Emerg Med 2019; 26:317-326. [PMID: 30636353 DOI: 10.1111/acem.13684] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/18/2018] [Accepted: 12/22/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE With the rising number of female physicians, there will be more children than ever born in residency, and the current system is inadequate to handle this increase in new resident parents. Residency is stressful and rigorous in isolation, let alone when pregnant or with a new child. Policies that ease these stressful transitions are generally either insufficient or do not exist. Therefore, we created a comprehensive return-to-work policy for resident parents and piloted its implementation. Our policy aims to: 1) establish a clear, shared understanding of the regulatory and training requirements as they pertain to parental leave; 2) facilitate a smooth transition for new parents returning to work; and 3) summarize the local and institutional resources available for both males and females during residency training. METHOD In Fall 2017, a task force was convened to draft a return-to-work policy for new resident parents. The task force included nine key stakeholders (i.e., residents, faculty, and administration) at our institution and was made up of three graduate medical education (GME) program directors, a vice chair of education, a designated institutional official (DIO), a chief resident, and three members of our academic department's faculty affairs committee. The task force was selected because of individual expertise in gender equity issues, mentorship of resident parents, GME, and departmental administration. RESULTS After development, the policy was piloted from November 2017 to June 2018. Our pilot implementation period included seven new resident parents. All of these residents received schedules that met the return-to-work scheduling terms of our return-to-work policy including no overnight shifts, no sick call, and no more than three shifts in a row. Of equal importance, throughout our pilot, the emergency department schedules at all of our clinical sites remained fully staffed and our sick call pool was unaffected. CONCLUSION Our return-to-work policy for new resident parents provides a comprehensive guide to training requirements and family leave policies, an overview of available resources, and a scheduling framework that makes for a smooth transition back to clinical duties.
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Affiliation(s)
- Alexandra June Gordon
- Department of Medicine Stanford University School of Medicine Palo Alto CA
- Department of Emergency Medicine Stanford University School of Medicine Palo Alto CA
| | | | - Ann M. Dohn
- Graduate Medical Education Stanford University School of Medicine Palo AltoCA
| | - Rebecca Smith‐Coggins
- Department of Emergency Medicine Stanford University School of Medicine Palo Alto CA
| | - N. Ewen Wang
- Department of Emergency Medicine Stanford University School of Medicine Palo Alto CA
| | - Sarah R. Williams
- Department of Emergency Medicine Stanford University School of Medicine Palo Alto CA
- Stanford/Kaiser Emergency Medicine Residency Program Palo Alto CA
| | - Michael A. Gisondi
- Department of Emergency Medicine Stanford University School of Medicine Palo Alto CA
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Ijaz N, Strehlow M, Ewen Wang N, Pirrotta E, Tariq A, Mahmood N, Mahadevan S. Epidemiology of patients presenting to a pediatric emergency department in Karachi, Pakistan. BMC Emerg Med 2018; 18:22. [PMID: 30075749 PMCID: PMC6091113 DOI: 10.1186/s12873-018-0175-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 07/27/2018] [Indexed: 01/07/2023] Open
Abstract
Background There is little data describing pediatric emergencies in resource-poor countries, such as Pakistan. We studied the demographics, management, and outcomes of patients presenting to the highest-volume, public, pediatric emergency department (ED) in Karachi, Pakistan. Methods In this prospective, observational study, we approached all patients presenting to the 50-bed ED during 28 12-h study periods over four consecutive weeks (July 2013). Participants’ chief complaints and medical care were documented. Patients were followed-up at 48-h and 14-days via telephone. Results Of 3115 participants, 1846 were triaged to the outpatient department and 1269 to the ED. Patients triaged to the ED had a median age of 2.0 years (IQR 0.5–4.0); 30% were neonates (< 28 days). Top chief complaints were fever (45.5%), diarrhea/vomiting (32.3%), respiratory (23.1%), abdominal (7.5%), and otolaryngological problems (5.8%). Temperature, pulse and respiratory rate, and blood glucose were documented for 66, 42, and 1.5% of patients, respectively. Interventions included medications (92%), IV fluids (83%), oxygen (35%), and advanced airway management (5%). Forty-five percent of patients were admitted; 11 % left against medical advice. Outcome data was available at time of ED disposition, 48-h, and 14 days for 83, 62, and 54% of patients, respectively. Of participants followed-up, 4.3% died in the ED, 11.5% within 48 h, and 19.6% within 14 days. Conclusions This first epidemiological study at Pakistan’s largest pediatric ED reveals dramatically high mortality, particularly among neonates. Future research in developing countries should focus on characterizing reasons for high mortality through pre-ED arrival tracking, ED care quality assessment, and post-ED follow-up. Electronic supplementary material The online version of this article (10.1186/s12873-018-0175-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nadir Ijaz
- Department of Emergency Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Rm M121, Alway Building MC 5119, Stanford, CA, 94305, USA
| | - Matthew Strehlow
- Department of Emergency Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Rm M121, Alway Building MC 5119, Stanford, CA, 94305, USA.
| | - N Ewen Wang
- Department of Emergency Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Rm M121, Alway Building MC 5119, Stanford, CA, 94305, USA
| | - Elizabeth Pirrotta
- Department of Emergency Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Rm M121, Alway Building MC 5119, Stanford, CA, 94305, USA
| | - Areeba Tariq
- Honors Program in Medical Education, Northwestern University, Evanston, IL, USA
| | - Naseeruddin Mahmood
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Swaminatha Mahadevan
- Department of Emergency Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Rm M121, Alway Building MC 5119, Stanford, CA, 94305, USA
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Arroyo AJC, Chee CP, Camargo CA, Wang NE. Where do children die from asthma? National data from 2003 to 2015. J Allergy Clin Immunol Pract 2017; 6:1034-1036. [PMID: 28970087 DOI: 10.1016/j.jaip.2017.08.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 08/28/2017] [Accepted: 08/30/2017] [Indexed: 11/24/2022]
Affiliation(s)
- Anna J Chen Arroyo
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, Mass.
| | - Christine Pal Chee
- Health Economics Resource Center (HERC), Veterans Affairs Palo Alto, Menlo Park, Calif; Public Policy Program, Stanford University, Stanford, Calif
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - N Ewen Wang
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, Calif
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Nguyen HT, Newton C, Pirrotta EA, Aguilar C, Wang NE. Variations in Utilization of Inpatient Rehabilitation Services among Pediatric Trauma Patients. J Pediatr 2017; 182:342-348.e1. [PMID: 27939128 DOI: 10.1016/j.jpeds.2016.11.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 10/21/2016] [Accepted: 11/09/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess clinical and nonclinical characteristics associated with the use of pediatric inpatient rehabilitation services among children with traumatic injuries. We hypothesized there would be no nonclinical variations in the use of pediatric inpatient rehabilitation services. STUDY DESIGN Retrospective analysis of 1139 patients who were injured seriously (0-18 years of age) from our institutional trauma registry (2004-2014). Patients' nonclinical and clinical characteristics were analyzed. We used a full matching technique to compare characteristics between those admitted to rehabilitation (cases) to those discharged home (controls). We matched patients by age category, sex, maximum Abbreviated Injury Scale, and body region of maximum Abbreviated Injury Scale. We used survey-based multivariate logistic regression to identify characteristics associated with inpatient rehabilitation services, controlling for multiple injuries, distance from home to rehabilitation center, year of service, hospital length of stay, and clinically relevant interactions. RESULTS Ninety-eight patients (8.6%) were admitted to inpatient rehabilitation and 968 (85.0%) were discharged home. Black and other minority patients had increased odds of receiving inpatient rehabilitation compared with white patients (OR, 7.6 [P< .001] and OR, 1.6 [P= .03], respectively). Patients with private compared with public insurance had increased odds of receiving inpatient rehabilitation (OR, 2.4; P< .001). CONCLUSIONS Pediatric inpatient rehabilitation beds are a scarce resource that should be available to those with the greatest clinical need. The mechanism creating differences in the use of inpatient rehabilitation based on nonclinical characteristics such as race/ethnicity or insurance status must be understood to prevent disparities in access to inpatient rehabilitation services.
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Affiliation(s)
- Huong T Nguyen
- Divisions of Pediatric Surgery and Trauma Services, University of California, San Francisco Benioff Children's Hospital Oakland, Oakland, CA; Department of Emergency Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Christopher Newton
- Divisions of Pediatric Surgery and Trauma Services, University of California, San Francisco Benioff Children's Hospital Oakland, Oakland, CA
| | - Elizabeth A Pirrotta
- Department of Emergency Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Christine Aguilar
- Division of Pediatric Rehabilitation Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - N Ewen Wang
- Department of Emergency Medicine, School of Medicine, Stanford University, Stanford, CA.
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Anderson ES, Galbraith JW, Deering LJ, Pfeil SK, Todorovic T, Rodgers JB, Forsythe JM, Franco R, Wang H, Wang NE, White DAE. Continuum of Care for Hepatitis C Virus Among Patients Diagnosed in the Emergency Department Setting. Clin Infect Dis 2017; 64:1540-1546. [DOI: 10.1093/cid/cix163] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 02/15/2017] [Indexed: 12/17/2022] Open
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Hernandez-Boussard T, Burns CS, Wang NE, Baker LC, Goldstein BA. The Affordable Care Act reduces emergency department use by young adults: evidence from three States. Health Aff (Millwood) 2016; 33:1648-54. [PMID: 25201671 DOI: 10.1377/hlthaff.2014.0103] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Affordable Care Act (ACA) extended eligibility for health insurance for young adults ages 19-25. This extension may have affected how young adults use emergency department (ED) care and other health services. To test the impact of the ACA on how young adults used ED services, we used 2009-11 state administrative records from California, Florida, and New York to compare changes in ED use in young adults ages 19-25 before and after the ACA provision was implemented with changes in the same period for people ages 26-31 (the control group). Following implementation of the ACA provision, the younger group had a decrease of 2.7 ED visits per 1,000 people compared to the older group--a relative change of -2.1 percent. The largest relative decreases were found in women (-3.0 percent) and blacks (-3.4 percent). This relative decrease in ED use implies a total reduction of more than 60,000 visits from young adults ages 19-25 across the three states in 2011. When we compared the probability of ever using the ED before and after implementation of the ACA provision, we found a minimal decrease (-0.4 percent) among the younger group compared to the older group. This suggests that the change in the number of visits was driven by fewer visits among ED users, not by changes in the number of people who ever visited the ED.
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Affiliation(s)
- Tina Hernandez-Boussard
- Tina Hernandez-Boussard is an assistant professor of surgery and biomedical informatics (courtesy) at Stanford University, in California
| | - Carson S Burns
- Carson S. Burns is a medical student at the Stanford University School of Medicine
| | - N Ewen Wang
- N. Ewen Wang is an associate professor of surgery at Stanford University
| | - Laurence C Baker
- Laurence C. Baker is a professor of health research and policy at Stanford University
| | - Benjamin A Goldstein
- Benjamin A. Goldstein is a biostatistician at the Stanford University School of Medicine
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Staudenmayer K, Wang NE, Weiser TG, Maggio P, Mackersie RC, Spain D, Hsia RY. The Triage of Injured Patients: Mechanism of Injury, Regardless of Injury Severity, Determines Hospital Destination. Am Surg 2016. [DOI: 10.1177/000313481608200422] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The target rate for trauma undertriage is <5 per cent, but rates are as high as 30 to 40 per cent in many trauma systems. Wehypothesized that high undertriage rates were duetothe tendencyto undertriage injured elderly patients and a growing elderly population. We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database over a 5-year period. All hospital admissions and emergency department visits associated with injury were longitudinally linked. The primary outcome was triage pattern. Triage patterns were stratified across three dimensions: age, mechanism of injury, and access to care. A total of 60,182 severely injured patients were included in the analysis. Fall-related injuries were frequently undertriaged compared with injuries from motor vehicle collisions (MVCs) and penetrating trauma (52% vs 12% and 10%, respectively). This pattern was true for all age groups. Conversely, MVCs and penetrating traumas were associated with high rates of overtriage (>70% for both). In conclusion, in contrast to our hypothesis, we found that triage is largely determined by mechanism of injury regardless of injury severity. High rates of undertriage are largely due to the undertriage of fall-related injuries, which occurs in both younger and older adults. Patients injured after MVCs and penetrating trauma victims are brought to trauma centers regardless of injury severity, resulting in high rates of overtriage. These findings suggest an opportunity to improve trauma system performance.
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Affiliation(s)
- Kristan Staudenmayer
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - N. Ewen Wang
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Thomas G. Weiser
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Paul Maggio
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | | | - David Spain
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Renee Y. Hsia
- Department of Emergency Medicine, University of California, San Francisco, California
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Staudenmayer K, Wang NE, Weiser TG, Maggio P, Mackersie RC, Spain D, Hsia RY. The Triage of Injured Patients: Mechanism of Injury, Regardless of Injury Severity, Determines Hospital Destination. Am Surg 2016; 82:356-361. [PMID: 27097630 PMCID: PMC7255776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The target rate for trauma undertriage is <5 per cent, but rates are as high as 30 to 40 per cent in many trauma systems. We hypothesized that high undertriage rates were due to the tendency to undertriage injured elderly patients and a growing elderly population. We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database over a 5-year period. All hospital admissions and emergency department visits associated with injury were longitudinally linked. The primary outcome was triage pattern. Triage patterns were stratified across three dimensions: age, mechanism of injury, and access to care. A total of 60,182 severely injured patients were included in the analysis. Fall-related injuries were frequently undertriaged compared with injuries from motor vehicle collisions (MVCs) and penetrating trauma (52% vs 12% and 10%, respectively). This pattern was true for all age groups. Conversely, MVCs and penetrating traumas were associated with high rates of overtriage (>70% for both). In conclusion, in contrast to our hypothesis, we found that triage is largely determined by mechanism of injury regardless of injury severity. High rates of undertriage are largely due to the undertriage of fall-related injuries, which occurs in both younger and older adults. Patients injured after MVCs and penetrating trauma victims are brought to trauma centers regardless of injury severity, resulting in high rates of overtriage. These findings suggest an opportunity to improve trauma system performance.
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Affiliation(s)
- Kristan Staudenmayer
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - N. Ewen Wang
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Thomas G. Weiser
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Paul Maggio
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | | | - David Spain
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Rene Y. Hsia
- Department of Emergency Medicine, University of California, San Francisco, California
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Newgard CD, Yang Z, Nishijima D, McConnell KJ, Trent SA, Holmes JF, Daya M, Mann NC, Hsia RY, Rea TD, Wang NE, Staudenmayer K, Delgado MK. Cost-Effectiveness of Field Trauma Triage among Injured Adults Served by Emergency Medical Services. J Am Coll Surg 2016; 222:1125-37. [PMID: 27178369 DOI: 10.1016/j.jamcollsurg.2016.02.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 01/25/2016] [Accepted: 02/16/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND The American College of Surgeons Committee on Trauma sets national targets for the accuracy of field trauma triage at ≥95% sensitivity and ≥65% specificity, yet the cost-effectiveness of realizing these goals is unknown. We evaluated the cost-effectiveness of current field trauma triage practices compared with triage strategies consistent with the national targets. STUDY DESIGN This was a cost-effectiveness analysis using data from 79,937 injured adults transported by 48 emergency medical services agencies to 105 trauma and nontrauma hospitals in 6 regions of the western United States from 2006 through 2008. Incremental differences in survival, quality-adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio (costs per QALY gained) were estimated for each triage strategy during a 1-year and lifetime horizon using a decision analytic Markov model. We considered an incremental cost-effectiveness ratio threshold of <$100,000 to be cost-effective. RESULTS For these 6 regions, a high-sensitivity triage strategy consistent with national trauma policy (sensitivity 98.6%, specificity 17.1%) would cost $1,317,333 per QALY gained, and current triage practices (sensitivity 87.2%, specificity 64.0%) cost $88,000 per QALY gained, compared with a moderate sensitivity strategy (sensitivity 71.2%, specificity 66.5%). Refining emergency medical services transport patterns by triage status improved cost-effectiveness. At the trauma-system level, a high-sensitivity triage strategy would save 3.7 additional lives per year at a 1-year cost of $8.78 million, and a moderate sensitivity approach would cost 5.2 additional lives and save $781,616 each year. CONCLUSIONS A high-sensitivity approach to field triage consistent with national trauma policy is not cost-effective. The most cost-effective approach to field triage appears closely tied to triage specificity and adherence to triage-based emergency medical services transport practices.
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Affiliation(s)
- Craig D Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR.
| | - Zhuo Yang
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Daniel Nishijima
- Department of Emergency Medicine, University of California at Davis, Sacramento, CA
| | - K John McConnell
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR; Center for Health Systems Effectiveness, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | - Stacy A Trent
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO; Department of Epidemiology, Colorado School of Public Health, University of Colorado School of Medicine, Aurora, CO
| | - James F Holmes
- Department of Emergency Medicine, University of California at Davis, Sacramento, CA
| | - Mohamud Daya
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | - N Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Renee Y Hsia
- Department of Emergency Medicine, Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco General Hospital, San Francisco, CA
| | - Tom D Rea
- Department of Medicine, University of Washington, Seattle, WA
| | - N Ewen Wang
- Department of Emergency Medicine, Stanford University, Palo Alto, CA
| | | | - M Kit Delgado
- Department of Emergency Medicine, Center for Emergency Care Policy Research, Center for Clinical Epidemiology and Biostatistics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Shea KM, Ladd ER, Lipman GS, Bagley P, Pirrotta EA, Vongsachang H, Wang NE, Auerbach PS. The 6-Minute Walk Test as a Predictor of Summit Success on Denali. Wilderness Environ Med 2015; 27:19-24. [PMID: 26712335 DOI: 10.1016/j.wem.2015.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 09/15/2015] [Accepted: 10/06/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To test whether the 6-minute walk test (6MWT), including postexercise vital sign measurements and distance walked, predicts summit success on Denali, AK. METHODS This was a prospective observational study of healthy volunteers between the ages of 18 and 65 years who had been at 4267 m for less than 24 hours on Denali. Physiologic measurements were made after the 6MWT. Subjects then attempted to summit at their own pace and, at the time of descent, completed a Lake Louise Acute Mountain Sickness Questionnaire and reported maximum elevation reached. RESULTS One hundred twenty-one participants enrolled in the study. Data were collected on 111 subjects (92% response rate), of whom 60% summited. On univariate analysis, there was no association between any postexercise vital sign and summit success. Specifically, there was no significant difference in the mean postexercise peripheral oxygen saturation (Spo2) between summiters (75%) and nonsummiters (74%; 95% CI, -3 to 1; P = .37). The distance a subject walked in 6 minutes (6MWTD) was longer in summiters (617 m) compared with nonsummiters (560 m; 95% CI, 7.6 to 106; P = .02). However, this significance was not maintained on a multivariate analysis performed to control for age, sex, and guide status (P = .08), leading to the conclusion that 6MWTD was not a robust predictor of summit success. CONCLUSIONS This study did not show a correlation between postexercise oxygen saturation or 6MWTD and summit success on Denali.
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Affiliation(s)
- Katherine M Shea
- Stanford/Kaiser Emergency Medicine Residency Program, Stanford, CA (Drs Shea and Ladd).
| | - Eric R Ladd
- Stanford/Kaiser Emergency Medicine Residency Program, Stanford, CA (Drs Shea and Ladd)
| | - Grant S Lipman
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA (Drs Lipman, Wang, and Auerbach; Ms Pirrotta, and Ms Vongsachang)
| | - Patrick Bagley
- University of New England College of Osteopathic Medicine, Biddeford, ME (Mr Bagley)
| | - Elizabeth A Pirrotta
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA (Drs Lipman, Wang, and Auerbach; Ms Pirrotta, and Ms Vongsachang)
| | - Hurnan Vongsachang
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA (Drs Lipman, Wang, and Auerbach; Ms Pirrotta, and Ms Vongsachang)
| | - N Ewen Wang
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA (Drs Lipman, Wang, and Auerbach; Ms Pirrotta, and Ms Vongsachang)
| | - Paul S Auerbach
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA (Drs Lipman, Wang, and Auerbach; Ms Pirrotta, and Ms Vongsachang)
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Yokell MA, Delgado MK, Zaller ND, Wang NE, McGowan SK, Green TC. Presentation of prescription and nonprescription opioid overdoses to US emergency departments. JAMA Intern Med 2014; 174:2034-7. [PMID: 25347221 DOI: 10.1001/jamainternmed.2014.5413] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Michael A Yokell
- Division of Emergency Medicine, Stanford University School of Medicine, Stanford, California
| | - M Kit Delgado
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia3Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nickolas D Zaller
- Division of Infectious Diseases, The Miriam Hospital, Providence, Rhode Island5Department of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island6currently affiliated with Boozman College of Public Health, Univer
| | - N Ewen Wang
- Division of Emergency Medicine, Stanford University School of Medicine and Stanford Hospital, Stanford, California
| | | | - Traci Craig Green
- Department of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island9Department of Emergency Medicine, Rhode Island Hospital, Providence
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Delgado MK, Yokell MA, Staudenmayer KL, Spain DA, Hernandez-Boussard T, Wang NE. Factors associated with the disposition of severely injured patients initially seen at non–trauma center emergency departments: disparities by insurance status. JAMA Surg 2014; 149:422-30. [PMID: 24554059 DOI: 10.1001/jamasurg.2013.4398] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Trauma is the leading cause of potential years of life lost before age 65 years in the United States. Timely care in a designated trauma center has been shown to reduce mortality by 25%. However, many severely injured patients are not transferred to trauma centers after initially being seen at non–trauma center emergency departments (EDs). OBJECTIVES To determine patient-level and hospital-level factors associated with the decision to admit rather than transfer severely injured patients who are initially seen at non–trauma center EDs and to ascertain whether insured patients are more likely to be admitted than transferred compared with uninsured patients. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of the 2009 Nationwide Emergency Department Sample. We included all ED encounters for major trauma (Injury Severity Score, >15) seen at non–trauma centers in patients aged 18 to 64 years. We excluded ED discharges and ED deaths. We quantified the absolute risk difference between admission vs transfer by insurance status, while adjusting for age, sex, mechanism of injury, Injury Severity Score, weekend admission and month of visit, and urban vs rural status and median household income of the home zip code, as well as annual ED visit volume and teaching status and US region. MAIN OUTCOMES AND MEASURES Inpatient admission vs transfer to another acute care facility. RESULTS In 2009, a total of 4513 observations from 636 non–trauma center EDs were available for analysis, representing a nationally weighted population of 19,312 non–trauma center ED encounters for major trauma. Overall, 54.5% in 2009 were admitted to the non–trauma center. Compared with patients without insurance, the adjusted absolute risk of admission vs transfer was 14.3% (95% CI, 9.2%-19.4%) higher for patients with Medicaid and 11.2% (95% CI, 6.9%-15.4%) higher for patients with private insurance. Other factors associated with admission vs transfer included severe abdominal injuries (risk difference, 15.9%; 95% CI, 9.4%-22.3%), urban teaching hospital vs non–teaching hospital (risk difference, 26.2%; 95% CI, 15.2%-37.2%), and annual ED visit volume (risk difference, 3.4%; 95% CI, 1.6%-5.3% higher for every additional 10,000 annual ED visits). CONCLUSIONS AND RELEVANCE Patients with severe injuries initially evaluated at non–trauma center EDs were less likely to be transferred if insured and were at risk of receiving suboptimal trauma care. Efforts in monitoring and optimizing trauma interhospital transfers and outcomes at the population level are warranted.
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Ladd ER, Shea KM, Lipman GS, Bagley P, Pirrotta E, Vongsachang H, Ewen Wang N, Auerbach PS. Hydration Status as Predictor of Summit Success on Mount McKinley. Wilderness Environ Med 2014. [DOI: 10.1016/j.wem.2014.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Vogel LD, Vongsachang H, Pirrotta E, Holmes JM, Sherck J, Newton C, D'Souza P, Spain DA, Wang NE. Variations in pediatric trauma transfer patterns in Northern California pediatric trauma centers (2001-2009). Acad Emerg Med 2014; 21:1023-30. [PMID: 25269583 DOI: 10.1111/acem.12463] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 04/30/2014] [Accepted: 05/23/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Due to the scarcity of specialized resources for pediatric trauma, "regionalization," or a system designed to get "the right child, to the right place, at the right time," is vital to quality pediatric trauma care. In Northern California, four pediatric trauma centers serve 3.9 million children within a geographically diverse area of 113,630 square miles. A significant proportion of children with trauma is initially triaged to nontrauma hospitals and may require subsequent transfer to a specialty center. Trauma transfer patterns to a pediatric trauma center may provide insight into regional primary triage practices. Transfers from hospitals in close proximity to pediatric trauma centers might suggest that some children could have avoided transfer with minimal additional transport time. While pediatric trauma centers are scarce and serve as regional resources, transfers from beyond the regular catchment area of a trauma center could be an indication of clinical need. OBJECTIVES The objective of this study was to gain an understanding of patterns of pediatric trauma transfer to all pediatric trauma centers within the region as a first step in assessing the efficacy and efficiency of trauma triage. The authors examined three groups of transfer patients: transfers from within the same county as the pediatric trauma center (near transfers), transfers from counties adjacent to the pediatric trauma center (catchment transfers), and transfers from more distant counties (far transfers). The hypothesis was that catchment transfers would form the bulk of transfers, near transfers would compose < 10% of total transfers, and far transfers would be younger and more severely injured than catchment transfers. METHODS This was a retrospective analysis of institutional trauma registry data of children < 18 years from all pediatric trauma centers in Northern California from 2001 through 2009. Transfers were characterized by the location of the transfer hospital relative to the location of the pediatric trauma center. Characteristics associated with near transfer compared to primary triage to a pediatric trauma center were identified, as well as characteristics associated with far transfer compared to catchment transfer. RESULTS A total of 2,852 of 11,952 (23.9%) pediatric trauma patients were transfers. Near transfers comprised 24.5% of cases, catchment transfers were 37.4%, and far transfers were 38.2%. After controlling for demographic, clinical, and geographic factors, younger age, higher Injury Severity Score (ISS), public versus private insurance, and an injury mechanism of "fall" were associated with near transfer rather than direct triage. Older age, higher ISS, and mechanism of "motor vehicle crash" were associated with far rather than catchment transfer. CONCLUSIONS This analysis of patterns of transfer to all pediatric trauma centers within Northern California gives the most comprehensive population view of pediatric trauma triage to date, to the authors' knowledge. Trauma transfers comprise an important minority of patients cared for at pediatric trauma centers. The number of near transfers documented indicates the potential to improve the primary triage process of patients to pediatric trauma centers. The frequency of far transfers substantiates the well-known shortage of pediatric trauma expertise. Development of regionwide standardized transfer protocols and agreements between hospitals, as well as standardized monitoring of the process and outcomes, could increase efficiency of care.
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Affiliation(s)
- Lara D. Vogel
- The Stanford University School of Medicine; Stanford CA
| | - Hurnan Vongsachang
- The Division of Emergency Medicine; Stanford University School of Medicine; Stanford CA
| | - Elizabeth Pirrotta
- The Division of Emergency Medicine; Stanford University School of Medicine; Stanford CA
| | - James M. Holmes
- The Department of Emergency Medicine; University of California at Davis; School of Medicine; Sacramento CA
| | - John Sherck
- The Department of Surgery; Santa Clara Valley Medical Center; San Jose CA
| | | | - Peter D'Souza
- The Division of Emergency Medicine; Stanford University School of Medicine; Stanford CA
| | - David A. Spain
- The Division of Trauma and Critical Care Surgery; Stanford University School of Medicine; Stanford CA
| | - N. Ewen Wang
- The Division of Emergency Medicine; Stanford University School of Medicine; Stanford CA
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Kanak M, Delgado MK, Camargo CA, Wang NE. Availability of insurance linkage programs in U.S. Emergency departments. West J Emerg Med 2014; 15:529-35. [PMID: 25035763 PMCID: PMC4100863 DOI: 10.5811/westjem.2014.4.20223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 03/22/2014] [Accepted: 04/15/2014] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION As millions of uninsured citizens who use emergency department (ED) services are now eligible for health insurance under the Affordable Care Act, the ED is ideally situated to facilitate linkage to insurance. Forty percent of U.S. EDs report having an insurance linkage program. This is the first national study to examine the characteristics of EDs that offer or do not offer these programs. METHODS This was a secondary analysis of data from the National Survey for Preventive Health Services in U.S. EDs conducted in 2008-09. We compared EDs with and without insurance programs across demographic and operational factors using univariate analysis. We then tested our hypotheses using multivariable logistic regression. We also further examined program capacity and priority among the sub-group of EDs with no insurance linkage program. RESULTS After adjustment, ED-insurance linkage programs were more likely to be located in the West (RR= 2.06, 95% CI = 1.33 - 2.72). The proportion of uninsured patients in an ED, teaching hospital status, and public ownership status were not associated with insurance linkage availability. EDs with linkage programs also offer more preventive services (RR = 1.87, 95% CI = 1.37-2.35) and have greater social worker availability (RR = 1.71, 95% CI = 1.12-2.33) than those who do not. Four of five EDs with a patient mix of ≥25% uninsured and no insurance linkage program reported that they could not offer a program with existing staff and funding. CONCLUSION Availability of insurance linkage programs in the ED is not associated with the proportion of uninsured patients served by an ED. Policy or hospital-based interventions to increase insurance linkage should first target the 27% of EDs with high rates of uninsured patients that lack adequate program capacity. Further research on barriers to implementation and cost effectiveness may help to facilitate increased adoption of insurance linkage programs.
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Affiliation(s)
- Mia Kanak
- Stanford University School of Medicine, Stanford, California
| | - M Kit Delgado
- Department of Emergency Medicine and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - N Ewen Wang
- Division of Emergency Medicine, Stanford University School of Medicine, Stanford, California
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Yokell MA, Camargo CA, Wang NE, Delgado MK. Characteristics of United States emergency departments that routinely perform alcohol risk screening and counseling for patients presenting with drinking-related complaints. West J Emerg Med 2014; 15:438-45. [PMID: 25035750 PMCID: PMC4100850 DOI: 10.5811/westjem.2013.12.18833] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Revised: 10/17/2013] [Accepted: 12/19/2013] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Emergency department (ED) screening and counseling for alcohol misuse have been shown to reduce at-risk drinking. However, barriers to more widespread adoption of this service remain unclear. METHODS We performed a secondary analysis of a nationwide survey of 277 EDs to determine the proportion of EDs that routinely perform alcohol screening and counseling among patients presenting with alcohol-related complaints and to identify potential institutional barriers and facilitators to routine screening and counseling. The survey was randomly mailed to 350 EDs sampled from the 2007 National Emergency Department Inventory (NEDI), with 80% of ED medical directors responding after receiving the mailing or follow-up fax/email. The survey asked about a variety of preventive services and ED directors' opinions regarding perceived barriers to offering preventive services in their EDs. RESULTS Overall, only 27% of all EDs and 22% of Level I/II trauma center EDs reported routinely screening and counseling patients presenting with drinking-related complaints. Rates of routine screening and counseling were similar across geographic areas, crowding status, and urban-rural status. EDs that performed routine screening and counseling often offered other preventive services, such as tobacco cessation (P<0.01) and primary care linkage (P=0.01). EDs with directors who expressed concern about increased financial costs to the ED, inadequate follow-up, and diversion of nurse/physician time all had lower rates of screening and counseling and also more frequently reported lacking the perceived capacity to perform routine counseling and screening. Among EDs that did not routinely perform alcohol screening and counseling, more crowded than non-crowded (P<0.01) and more metro than rural (P<0.01) EDs reported lacking the capacity to perform routine screening and counseling. The capacity to perform routine screening also decreased as ED visit volume increased (P=0.04). CONCLUSION To increase routine alcohol screening and counseling for patients presenting with alcohol-related complaints, ED directors' perceived barriers related to an ED's capacity to perform screening, such as limited financial and staff resources, should be addressed, as should directors' concerns regarding the implementation of preventive health services in EDs. Uniform reimbursement methods should be used to increase ED compensation for performing this important and effective service.
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Affiliation(s)
- Michael A. Yokell
- Stanford University School of Medicine, Department of Emergency Medicine, Stanford, California
| | - Carlos A. Camargo
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - N. Ewen Wang
- Stanford University School of Medicine, Department of Emergency Medicine, Stanford, California
| | - M. Kit Delgado
- University of Pennsylvania, Department of Emergency Medicine, Philadelphia, Pennsylvania
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Barnett AS, Wang NE, Sahni R, Hsia RY, Haukoos JS, Barton ED, Holmes JF, Newgard CD. Variation in prehospital use and uptake of the national Field Triage Decision Scheme. PREHOSP EMERG CARE 2014; 17:135-48. [PMID: 23452003 DOI: 10.3109/10903127.2012.749966] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The Field Triage Decision Scheme is a national guideline that has been implemented widely for prehospital emergency medical services (EMS) and trauma systems. However, little is known about the uptake, modification, or variation in field application of triage criteria between trauma systems. OBJECTIVE To describe and compare the use of field triage criteria by EMS personnel in six regions, including the timing of guideline uptake and the use of nonguideline criteria. METHODS This was a retrospective cohort study of injured children and adults transported by 48 EMS agencies to 105 hospitals (trauma centers and non-trauma centers) in six Western U.S. regions from 2006 through 2008. We used probabilistic linkage to match patient-level prehospital information from multiple sources, including EMS records, base-hospital phone communication records, and trauma registry data files. Triage criteria were evaluated individually and grouped by "steps" (physiologic, anatomic, mechanism, and special considerations). We used descriptive statistics to compare the frequency of triage criteria use (overall and between regions) and to evaluate the timing of guideline uptake across multiple versions of the guidelines. RESULTS A total of 260,027 injured patients were evaluated and transported by EMS over the three-year study period, of whom 46,414 (18%) met at least one field triage criterion and formed the primary sample for analysis. The three most common criteria cited (of 33 in use) were EMS provider judgment (26%), age <5 or >55 years (10%), and Glasgow Coma Scale (GCS) score <14 (9%). Of the 33 criteria in use, five (15%) were previously retired from the guidelines and seven (21%) were never included in the guidelines. 11,048 (24%) patients had more than one criterion applied (range 1-21). There was large variation in the type and frequency of criteria used between systems, particularly among the nonphysiologic triage steps. Only one of six regions had translated the most recent guidelines into field use within two years after release. CONCLUSION There is large variation between regions in the frequency and type of field triage criteria used. Field uptake of guideline revisions appears to be slow and variable, suggesting opportunities for improvement in dissemination and implementation of updated guidelines.
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Affiliation(s)
- Andy S Barnett
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon 97239-3098, USA
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Abstract
PURPOSE To determine the agents used by emergency medicine (EM) physicians in pediatric procedural sedation and the associated adverse events (AEs) and to provide recommendations for optimizing drug therapy in pediatric patients. METHODS We conducted a prospective study at Stanford Hospital's pediatric emergency department (ED) from April 2007 to April 2008 to determine the medications most frequently used in pediatric procedural sedation as well as their effectiveness and AEs. Patients, 18 years old or younger, who required procedural sedation in the pediatric ED were eligible for the study. The data collected included medical record number, sex, age, height, weight, procedure type and length, physician, and agents used. For each agent, the dose, route, time from administration to onset of sedation, duration of sedation, AEs, and sedation score were recorded. Use of supplemental oxygen and interventions during procedural sedation were also recorded. RESULTS We found that in a convenience sample of 196 children (202 procedures) receiving procedural sedation in a university-based ED, 8 different medications were used (ketamine, etomidate, fentanyl, hydromorphone, methohexital, midazolam, pentobarbital, and thiopental). Ketamine was the most frequently used medication (88%), regardless of the procedure. Only twice in the study was the medication that was initially used for procedural sedation changed completely. Fracture reduction was the most frequently performed procedure (41%), followed by laceration/suture repair (32%). There were no serious AEs reported. CONCLUSION EM-trained physicians can safely perform pediatric procedural sedation in the ED. In the pediatric ED, the most common procedure requiring conscious sedation is fracture reduction, with ketamine as the preferred agent.
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Affiliation(s)
- Magdalena E Cudny
- Clinical Pharmacist, Department of Pharmacy, Stanford Hospital and Clinics, Stanford, California
| | - N Ewen Wang
- Associate Professor, Department of Surgery, Division of Emergency Medicine, Stanford University School of Medicine, and Associate Director of Pediatric Emergency Medicine, Stanford Hospital and Clinics, Stanford, California
| | - Sandra L Bardas
- Clinical Pharmacist, Emergency Medicine, Stanford Hospital and Clinics, Stanford, California
| | - Carolyn N Nguyen
- Clinical Pharmacist, Emergency Medicine, Stanford Hospital and Clinics, Stanford, California
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Cudny ME, Wang NE, Bardas SL, Nguyen CN. Adverse events associated with procedural sedation in pediatric patients in the emergency department. Hosp Pharm 2014; 48:134-42. [PMID: 24421451 DOI: 10.1310/hpj4802-134] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the agents used by emergency medicine (EM) physicians in pediatric procedural sedation and the associated adverse events (AEs) and to provide recommendations for optimizing drug therapy in pediatric patients. METHODS We conducted a prospective study at Stanford Hospital's pediatric emergency department (ED) from April 2007 to April 2008 to determine the medications most frequently used in pediatric procedural sedation as well as their effectiveness and AEs. Patients, 18 years old or younger, who required procedural sedation in the pediatric ED were eligible for the study. The data collected included medical record number, sex, age, height, weight, procedure type and length, physician, and agents used. For each agent, the dose, route, time from administration to onset of sedation, duration of sedation, AEs, and sedation score were recorded. Use of supplemental oxygen and interventions during procedural sedation were also recorded. RESULTS We found that in a convenience sample of 196 children (202 procedures) receiving procedural sedation in a university-based ED, 8 different medications were used (ketamine, etomidate, fentanyl, hydromorphone, methohexital, midazolam, pentobarbital, and thiopental). Ketamine was the most frequently used medication (88%), regardless of the procedure. Only twice in the study was the medication that was initially used for procedural sedation changed completely. Fracture reduction was the most frequently performed procedure (41%), followed by laceration/suture repair (32%). There were no serious AEs reported. CONCLUSION EM-trained physicians can safely perform pediatric procedural sedation in the ED. In the pediatric ED, the most common procedure requiring conscious sedation is fracture reduction, with ketamine as the preferred agent.
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Affiliation(s)
- Magdalena E Cudny
- Clinical Pharmacist, Department of Pharmacy, Stanford Hospital and Clinics, Stanford, California
| | - N Ewen Wang
- Associate Professor, Department of Surgery, Division of Emergency Medicine, Stanford University School of Medicine, and Associate Director of Pediatric Emergency Medicine, Stanford Hospital and Clinics, Stanford, California
| | - Sandra L Bardas
- Clinical Pharmacist, Emergency Medicine, Stanford Hospital and Clinics, Stanford, California
| | - Carolyn N Nguyen
- Clinical Pharmacist, Emergency Medicine, Stanford Hospital and Clinics, Stanford, California
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Newgard CD, Kuppermann N, Holmes JF, Haukoos JS, Wetzel B, Hsia RY, Wang NE, Bulger EM, Staudenmayer K, Mann NC, Barton ED, Wintemute G. Gunshot injuries in children served by emergency services. Pediatrics 2013; 132:862-70. [PMID: 24127481 PMCID: PMC3813400 DOI: 10.1542/peds.2013-1350] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To describe the incidence, injury severity, resource use, mortality, and costs for children with gunshot injuries, compared with other injury mechanisms. METHODS This was a population-based, retrospective cohort study (January 1, 2006-December 31, 2008) including all injured children age ≤ 19 years with a 9-1-1 response from 47 emergency medical services agencies transporting to 93 hospitals in 5 regions of the western United States. Outcomes included population-adjusted incidence, injury severity score ≥ 16, major surgery, blood transfusion, mortality, and average per-patient acute care costs. RESULTS A total of 49,983 injured children had a 9-1-1 emergency medical services response, including 505 (1.0%) with gunshot injuries (83.2% age 15-19 years, 84.5% male). The population-adjusted annual incidence of gunshot injuries was 7.5 cases/100,000 children, which varied 16-fold between regions. Compared with children who had other mechanisms of injury, those injured by gunshot had the highest proportion of serious injuries (23%, 95% confidence interval [CI] 17.6-28.4), major surgery (32%, 95% CI 26.1-38.5), in-hospital mortality (8.0%, 95% CI 4.7-11.4), and costs ($28,510 per patient, 95% CI 22,193-34,827). CONCLUSIONS Despite being less common than other injury mechanisms, gunshot injuries cause a disproportionate burden of adverse outcomes in children, particularly among older adolescent males. Public health, injury prevention, and health policy solutions are needed to reduce gunshot injuries in children.
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Affiliation(s)
- Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California at Davis, Sacramento, California
| | - James F. Holmes
- Department of Emergency Medicine, University of California at Davis, Sacramento, California
| | - Jason S. Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado;,Department of Epidemiology, Colorado School of Public Health, University of Colorado School of Medicine, Aurora, Colorado
| | - Brian Wetzel
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Renee Y. Hsia
- Department of Emergency Medicine, University of California San Francisco, San Francisco General Hospital, San Francisco, California
| | | | - Eileen M. Bulger
- Department of Surgery, University of Washington, Seattle, Washington
| | | | - N. Clay Mann
- Intermountain Injury Control Research Center, University of Utah, Salt Lake City, Utah; and
| | - Erik D. Barton
- Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Garen Wintemute
- Department of Emergency Medicine, University of California at Davis, Sacramento, California
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Delgado MK, Staudenmayer KL, Wang NE, Spain DA, Weir S, Owens DK, Goldhaber-Fiebert JD. Cost-effectiveness of helicopter versus ground emergency medical services for trauma scene transport in the United States. Ann Emerg Med 2013; 62:351-364.e19. [PMID: 23582619 PMCID: PMC3999834 DOI: 10.1016/j.annemergmed.2013.02.025] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 02/15/2013] [Accepted: 02/26/2013] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE We determine the minimum mortality reduction that helicopter emergency medical services (EMS) should provide relative to ground EMS for the scene transport of trauma victims to offset higher costs, inherent transport risks, and inevitable overtriage of patients with minor injury. METHODS We developed a decision-analytic model to compare the costs and outcomes of helicopter versus ground EMS transport to a trauma center from a societal perspective during a patient's lifetime. We determined the mortality reduction needed to make helicopter transport cost less than $100,000 and $50,000 per quality-adjusted life-year gained compared with ground EMS. Model inputs were derived from the National Study on the Costs and Outcomes of Trauma, National Trauma Data Bank, Medicare reimbursements, and literature. We assessed robustness with probabilistic sensitivity analyses. RESULTS Helicopter EMS must provide a minimum of a 15% relative risk reduction in mortality (1.3 lives saved/100 patients with the mean characteristics of the National Study on the Costs and Outcomes of Trauma cohort) to cost less than $100,000 per quality-adjusted life-year gained and a reduction of at least 30% (3.3 lives saved/100 patients) to cost less than $50,000 per quality-adjusted life-year. Helicopter EMS becomes more cost-effective with significant reductions in patients with minor injury who are triaged to air transport or if long-term disability outcomes are improved. CONCLUSION Helicopter EMS needs to provide at least a 15% mortality reduction or a measurable improvement in long-term disability to compare favorably with other interventions considered cost-effective. Given current evidence, it is not clear that helicopter EMS achieves this mortality or disability reduction. Reducing overtriage of patients with minor injury to helicopter EMS would improve its cost-effectiveness.
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Affiliation(s)
- M. Kit Delgado
- Department of Surgery, Division of Emergency Medicine, Stanford University School of Medicine
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine
- Stanford Investigators for Surgery, Trauma, and Emergency Medicine (SISTEM), Stanford University School of Medicine
| | - Kristan L. Staudenmayer
- Department of Surgery, Division of General Surgery, Trauma/Critical Care Section, Stanford University School of Medicine
- Stanford Investigators for Surgery, Trauma, and Emergency Medicine (SISTEM), Stanford University School of Medicine
| | - N. Ewen Wang
- Department of Surgery, Division of Emergency Medicine, Stanford University School of Medicine
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine
- Stanford Investigators for Surgery, Trauma, and Emergency Medicine (SISTEM), Stanford University School of Medicine
| | - David A. Spain
- Department of Surgery, Division of General Surgery, Trauma/Critical Care Section, Stanford University School of Medicine
- Stanford Investigators for Surgery, Trauma, and Emergency Medicine (SISTEM), Stanford University School of Medicine
| | - Sharada Weir
- University of Massachusetts School of Medicine, Center for Health Policy and Research, Stanford University School of Medicine
| | - Douglas K. Owens
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine
- VA Palo Alto Health Care System, Palo Alto CA, Stanford University School of Medicine
| | - Jeremy D. Goldhaber-Fiebert
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine
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Vogel L, Pirrotta E, Ewen Wang N. A Population-Wide Study of Pediatric Access to Trauma Centers in California, 2005-2011. Ann Emerg Med 2013. [DOI: 10.1016/j.annemergmed.2013.07.467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Mell MW, Wang NE, Morrison DE, Hernandez-Boussard T. No Difference in Mortality After Inter-Facility Transfer for Patients with Ruptured Abdominal Aortic Aneurysm. J Vasc Surg 2013. [DOI: 10.1016/j.jvs.2013.05.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Newgard CD, Hsia RY, Mann NC, Schmidt T, Sahni R, Bulger EM, Wang NE, Holmes JF, Fleischman R, Zive D, Staudenmayer K, Haukoos JS, Kuppermann N. The trade-offs in field trauma triage: a multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies. J Trauma Acute Care Surg 2013; 74:1298-306; discussion 1306. [PMID: 23609282 PMCID: PMC3726266 DOI: 10.1097/ta.0b013e31828b7848] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND National benchmarks for trauma triage sensitivity (≥95%) and specificity (≥50%) have not been rigorously evaluated across broad populations of injured patients. We evaluated the impact of different field triage schemes for identifying seriously injured patients across a range of sensitivity values. Impact metrics included specificity and number of undertriaged and overtriaged patients compared with current triage practices. METHODS This was a retrospective cohort study of injured children and adults transported by 48 emergency medical service (EMS) agencies to 105 hospitals in 6 regions of the Western United States from 2006 through 2008. Hospital outcomes were probabilistically linked to EMS records through trauma registries, state discharge databases, and state emergency department databases. The primary outcome was an Injury Severity Score (ISS) of 16 or greater. We evaluated 40 field predictor variables, including 31 current field triage criteria, using classification and regression tree analysis and cross-validation to generate estimates for sensitivity and specificity. RESULTS A total of 89,261 injured patients were evaluated and transported by EMS providers during the 3-year period, of whom 5,711 (6.4%) had ISS of 16 or greater. As the 95% sensitivity target for triage was approached (from the current value of 87.5%), decision tree complexity increased, specificity decreased (from 62.8% to 18.7%), and the number of triage-positive patients without serious injury doubled (67,927 vs. 31,104). Analyses restricted to children and older adults were similar. The most consistent modification to the current triage algorithm to increase sensitivity without a major decrease in specificity was altering the Glasgow Coma Scale (GCS) score cutoff point from 13 or less to 14 or less (sensitivity increase to 90.4%). CONCLUSION Reaching the field triage sensitivity benchmark of 95% would require a large decrease in specificity (increase in overtriage). A 90% sensitivity target seems more realistic and may be obtainable by modest changes to the current triage algorithm.
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Affiliation(s)
- Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Renee Y. Hsia
- Department of Emergency Medicine, University of California San Francisco, San Francisco General Hospital, San Francisco, California
| | - N. Clay Mann
- Intermountain Injury Control Research Center, University of Utah, Salt Lake City, Utah
| | - Terri Schmidt
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
- Clackamas County American Medical Response, Clackamas, Oregon
| | - Ritu Sahni
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
- Lake Oswego Fire Department, Lake Oswego, Oregon
| | - Eileen M. Bulger
- Department of Surgery, University of Washington, Seattle, Washington
| | - N. Ewen Wang
- Department of Emergency Medicine, Stanford University, Palo Alto, California
| | - James F. Holmes
- Department of Emergency Medicine, University of California at Davis, Sacramento, California
| | - Ross Fleischman
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Dana Zive
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Jason S. Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado, Department of Epidemiology, Colorado School of Public Health, University of Colorado School of Medicine, Aurora, Colorado
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California at Davis, Sacramento, California
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Huffman LC, Wang NE, Saynina O, Wren FJ, Wise PH, Horwitz SM. Predictors of hospitalization after an emergency department visit for California youths with psychiatric disorders. Psychiatr Serv 2012; 63:896-905. [PMID: 22710574 DOI: 10.1176/appi.ps.201000482] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study examined patient, hospital, and county characteristics associated with hospitalization after emergency department visits for pediatric mental health problems. METHODS Retrospective analysis of emergency department encounters (N=324,997) of youths age five years to 17 years with psychiatric diagnoses was conducted with 2005-2009 California Office of Statewide Health Planning and Development emergency department statewide data. RESULTS For youths with any psychiatric diagnosis, 23.4% of emergency department encounters resulted in hospitalization. In these cases, hospitalization largely was predicted by clinical need. Nonclinical factors that decreased the likelihood of hospitalization included demographic characteristics (such as younger age, lack of insurance, and rural residence) and resource characteristics (private hospital ownership, lack of psychiatric consultation in the emergency department, and lack of pediatric psychiatric beds). For youths with a significant psychiatric diagnosis plus a suicide attempt, 53.8% of emergency department encounters resulted in hospitalization. In these presumably more life-threatening cases, nonclinical factors that decreased the likelihood of hospitalization persisted: demographic characteristics (lack of insurance and rural residence) and resource characteristics (public hospital ownership, lack of psychiatric consultation, and lack of pediatric psychiatric beds). CONCLUSIONS Mental health service delivery can improve only by addressing nonclinical demographic and resource obstacles that independently decrease the likelihood of hospitalization after an emergency department visit for a mental health issue; this is true even for the most severely ill youths-those with a suicide attempt as well as a serious psychiatric diagnosis.
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Affiliation(s)
- Lynne C Huffman
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA.
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Newgard CD, Kampp M, Nelson M, Holmes JF, Zive D, Rea T, Bulger EM, Liao M, Sherck J, Hsia RY, Wang NE, Fleischman RJ, Barton ED, Daya M, Heineman J, Kuppermann N. Deciphering the use and predictive value of "emergency medical services provider judgment" in out-of-hospital trauma triage: a multisite, mixed methods assessment. J Trauma Acute Care Surg 2012; 72:1239-48. [PMID: 22673250 PMCID: PMC3376024 DOI: 10.1097/ta.0b013e3182468b51] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND "Emergency medical services (EMS) provider judgment" was recently added as a field triage criterion to the national guidelines, yet its predictive value and real world application remain unclear. We examine the use and independent predictive value of EMS provider judgment in identifying seriously injured persons. METHODS We analyzed a population-based retrospective cohort, supplemented by qualitative analysis, of injured children and adults evaluated and transported by 47 EMS agencies to 94 hospitals in five regions across the Western United States from 2006 to 2008. We used logistic regression models to evaluate the independent predictive value of EMS provider judgment for Injury Severity Score ≥ 16. EMS narratives were analyzed using qualitative methods to assess and compare common themes for each step in the triage algorithm, plus EMS provider judgment. RESULTS 213,869 injured patients were evaluated and transported by EMS over the 3-year period, of whom 41,191 (19.3%) met at least one of the field triage criteria. EMS provider judgment was the most commonly used triage criterion (40.0% of all triage-positive patients; sole criterion in 21.4%). After accounting for other triage criteria and confounders, the adjusted odds ratio of Injury Severity Score ≥ 16 for EMS provider judgment was 1.23 (95% confidence interval, 1.03-1.47), although there was variability in predictive value across sites. Patients meeting EMS provider judgment had concerning clinical presentations qualitatively similar to those meeting mechanistic and other special considerations criteria. CONCLUSIONS Among this multisite cohort of trauma patients, EMS provider judgment was the most commonly used field trauma triage criterion, independently associated with serious injury, and useful in identifying high-risk patients missed by other criteria. However, there was variability in predictive value between sites.
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Affiliation(s)
- Craig D Newgard
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland, Oregon 97239-3098, USA.
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Arroyo AC, Ewen Wang N, Saynina O, Bhattacharya J, Wise PH. The association between insurance status and emergency department disposition of injured California children. Acad Emerg Med 2012; 19:541-51. [PMID: 22594358 DOI: 10.1111/j.1553-2712.2012.01356.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This study examined the relationship between insurance status and emergency department (ED) disposition of injured California children. METHODS Multivariate regression models were built using data obtained from the 2005 through 2009 California Office of Statewide Health Planning and Development (OSHPD) data sets for all ED visits by injured children younger than 19 years of age. RESULTS Of 3,519,530 injury-related ED visits, 52% were insured by private, and 36% were insured by public insurance, while 11% of visits were not insured. After adjustment for injury characteristics and demographic variables, publicly insured children had a higher likelihood of admission for mild, moderate, and severe injuries compared to privately insured children (mild injury adjusted odds ratio [AOR] = 1.36, 95% confidence interval [CI] = 1.34 to 1.39; moderate and severe injury AOR = 1.34, 95% CI = 1.28 to 1.41). However, uninsured children were less likely to be admitted for mild, moderate, and severe injuries compared to privately insured children (mild injury AOR = 0.63, 95% CI = 0.61 to 0.66; moderate and severe injury AOR = 0.50, 95% CI = 0.46 to 0.55). While publicly insured children with moderate and severe injuries were as likely as privately insured children to experience an ED death (AOR = 0.91, 95% CI = 0.70 to 1.18), uninsured children with moderate and severe injuries were more likely to die in the ED compared to privately insured children (AOR = 3.11, 95% CI = 2.38 to 4.06). CONCLUSIONS Privately insured, publicly insured, and uninsured injured children have disparate patterns of ED disposition. Policy and clinical efforts are needed to ensure that all injured children receive equitable emergency care.
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Newgard C, Malveau S, Staudenmayer K, Wang NE, Hsia RY, Mann NC, Holmes JF, Kuppermann N, Haukoos JS, Bulger EM, Dai M, Cook LJ. Evaluating the use of existing data sources, probabilistic linkage, and multiple imputation to build population-based injury databases across phases of trauma care. Acad Emerg Med 2012; 19:469-80. [PMID: 22506952 DOI: 10.1111/j.1553-2712.2012.01324.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective was to evaluate the process of using existing data sources, probabilistic linkage, and multiple imputation to create large population-based injury databases matched to outcomes. METHODS This was a retrospective cohort study of injured children and adults transported by 94 emergency medical systems (EMS) agencies to 122 hospitals in seven regions of the western United States over a 36-month period (2006 to 2008). All injured patients evaluated by EMS personnel within specific geographic catchment areas were included, regardless of field disposition or outcome. The authors performed probabilistic linkage of EMS records to four hospital and postdischarge data sources (emergency department [ED] data, patient discharge data, trauma registries, and vital statistics files) and then handled missing values using multiple imputation. The authors compare and evaluate matched records, match rates (proportion of matches among eligible patients), and injury outcomes within and across sites. RESULTS There were 381,719 injured patients evaluated by EMS personnel in the seven regions. Among transported patients, match rates ranged from 14.9% to 87.5% and were directly affected by the availability of hospital data sources and proportion of missing values for key linkage variables. For vital statistics records (1-year mortality), estimated match rates ranged from 88.0% to 98.7%. Use of multiple imputation (compared to complete case analysis) reduced bias for injury outcomes, although sample size, percentage missing, type of variable, and combined-site versus single-site imputation models all affected the resulting estimates and variance. CONCLUSIONS This project demonstrates the feasibility and describes the process of constructing population-based injury databases across multiple phases of care using existing data sources and commonly available analytic methods. Attention to key linkage variables and decisions for handling missing values can be used to increase match rates between data sources, minimize bias, and preserve sampling design.
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Affiliation(s)
- Craig Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, USA.
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Newgard CD, Zive D, Holmes JF, Bulger EM, Staudenmayer K, Liao M, Rea T, Hsia RY, Wang NE, Fleischman R, Jui J, Mann NC, Haukoos JS, Sporer KA, Gubler KD, Hedges JR. A multisite assessment of the American College of Surgeons Committee on Trauma field triage decision scheme for identifying seriously injured children and adults. J Am Coll Surg 2012; 213:709-21. [PMID: 22107917 DOI: 10.1016/j.jamcollsurg.2011.09.012] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Revised: 09/06/2011] [Accepted: 09/06/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND The American College of Surgeons Committee on Trauma (ACSCOT) has developed and updated field trauma triage protocols for decades, yet the ability to identify major trauma patients remains unclear. We estimate the diagnostic value of the Field Triage Decision Scheme for identifying major trauma patients (Injury Severity Score [ISS] ≥ 16) in a large and diverse multisite cohort. STUDY DESIGN This was a retrospective cohort study of injured children and adults transported by 94 emergency medical services (EMS) agencies to 122 hospitals in 7 regions of the Western US from 2006 through 2008. Patients who met any of the field trauma triage criteria (per EMS personnel) were considered triage positive. Hospital outcomes measures were probabilistically linked to EMS records through trauma registries, state discharge data, and emergency department data. The primary outcome defining a "major trauma patient" was ISS ≥ 16. RESULTS There were 122,345 injured patients evaluated and transported by EMS over the 3-year period, 34.5% of whom met at least 1 triage criterion and 5.8% had ISS ≥ 16. The overall sensitivity and specificity of the criteria for identifying major trauma patients were 85.8% (95% CI 85.0% to 86.6%) and 68.7% (95% CI 68.4% to 68.9%), respectively. Triage sensitivity and specificity, respectively, differed by age: 84.1% and 66.4% (0 to 17 years); 89.5% and 64.3% (18 to 54 years); and 79.9% and 75.4% (≥55 years). Evaluating the diagnostic value of triage by hospital destination (transport to Level I/II trauma centers) did not substantially improve these findings. CONCLUSIONS The sensitivity of the Field Triage Decision Scheme for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders.
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Affiliation(s)
- Craig D Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA.
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Delgado MK, Acosta CD, Ginde AA, Wang NE, Strehlow MC, Khandwala YS, Camargo CA. National survey of preventive health services in US emergency departments. Ann Emerg Med 2011; 57:104-108.e2. [PMID: 20889237 DOI: 10.1016/j.annemergmed.2010.07.015] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2010] [Revised: 07/08/2010] [Accepted: 07/15/2010] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE We describe the availability of preventive health services in US emergency departments (EDs), as well as ED directors' preferred service and perceptions of barriers to offering preventive services. METHODS Using the 2007 National Emergency Department Inventory (NEDI)-USA, we randomly sampled 350 (7%) of 4,874 EDs. We surveyed directors of these EDs to determine the availability of (1) screening and referral programs for alcohol, tobacco, geriatric falls, intimate partner violence, HIV, diabetes, and hypertension; (2) vaccination programs for influenza and pneumococcus; and (3) linkage programs to primary care and health insurance. ED directors were asked to select the service they would most like to implement and to rate 5 potential barriers to offering preventive services. RESULTS Two hundred seventy-seven EDs (80%) responded across 46 states. Availability of services ranged from 66% for intimate partner violence screening to 19% for HIV screening. ED directors wanted to implement primary care linkage most (17%) and HIV screening least (2%). ED directors "agreed/strongly agreed" that the following are barriers to ED preventive care: cost (74%), increased patient length of stay (64%), lack of follow-up (60%), resource shifting leading to worse patient outcomes (53%), and philosophical opposition (27%). CONCLUSION Most US EDs offer preventive services, but availability and ED director preference for type of service vary greatly. The majority of EDs do not routinely offer Centers for Disease Control and Prevention-recommended HIV screening. Most ED directors are not philosophically opposed to offering preventive services but are concerned with added costs, effects on ED operations, and potential lack of follow-up.
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Affiliation(s)
- M Kit Delgado
- Center for Health Policy/Primary Care and Outcomes Research, Stanford University School of Medicine, Palo Alto, CA, USA.
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Acosta CD, Kit Delgado M, Gisondi MA, Raghunathan A, D'Souza PA, Gilbert G, Spain DA, Christensen P, Wang NE. Characteristics of pediatric trauma transfers to a level i trauma center: implications for developing a regionalized pediatric trauma system in california. Acad Emerg Med 2010; 17:1364-73. [PMID: 21122022 DOI: 10.1111/j.1553-2712.2010.00926.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND since California lacks a statewide trauma system, there are no uniform interfacility pediatric trauma transfer guidelines across local emergency medical services (EMS) agencies in California. This may result in delays in obtaining optimal care for injured children. OBJECTIVES this study sought to understand patterns of pediatric trauma patient transfers to the study trauma center as a first step in assessing the quality and efficiency of pediatric transfer within the current trauma system model. Outcome measures included clinical and demographic characteristics, distances traveled, and centers bypassed. The hypothesis was that transferred patients would be more severely injured than directly admitted patients, primary catchment transfers would be few, and out-of-catchment transfers would come from hospitals in close geographic proximity to the study center. METHODS this was a retrospective observational analysis of trauma patients ≤ 18 years of age in the institutional trauma database (2000-2007). All patients with a trauma International Classification of Diseases, 9th revision (ICD-9) code and trauma mechanism who were identified as a trauma patient by EMS or emergency physicians were recorded in the trauma database, including those patients who were discharged home. Trauma patients brought directly to the emergency department (ED) and patients transferred from other facilities to the center were compared. A geographic information system (GIS) was used to calculate the straight-line distances from the referring hospitals to the study center and to all closer centers potentially capable of accepting interfacility pediatric trauma transfers. RESULTS of 2,798 total subjects, 16.2% were transferred from other facilities within California; 69.8% of transfers were from the catchment area, with 23.0% transferred from facilities ≤ 10 miles from the center. This transfer pattern was positively associated with private insurance (risk ratio [RR] = 2.05; p < 0.001) and negatively associated with age 15-18 years (RR = 0.23; p = 0.01) and Injury Severity Score (ISS) > 18 (RR = 0.26; p < 0.01). The out-of-catchment transfers accounted for 30.2% of the patients, and 75.9% of these noncatchment transfers were in closer proximity to another facility potentially capable of accepting pediatric interfacility transfers. The overall median straight-line distance from noncatchment referring hospitals to the study center was 61.2 miles (IQR = 19.0-136.4), compared to 33.6 miles (IQR = 13.9-61.5) to the closest center. Transfer patients were more severely injured than directly admitted patients (p < 0.001). Out-of-catchment transfers were older than catchment patients (p < 0.001); ISS > 18 (RR = 2.06; p < 0.001) and age 15-18 (RR = 1.28; p < 0.001) were predictive of out-of-catchment patients bypassing other pediatric-capable centers. Finally, 23.7% of pediatric trauma transfer requests to the study institution were denied due to lack of bed capacity. CONCLUSIONS from the perspective an adult Level I trauma center with a certified pediatric intensive care unit (PICU), delays in definitive pediatric trauma care appear to be present secondary to initial transport to nontrauma community hospitals within close proximity of a trauma hospital, long transfer distances to accepting facilities, and lack of capacity at the study center. Given the absence of uniform trauma triage and transfer guidelines across state EMS systems, there appears to be a role for quality monitoring and improvement of the current interfacility pediatric trauma transfer system, including defined triage, transfer, and data collection protocols.
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Affiliation(s)
- Colleen D Acosta
- Division of Emergency Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Glickman SW, Kit Delgado M, Hirshon JM, Hollander JE, Iwashyna TJ, Jacobs AK, Kilaru AS, Lorch SA, Mutter RL, Myers SR, Owens PL, Phelan MP, Pines JM, Seymour CW, Ewen Wang N, Branas CC. Defining and measuring successful emergency care networks: a research agenda. Acad Emerg Med 2010; 17:1297-305. [PMID: 21122011 DOI: 10.1111/j.1553-2712.2010.00930.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The demands on emergency services have grown relentlessly, and the Institute of Medicine (IOM) has asserted the need for "regionalized, coordinated, and accountable emergency care systems throughout the country." There are large gaps in the evidence base needed to fix the problem of how emergency care is organized and delivered, and science is urgently needed to define and measure success in the emerging network of emergency care. In 2010, Academic Emergency Medicine convened a consensus conference entitled "Beyond Regionalization: Integrated Networks of Emergency Care." This article is a product of the conference breakout session on "Defining and Measuring Successful Networks"; it explores the concept of integrated emergency care delivery and prioritizes a research agenda for how to best define and measure successful networks of emergency care. The authors discuss five key areas: 1) the fundamental metrics that are needed to measure networks across time-sensitive and non-time-sensitive conditions; 2) how networks can be scalable and nimble and can be creative in terms of best practices; 3) the potential unintended consequences of networks of emergency care; 4) the development of large-scale, yet feasible, network data systems; and 5) the linkage of data systems across the disease course. These knowledge gaps must be filled to improve the quality and efficiency of emergency care and to fulfill the IOM's vision of regionalized, coordinated, and accountable emergency care systems.
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Affiliation(s)
- Seth W Glickman
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
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Ramarajan N, Krishnamoorthi R, Barth R, Ghanouni P, Mueller C, Dannenburg B, Wang NE. An interdisciplinary initiative to reduce radiation exposure: evaluation of appendicitis in a pediatric emergency department with clinical assessment supported by a staged ultrasound and computed tomography pathway. Acad Emerg Med 2009; 16:1258-65. [PMID: 20053244 DOI: 10.1111/j.1553-2712.2009.00511.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES In the emergency department (ED), a significant amount of radiation exposure is due to computed tomography (CT) scans performed for the diagnosis of appendicitis. Children are at increased risk of developing cancer from low-dose radiation and it is therefore desirable to utilize CT only when appropriate. Ultrasonography (US) eliminates radiation but has sensitivity inferior to that of CT. We describe an interdisciplinary initiative to use a staged US and CT pathway to maximize diagnostic accuracy while minimizing radiation exposure. METHODS This was a retrospective outcomes analysis of patients presenting after hours for suspected appendicitis at an academic children's hospital ED over a 6-year period. The pathway established US as the initial imaging modality. CT was recommended only if US was equivocal. Clinical and pathologic outcomes from ED diagnosis and disposition, histopathology and return visits, were correlated with the US and CT. ED diagnosis and disposition, pathology, and return visits were used to determine outcome. RESULTS A total of 680 patients met the study criteria. A total of 407 patients (60%) followed the pathway. Two-hundred of these (49%) were managed definitively without CT. A total of 106 patients (26%) had a positive US for appendicitis; 94 (23%) had a negative US. A total of 207 patients had equivocal US with follow-up CT. A total of 144 patients went to the operating room (OR); 10 patients (7%) had negative appendectomies. One case of appendicitis was missed (<0.5%). The sensitivity, specificity, negative predictive value, and positive predictive values of our staged US-CT pathway were 99%, 91%, 99%, and 85%, respectively. A total of 228 of 680 patients (34%) had an equivocal US with no follow-up CT. Of these patients, 10 (4%) went to the OR with one negative appendectomy. A total of 218 patients (32%) were observed clinically without complications. CONCLUSIONS Half of the patients who were treated using this pathway were managed with definitive US alone with an acceptable negative appendectomy rate (7%) and a missed appendicitis rate of less than 0.5%. Visualization of a normal appendix (negative US) was sufficient to obviate the need for a CT in the authors' experience. Emergency physicians (EPs) used an equivocal US in conjunction with clinical assessment to care for one-third of study patients without a CT and with no known cases of missed appendicitis. These data suggest that by employing US first on all children needing diagnostic imaging for diagnosis of acute appendicitis, radiation exposure may be substantially decreased without a decrease in safety or efficacy.
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Affiliation(s)
- Naresh Ramarajan
- Division of Pediatric Emergency Medicine, Stanford University School of Medicine, Stanford, CA, USA
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