National community disparities in prehospital penetrating trauma adjusted for income, 2020-2021.

INTRODUCTION: While Black individuals experienced disproportionately increased firearm violence and deaths during the COVID-19 pandemic, less is known about community level disparities. We sought to evaluate national community race and ethnicity differences in 2020 and 2021 rates of penetrating trauma. METHODS: We linked the 2018-2021 National Emergency Medical Services Information System databases to ZIP Code demographics. We stratified encounters into majority race/ethnicity communities (>50% White, Black, or Hispanic/Latino). We used logistic regression to compare penetrating trauma for each community in 2020 and 2021 to a combined 2018-2019 historical baseline. Majority Black and majority Hispanic/Latino communities were compared to majority White communities for each year. Analyses were adjusted for household income. RESULTS: We included 87,504,097 encounters (259,449 penetrating traumas). All communities had increased odds of trauma in 2020 when compared to 2018-2019, but this increase was largest for Black communities (aOR 1.4, [1.3-1.4]; White communities - aOR 1.2, [1.2-1.3]; Hispanic/Latino communities - aOR 1.1. [1.1-1.2]). There was a similar trend of increased penetrating trauma in 2021 for Black (aOR 1.2, [1.2-1.3]); White (aOR 1.2, [1.1-1.2]); Hispanic/Latino (aOR 1.1, [1.1-1.1]). Comparing penetrating trauma in each year to White communities, Black communities had higher odds of trauma in all years (2018/2019 - aOR 3.0, [3.0-3.1]; 2020 - aOR 3.3, [3.3-3.4]; 2021 - aOR 3.3, [3.2-3.2]). Hispanic/Latino also had more trauma each year but to a lesser degree (2018/2019 - aOR 2.0, [2.0-2.0]; 2020 - aOR 1.8, [1.8-1.9]; 2021 - aOR 1.9, [1.8-1.9]). CONCLUSION: Black communities were most impacted by increased penetrating trauma rates in 2020 and 2021 even after adjusting for income.

The cost of emergency care for children across differing levels of emergency department pediatric readiness.

High emergency department (ED) pediatric readiness is associated with improved survival in children, but the cost is unknown. We evaluated the costs of emergency care for children across quartiles of ED pediatric readiness. This was a retrospective cohort study of children aged 0-17 years receiving emergency services in 747 EDs in 9 states from January 1, 2012, through December 31, 2017. We measured ED pediatric readiness using the weighted Pediatric Readiness Score (range: 0-100). The primary outcome was the total cost of acute care (ED and inpatient) in 2022 dollars, adjusted for ED case mix and hospital characteristics. A total of 15 138 599 children received emergency services, including 27.6% with injuries and 72.4% with acute medical illness. The average adjusted per-patient cost by quartile of ED pediatric readiness ranged from $991 (quartile 1) to $1064 (quartile 4) for injured children and $1104-$1217 for medical children. The resulting cost differences were $72 (95% CI: -$6 to $151) and $113 (95% CI: $20-$206), respectively. Receiving emergency care in high-readiness EDs was not associated with marked increases in the cost of delivering services.

"Make the Call, Don't Miss a Beat" Campaign: Effect on Emergency Medical Services Use in Women with Heart Attack Signs.

BACKGROUND: Our objective was to evaluate the relationship between the "Make The Call, Don't Miss a Beat" national mass media campaign and emergency medical services (EMS) use among women with possible heart attack symptoms. METHODS: We linked campaign TV public service advertisement data with national EMS activation data for 2010 to 2014. We identified EMS activations (i.e., responses) for possible heart attack symptoms and for unintentional injuries for both women and men. We estimated the impact of the campaign on the fraction of the 1.7 to 15.9 million activations of women with possible heart attack symptoms compared with 1.9 million female activations for unintentional injuries within each EMS agency and month using quasi-binomial logistic regression controlling for time and state. RESULTS: Of the 3,175 U S. counties, 90% were exposed to the campaign. However, less than 2% of U.S. counties reached moderate TV exposure (≥300 gross rating points) during the entire campaign period. We did not observe an increase in the fraction of female activations for possible heart attack during periods or in counties with higher campaign exposure. CONCLUSIONS: This mass media campaign that relied heavily on TV public service advertisements was not associated with increased EMS use by women with possible heart attack symptoms, even among counties that were more highly exposed to the campaign advertisements.

Hypoglycemia Emergencies: Factors Associated with Prehospital Care, Transportation Status, Emergency Department Disposition, and Cost.

Objectives: The objectives of this study were to evaluate demographic/clinical characteristics and treatment/transportation decisions by emergency medical services (EMS) for patients with hypoglycemia and link EMS activations to patient disposition, outcomes, and costs to the emergency medical system. This evaluation was to identify potential areas where improvements in prehospital healthcare could be made. Methods: This was a retrospective analysis of the National Emergency Medical Services Information System (NEMSIS) registry and three national surveys: Nationwide Emergency Department Sample (NEDS), National Hospital Ambulatory Medical Care Survey (NHAMCS), and Medical Expenditure Panel Survey (MEPS) from 2013, to examine care of hypoglycemia from the prehospital and the emergency department (ED) perspectives. Results: The study estimated 270,945 hypoglycemia EMS incidents from the NEMSIS registry. Treatments were consistent with national guidelines (i.e., oral glucose, intravenous [IV] dextrose, or glucagon), and patients were more likely to be transported to the ED if the incident was in a rural setting or they had other chief concerns related to the pulmonary or cardiovascular system. Use of IV dextrose decreased the likelihood of transportation. Approximately 43% of patients were not transported from the scene. Data from the NEDS survey estimated 258,831 ED admissions for hypoglycemia, and 41% arrived by ambulance. The median ambulance expenditure was $664 ± 98. From the ED, 74% were released. The average ED charge that did not lead to hospital admission was $3106 ± 86. Increased odds of overnight admission included infection and acute renal failure. Conclusions: EMS activations for hypoglycemia are sizeable and yet a considerable proportion of patients are not transported to or are discharged from the ED. Seemingly, these events resolved and were not medically complex. It is possible that implementation and appropriate use of EMS treat-and-release protocols along with utilizing programs to educate patients on hypoglycemia risk factors and emergency preparedness could partially reduce the burden of hypoglycemia to the healthcare system.

Injury-based Geographic Access to Trauma Centers.

OBJECTIVE: Previous studies examining access to trauma care use patient residence as a proxy for location and need for services, which could result in a flawed understanding of access to trauma centers. The objective of this study was to examine the geographic access of the U.S. population to trauma centers based on trauma incident locations. METHODS: We conducted a cross-sectional study using 9-1-1 emergency medical services activations associated with traumatic injury from the 2014 National Emergency Medical Services Information System and trauma centers participating in the 2014 American Hospital Association Annual Survey. The measures included the percentage of trauma incidents that could reach a trauma center within 60 minutes by ground ambulance, capacity-to-demand ratio for each trauma center, and overall trauma care accessibility ratio for each U.S. zip code. RESULTS: A total of 92.9% of all trauma incidents could be transported to an existing trauma center within 60 minutes by ground ambulance, and 85.3% could be transported to a Level I or II trauma center within this time frame in the 32 study states. While 94.7% of trauma incidents in the Northeast area could be transported to a Level I or II trauma center within a 60-minute driving time, the capacity-to-demand ratios of trauma centers in this region were low, indicating high utilization of those trauma center resources. By using the accessibility measure, we found that some Midwestern and Southern states had higher amounts of accessible trauma center resources relative to the number of injuries than Northeastern states. CONCLUSIONS: These findings suggest that greater access to trauma care and significant variations can be observed throughout the 32 study states when using trauma incident location rather than patient residence to calculate access to trauma care. The proposed capacity-to-demand ratio and accessibility ratio can be applied to many other needs assessments in health care.

Prehospital Pain Management: Disparity By Age and Race.

IMPORTANCE: Historically, pain management in the prehospital setting, specifically pediatric pain management, has been inadequate despite many EMS (emergency medical services) transports related to traumatic injury with pain noted as a symptom. The National Emergency Services Information System (NEMSIS) database offers the largest national repository of prehospital data, and can be used to assess current patterns of EMS pain management across the country. OBJECTIVES: To analyze prehospital management of pain using NEMSIS data, and to assess if variables such as patient age and/or race/ethnicity are associated with disparity in pain treatment. DESIGN/SETTING/PARTICIPANTS: A retrospective descriptive study over a three-year period (2012-2014) of the NEMSIS database for patients evaluated for three potentially painful medical impressions (fracture, burn, penetrating injury) to assess the presence of documented pain as a symptom, and if patients received treatment with analgesic medications. Results were analyzed according to type of pain medication given, age categories, and race/ethnicity of the patients. MAIN OUTCOMES: Percentage of EMS transports documenting the three painful impressions that had pain documented as a symptom, received any of the six pain medications, and the disparity in documentation and treatment by age and race/ethnicity. RESULTS: There were 276,925 EMS records in the NEMSIS database that met inclusion criteria. Pain was listed as a primary or associated symptom for 29.5% of patients, and the youngest children (0-3 years) were least likely to have pain documented as a symptom (14.6%). Only 15.6% of all activations documented the receipt of prehospital pain medications. Children (<15 years) received pain medication 14.8% [95% CI 14.33, 15.34] of the time versus adults (≥15 years) 15.6% [95% CI 15.48, 15.76, p = 0.004]. Morphine and fentanyl were the most commonly administered medications to all age groups. Black patients were less likely to receive pain medication than other racial groups. CONCLUSIONS: Documentation of pain as a symptom and pain treatment continue to be infrequent in the prehospital setting in all age groups, especially young children. There appears to be a racial disparity with Black patients less often treated with analgesics. The broad incorporation of national NEMSIS data suggests that these inadequacies are a widespread challenge deserving further attention.

Delays in Emergency Care and Mortality during Major U.S. Marathons.

BACKGROUND: Large marathons frequently involve widespread road closures and infrastructure disruptions, which may create delays in emergency care for nonparticipants with acute medical conditions who live in proximity to marathon routes. METHODS: We analyzed Medicare data on hospitalizations for acute myocardial infarction or cardiac arrest among Medicare beneficiaries (≥65 years of age) in 11 U.S. cities that were hosting major marathons during the period from 2002 through 2012 and compared 30-day mortality among the beneficiaries who were hospitalized on the date of a marathon, those who were hospitalized on the same day of the week as the day of the marathon in the 5 weeks before or the 5 weeks after the marathon, and those who were hospitalized on the same day as the marathon but in surrounding ZIP Code areas unaffected by the marathon. We also analyzed data from a national registry of ambulance transports and investigated whether ambulance transports occurring before noon in marathon-affected areas (when road closures are likely) had longer scene-to-hospital transport times than on nonmarathon dates. We also compared transport times on marathon dates with those on nonmarathon dates in these same areas during evenings (when roads were reopened) and in areas unaffected by the marathon. RESULTS: The daily frequency of hospitalizations was similar on marathon and nonmarathon dates (mean number of hospitalizations per city, 10.6 and 10.5, respectively; P=0.71); the characteristics of the beneficiaries hospitalized on marathon and nonmarathon dates were also similar. Unadjusted 30-day mortality in marathon-affected areas on marathon dates was 28.2% (323 deaths in 1145 hospitalizations) as compared with 24.9% (2757 deaths in 11,074 hospitalizations) on nonmarathon dates (absolute risk difference, 3.3 percentage points; 95% confidence interval, 0.7 to 6.0; P=0.01; relative risk difference, 13.3%). This pattern persisted after adjustment for covariates and in an analysis that included beneficiaries who had five or more chronic medical conditions (a group that is unlikely to be hospitalized because of marathon participation). No significant differences were found with respect to where patients were hospitalized or the treatments they received in the hospital. Ambulance scene-to-hospital transport times for pickups before noon were 4.4 minutes longer on marathon dates than on nonmarathon dates (relative difference, 32.1%; P=0.005). No delays were found in evenings or in marathon-unaffected areas. CONCLUSIONS: Medicare beneficiaries who were admitted to marathon-affected hospitals with acute myocardial infarction or cardiac arrest on marathon dates had longer ambulance transport times before noon (4.4 minutes longer) and higher 30-day mortality than beneficiaries who were hospitalized on nonmarathon dates. (Funded by the National Institutes of Health.).

Evaluation of Rural vs Urban Trauma Patients Served by 9-1-1 Emergency Medical Services.

Importance: Despite a large rural US population, there are potential differences between rural and urban regions in the processes and outcomes following trauma. Objectives: To describe and evaluate rural vs urban processes of care, injury severity, and mortality among injured patients served by 9-1-1 emergency medical services (EMS). Design, Setting, and Participants: This was a preplanned secondary analysis of a prospective cohort enrolled from January 1 through December 31, 2011, and followed up through hospitalization. The study included 44 EMS agencies transporting to 28 hospitals in 2 rural and 5 urban counties in Oregon and Washington. A population-based, consecutive sample of 67 047 injured children and adults served by EMS (1971 rural and 65 076 urban) was enrolled. Among the 53 487 patients transported by EMS, a stratified probability sample of 17 633 patients (1438 rural and 16 195 urban) was created to track hospital outcomes (78.9% with in-hospital follow-up). Data analysis was performed from June 12, 2015, to May 20, 2016. Exposures: Rural was defined at the county level by 60 minutes or more driving proximity to the nearest level I or II trauma center and/or rural designation in the Centers for Medicare & Medicaid Services ambulance fee schedule by zip code. Main Outcomes and Measures: Mortality (out-of-hospital and in-hospital), need for early critical resources, and transfer rates. Results: Of the 53 487 injured patients transported by EMS (17 633 patients in the probability sample), 27 535 were women (51.5%); mean (SD) age was 51.6 (26.1) years. Rural vs urban sensitivity of field triage for identifying patients requiring early critical resources was 65.2% vs 80.5%, and only 29.4% of rural patients needing critical resources were initially transported to major trauma centers vs 88.7% of urban patients. After accounting for transfers, 39.8% of rural patients requiring critical resources were cared for in major trauma centers vs 88.7% of urban patients. Overall mortality did not differ between rural and urban regions (1.44% vs 0.89%; P = .09); however, 89.6% of rural deaths occurred within 24 hours compared with 64% of urban deaths. Rural regions had higher transfer rates (3.2% vs 2.7%) and longer transfer distances (median, 97.4 km; interquartile range [IQR], 51.7-394.5 km; range, 47.8-398.6 km vs 22.5 km; IQR, 11.6-24.6 km; range, 3.5-97.4 km). Conclusions and Relevance: Most high-risk trauma patients injured in rural areas were cared for outside of major trauma centers and most rural trauma deaths occurred early, although overall mortality did not differ between regions. There are opportunities for improved timeliness and access to major trauma care among patients injured in rural regions.

Cost-Effectiveness of Field Trauma Triage among Injured Adults Served by Emergency Medical Services.

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.

Triage of elderly trauma patients: a population-based perspective.

BACKGROUND: Elderly patients are frequently undertriaged. However, the associations between triage patterns and outcomes from a population perspective are unknown. We hypothesized that triage patterns would be associated with differences in outcomes. STUDY DESIGN: This is a population-based, retrospective, cohort study of all injured adults aged 55 years or older, from 3 counties in California and 4 in Utah (2006 to 2007). Prehospital data were linked to trauma registry data, state-level discharge data, emergency department records, and death files. The primary outcome was 60-day mortality. Patients treated at trauma centers were compared with those treated at nontrauma centers. Undertriage was defined as an Injury Severity Score (ISS) >15, with transport to a nontrauma center. RESULTS: There were 6,015 patients in the analysis. Patients who were taken to nontrauma centers were, on average, older (79.4 vs 70.7 years, p < 0.001), more often female (68.6% vs 50.2%, p < 0.01), and less often had an ISS >15 (2.2% vs 6.7%, p < 0.01). There were 244 patients with an ISS >15 and the undertriage rate was 32.8% (n = 80). Overall 60-day mortality for patients with an ISS >15 was 17%, with no difference between trauma and nontrauma centers in unadjusted or adjusted analyses. However, the median per-patient costs were $21,000 higher for severely injured patients taken to trauma centers. CONCLUSIONS: This is the first population-based analysis of triage patterns and outcomes in the elderly. We have shown high rates of undertriage that are not associated with higher mortality, but are associated with higher costs. Future work should focus on determining how to improve outcomes for this population.

The cost of overtriage: more than one-third of low-risk injured patients were taken to major trauma centers.

Regionalized trauma care has been widely implemented in the United States, with field triage by emergency medical services (EMS) playing an important role in identifying seriously injured patients for transport to major trauma centers. In this study we estimated hospital-level differences in the adjusted cost of acute care for injured patients transported by 94 EMS agencies to 122 hospitals in 7 regions, overall and by injury severity. Among 301,214 patients, the average adjusted per episode cost of care was $5,590 higher in a level 1 trauma center than in a nontrauma hospital. We found hospital-level differences in cost among patients with minor, moderate, and serious injuries. Of the 248,342 low-risk patients-those who did not meet field triage guidelines for transport to trauma centers-85,155 (34.3 percent) were still transported to major trauma centers, accounting for up to 40 percent of acute injury costs. Adhering to field triage guidelines that minimize the overtriage of low-risk injured patients to major trauma centers could save up to $136.7 million annually in the seven regions we studied.

The trade-offs in field trauma triage: a multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies.

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.

A multisite assessment of the American College of Surgeons Committee on Trauma field triage decision scheme for identifying seriously injured children and adults.

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.

Point of purchase cigarette promotions before and after the Master Settlement Agreement: exploring retail scanner data.

BACKGROUND: Evidence indicates that point of purchase (POP) advertising and promotions for cigarettes have increased since the Master Settlement Agreement (MSA). Retail promotions have the potential to offset the effects of cigarette tax and price increases and tobacco control programmes. OBJECTIVE: To describe the trend in the proportion of cigarette sales that occur as part of a POP promotion before and after the MSA. DESIGN: Scanner data were analysed on cigarette sales from a national sample of grocery stores, reported quarterly from 1994 through 2003. The proportion of total cigarette sales that occurred under any of three different types of POP promotions is presented. RESULTS: The proportion of cigarettes sold under a POP promotion increased notably over the sample period. Large increases in promoted sales are observed following implementation of the MSA and during periods of sustained cigarette excise tax increases. CONCLUSIONS: The observed pattern of promoted cigarette sales is suggestive of a positive relationship between retail cigarette promotions, the MSA, and state cigarette tax increases. More research is needed to describe fully the relationship between cigarette promotions and tobacco control policy.

Trauma system structure and viability in the current healthcare environment: a state-by-state assessment.

OBJECTIVE: Anecdotal reports suggest that some state trauma systems are struggling to remain solvent while others appear stable in the current health care environment. The purpose of this research is to characterize the current structure and viability of state trauma systems in the U.S. METHODS: Expert panels were convened in all 50 states to characterize the current structure of trauma care and to identify strengths, weakness, opportunities and threats facing trauma care delivery in each state. RESULTS: States continue to value the formalization of trauma systems. System operations, evaluation/research methods and trauma leadership are highly valued by states with mature systems. However, all states consider their trauma system severely threatened by inadequate funding and difficulty recruiting and retaining physicians and nurses. CONCLUSION: Trauma care systems are valued and demonstrate potential for future expansion. However, economic shortfalls and retention of medical personnel threaten the viability of current systems across the U.S.

Public health preparedness for mass-casualty events: a 2002 state-by-state assessment.

INTRODUCTION: The ongoing threat of a terrorist attack places public agencies under increasing pressure to ensure readiness in the event of a disaster. Yet, little published information exists regarding the current state of readiness, which would allow local and regional organizations to develop disaster preparedness plans that would function seamlessly across service areas. The objective of this study is to characterize state-level disaster readiness soon after September 2001 and correlate readiness with existing programs providing an organized response to medical emergencies. METHODS: During the first quarter of 2002, a cross-sectional survey assessing five components of disaster readiness was administered in all 50 states. The five components of disaster readiness included: (1) statewide disaster planning; (2) coordination; (3) training; (4) resource capacity; and (5) preparedness for biological/chemical terrorism. RESULTS: Most states reported the presence of a statewide disaster plan (94%), but few are tested by activation (48%), and still fewer contain a bioterrorism component (38%). All states have designated disaster operations centers (100%), but few states have an operating communications system linking health and medical resources (36%). Approximately half of states offer disaster training to medical professionals; about 10% of states require the training. Between 22-48% of states have various contingency plans to treat victims when service capacity is exceeded. Biochemical protective equipment for health professionals is lacking in all but one state, and only 10% of states indicate that all hospitals have decontamination capabilities. States with a functioning statewide trauma system were significantly more likely to possess key attributes of a functioning disaster readiness plan. CONCLUSION: These findings suggest that disaster plans are prevalent among states. However, key programs and policies were noticeably absent. Communication systems remain fragmented and adequate training programs and protective equipment for health personnel are markedly lacking. Statewide trauma systems may provide a framework upon which to build future medical disaster readiness capacity.

Resource utilization and its management in splenic trauma.

BACKGROUND: This study compared resource utilization and its management for splenic injury at 2 level-I trauma centers and a pediatric referral center with other facilities in a state currently developing a trauma system. METHODS: Management strategy, length of stay, and total charges for children were compared among the pediatric referral center, trauma centers, and other facilities. Adult management, length of stay, and total charges were compared between trauma centers and other facilities. RESULTS: Nonoperative management was more frequent in children at the pediatric referral center than trauma centers or other facilities and was more common in adults at trauma centers than at other facilities. Mean length of stay and total charges for children were significantly greater at the pediatric referral center and trauma centers than at other facilities and for adults at trauma centers than at other facilities. Facility type was associated with length of stay and total charges when injury type and severity were controlled. CONCLUSIONS: Nonoperative management of splenic injury is more common at trauma centers, and splenic trauma management may be more costly at trauma centers.

Developing research criteria to define medical necessity in emergency medical services.

"The Neely Conference: Developing Research Criteria to Define Medical Necessity in EMS" convened emergency medical services (EMS) physicians, researchers, administrators, providers, and federal agency representatives to begin the development of a set of uniform triage criteria and outcome measures that could be used to study and evaluate medical necessity among EMS patients. These standardized criteria might be used in research studies examining EMS dispatch and response (e.g., dispatch triage protocols, alternative response configurations), and EMS treatment and transport (e.g., field triage protocols, alternative care destinations). The conference process included review and analysis of the literature, expert judgment, and consensus building. There was general agreement on the following: 1. Any dispatch triage or field triage system that is developed must be designed to offer patients alternatives to EMS, not to refuse care to patients. 2. It is theoretically possible to develop a set of clinical criteria for need. Some groups of patients will clearly need a traditional EMS response and other groups will not, but this has yet to be defined. 3. In addition to clinical criteria, certain social and other nonclinical criteria such as pain or potential abuse may be used to justify a response. 4. Communication barriers, patient age, special needs, and other conditions complicate patient assessment but should not exclude patients from consideration for alternate triage or transport. 5. These research questions are important, and standard sets of outcome measures are needed so that different studies and innovative programs can be compared.

Defining research criteria to characterize medical necessity in emergency medical services: a consensus among experts at the Neely Conference.

OBJECTIVE: Researchers interested in ensuring appropriate use of emergency medical services (EMS) resources have attempted to define safe and effective protocols for triage either at the time of dispatch or after on-scene evaluation. Published work in this area is difficult to evaluate because protocols and outcome criteria vary from study to study. The goal of the Neely Conference was to bring together EMS experts to define a set of criteria to be used in research studies evaluating dispatch triage and field triage systems. METHODS: Thirty-one experts in EMS systems and research attended a day-long workshop to assess the current literature regarding dispatch triage and field triage, and make recommendations to standardize methods used to evaluate future triage protocols. Participants were surveyed during the workshop; consensus analysis techniques were used to determine if a formal consensus was reached. A Bayesian posterior probability of 0.99 was required to consider responses a "consensus." RESULTS: Participants considered current evidence regarding the usefulness of EMS triage criteria to be "weak." However, respondents agreed on a set of research criteria that could define the need for an EMS response and/or EMS transport. Field triage criteria were considered more plausible than dispatch criteria. Valid outcome criteria for assessing the effectiveness of triage protocols included ED assessment and the need for immediate surgery. Hospital admission, final diagnosis, and expert opinion were not considered adequate outcome measures. CONCLUSION: EMS experts agreed on a standard set of triage criteria and outcome measures for evaluating triage protocols supporting alternative forms of transport and care.

Repeat patients to the emergency department in a statewide database.

OBJECTIVES: To describe the epidemiology of repeat users of the emergency department (ED) using a statewide database. METHODS: Probabilistic linkage was used to convert three years of statewide ED visit data into a longitudinal, patient-based data set. Patients were classified as single, repeat (at least two visits within three years), or serial (four or more visits within a 365-day period) users of the ED. Serial patients were further stratified by the number of EDs attended. Descriptive statistics were used to assess differences between patient types. RESULTS: There were 1,370,607 separate visits associated with 780,074 patients from 1996 to 1998. While repeat and serial patients represented 33% of the patients, they accounted for 62% of the ED visits during the study period. Repeat and serial patients were younger and had smaller median ED charges per visit than single-use patients. Serial patients attending five or more EDs were more likely to be coded as self-pay than other serial patients. Diagnosis codes relating to sprains, back problems, and headaches were prevalent among serial patients who visited five or more EDs. Approximately 30% of serial patients during the first year remained serial patients in the second year. CONCLUSIONS: Due to the high turnover in serial patients, control groups in future studies are necessary to evaluate interventions aimed at decreasing serial ED use. The likelihood of serial ED users to use multiple EDs indicates that those studying serial ED use should collect data from multiple EDs.