Guidance Document for the Prehospital Use of Tranexamic Acid in Injured Patients.

Tranexamic acid (TXA) is being administered already in many prehospital air and ground systems. Insufficient evidence exists to support or refute the prehospital administration of TXA, and results are pending from several prehospital studies currently in progress. We have created this document to aid agencies and systems in best practices for TXA administration based on currently available best evidence. This document has been endorsed by the American College of Surgeons-Committee on Trauma, the American College of Emergency Physicians, and the National Association of EMS Physicians.

An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma.

This report describes the development of an evidence-based guideline for external hemorrhage control in the prehospital setting. This project included a systematic review of the literature regarding the use of tourniquets and hemostatic agents for management of life-threatening extremity and junctional hemorrhage. Using the GRADE methodology to define the key clinical questions, an expert panel then reviewed the results of the literature review, established the quality of the evidence and made recommendations for EMS care. A clinical care guideline is proposed for adoption by EMS systems. Key words: tourniquet; hemostatic agents; external hemorrhage.

Emergency department recognition program for pediatric services: does it make a difference?

OBJECTIVE: This study aimed to determine if a pediatric emergency care facility recognition (PECFR) program improved care processes for injured children younger than 15 years. METHODS: A controlled pre-post study design was used. Emergency department (ED) medical records were abstracted from 8 Delaware hospitals and 13 comparison hospitals in North Carolina in 2009 and again in 2013, 1 year after PECFR implementation. Data collected focused on pediatric processes of care, including vital sign assessment, pain assessment and management, treatment procedures, and diagnostic radiation. RESULTS: A majority of 1737 children (97%) had an Injury Severity Score of 9 or lower. Both hospital cohorts significantly increased initial pain assessment documentation over time (P < 0001). For children with extremity immobilization and a pain score of 5 or greater, the interval between pain assessment and pain management was significantly shorter in the Delaware hospitals (P < 0.01) compared with hospitals from North Carolina. A significant reduction in radiation use (flat film and computed tomographic imaging) was also found in Delaware hospitals (P < 0001) compared with the hospitals in North Carolina. CONCLUSIONS: Improvements in care to injured children associated with the PECFR program were limited to the interval between pain assessment and pain medication for children with extremity immobilization and to radiation use 1 year after the implementation of the PECFR program.

Analysis of preventable trauma deaths and opportunities for trauma care improvement in utah.

BACKGROUND: The objective is to determine the rate of preventable mortality and the volume and nature of opportunities for improvement (OFI) in care for cases of traumatic death occurring in the state of Utah. METHODS: A retrospective case review of deaths attributed to mechanical trauma throughout the state occurring between January 1, 2005, and December 31, 2005, was conducted. Cases were reviewed by a multidisciplinary panel of physicians and nonphysicians representing the prehospital and hospital phases of care. Deaths were judged frankly preventable, possibly preventable, or nonpreventable. The care rendered in both preventable and nonpreventable cases was evaluated for OFI according to nationally accepted guidelines. RESULTS: The overall preventable death rate (frankly and possibly preventable) was 7%. Among those patients surviving to be treated at a hospital, the preventable death rate was 11%. OFIs in care were identified in 76% of all cases; this cumulative proportion includes 51% of prehospital contacts, 67% of those treated in the emergency department (ED), and 40% of those treated post-ED (operating room, intensive care unit, and floor). Issues with care were predominantly related to management of the airway, fluid resuscitation, and chest injury diagnosis and management. CONCLUSIONS: The preventable death rate from trauma demonstrated in Utah is similar to that found in other settings where the trauma system is under development but has not reached full maturity. OFIs predominantly exist in the ED and relate to airway management, fluid resuscitation, and chest injury management. Resource organization and education of ED primary care providers in basic principles of stabilization and initial treatment may be the most cost-effective method of reducing preventable deaths in this mixed urban and rural setting. Similar opportunities exist in the prehospital and post-ED phases of care.

Collecting data on organizational structures of trauma centers: the CAFE web service.

BACKGROUND: During the past several decades, the American College of Surgeons has led efforts to standardize trauma care through their trauma center verification process and Trauma Quality Improvement Program. Despite these endeavors, great variability remains among trauma centers functioning at the same level. Little research has been conducted on the correlation between trauma center organizational structure and patient outcomes. We are attempting to close this knowledge gap with the Comparative Assessment Framework for Environments of Trauma Care (CAFE) project. METHODS: Our first action was to establish a shared terminology that we then used to build the Ontology of Organizational Structures of Trauma centers and Trauma systems (OOSTT). OOSTT underpins the web-based CAFE questionnaire that collects detailed information on the particular organizational attributes of trauma centers and trauma systems. This tool allows users to compare their organizations to an aggregate of other organizations of the same type, while collecting their data. RESULTS: In collaboration with the American College of Surgeons Committee on Trauma, we tested the system by entering data from three trauma centers and four trauma systems. We also tested retrieval of answers to competency questions. DISCUSSION: The data we gather will be made available to public health and implementation science researchers using visualizations. In the next phase of our project, we plan to link the gathered data about trauma center attributes to clinical outcomes.

Epidemiological and follow-back study of suicides in Alaska.

OBJECTIVES: To conduct an in-depth analysis of all suicides occurring in Alaska between September 1, 2003 and August 31, 2006, and to conduct follow-back interviews with key informants for select cases. STUDY DESIGN: Suicide data were gathered from the Alaska Bureau of Vital Statistics, law enforcement agencies and the Alaska medical examiner's office. Trained counsellors administered the 302 branching-question follow-back protocol during in-person interviews with key informants about the decedents. METHODS: Suicide death certificates, medical examiner's reports and police files were analysed retrospectively. Key informants were contacted for confidential interviews about the decedents' life, especially regarding risk and protective factors. Results. There were 426 suicides during the 36-month study period. The suicide rate was 21.4/100,000. Males out-numbered females 4 to 1. The age-group of 20 to 29 had both the greatest number of suicides and the highest rate per 100,000 population. Alaska Natives had a suicide rate that was three times higher than the non-Native population. Follow-back interviews were conducted with 71 informants for 56 of the suicide decedents. CONCLUSIONS: This research adds significant information to our existing knowledge of suicide in Alaska, particularly as it affects the younger age groups among the Alaska Native population and the role of alcohol/drugs.

Development and Validation of a Controlled Vocabulary: An OWL Representation of Organizational Structures of Trauma Centers and Trauma Systems.

In trauma care and trauma care research there exists an implementation gap regarding a consistent controlled vocabulary to describe organizational aspects of trauma centers and trauma systems. This paper describes the development and evaluation of a controlled vocabulary for trauma care organizations. We give a detailed description of the involvement of domain experts in the domain analysis workflow and the authoring of definitions and additional term descriptions. Finally, the paper details the evaluation methodology to assess the initial version of the controlled vocabulary. The results of the evaluation show that our development process yields terms most of which find approval from domain experts not involved in the development. In addition, our evaluation tools resulted in valuable domain expert input to optimize the controlled vocabulary.

Awareness of guidelines for use of automated external defibrillators in children within emergency medical services.

BACKGROUND: Ventricular fibrillation occurs in 10-20% of pediatric cardiac arrests. Survival rates in children with ventricular fibrillation can be as high as 30% when the rhythm is identified and treated promptly. In the last 5 years, recommendations have been made for the use of automated external defibrillators in children between 1 and 8 years of age. OBJECTIVE: The goal of this study was to determine the awareness of the ILCOR guidelines and statewide protocols concerning AED use in children ages 1-8 among emergency medical providers after new guideline release. Availability of pediatric capable AED equipment was also assessed. METHODS: Surveys were distributed to EMS providers in Iowa and Montana within 1 year of the ILCOR advisory statement in 2003 recommending use of AEDs in children ages 1-8, and again approximately 1 year after the 2005 ILCOR guidelines on cardiopulmonary resuscitation were published. In Iowa, there were concentrated efforts to disseminate information about AED use in children, while there were minimal efforts in Montana. RESULTS: Awareness of ILCOR guidelines for use of AEDs in children was low in both states in 2003 (29% in Iowa vs. 9% in Montana, p<0.001). After release of the 2005 guidelines, awareness improved significantly in both states but was still significantly greater in Iowa (83% vs. 60%, p<0.002). In 2003, less than 20% of respondents in both states reported access to pediatric capable AEDs. Availability of pediatric pads and cables increased significantly in 2006 but remained low in Montana (74% in Iowa vs. 37% in Montana, p<0.001). CONCLUSIONS: At the present time, publication of new or interim guidelines in the scientific literature alone is insufficient to ensure that new protocols are implemented. An effective and efficient method to disseminate new pediatric out-of-hospital protocols emergency care to become standard of care in a timely matter must be developed.

Does the Institution of a Statewide Trauma System Reduce Preventable Mortality and Yield a Positive Return on Investment for Taxpayers?

BACKGROUND: In July 2009, Arkansas began to annually fund $20 million for a statewide trauma system (TS). We studied injury deaths both pre-TS (2009) and post-TS (2013 to 2014), with attention to causes of preventive mortality, societal cost of those preventable mortality deaths, and benefit to tax payers of the lives saved. STUDY DESIGN: A multi-specialty trauma-expert panel met and reviewed records of 672 decedents (290 pre-TS and 382 post-TS) who met standardized inclusion criteria, were judged potentially salvageable, and were selected by a proportional sampling of the roughly 2,500 annual trauma deaths. Deaths were adjudicated into sub-categories of nonpreventable and preventable causes. The value of lives lost was calculated for those lives potentially saved in the post-TS period. RESULTS: Total preventable mortality was reduced from 30% of cases pre-TS to 16% of cases studied post-TS, a reduction of 14%. Extrapolating a 14% reduction of preventable mortality to the post-TS study period, using the same inclusion criteria of the post-TS, we calculate that 79 lives were saved in 2013 to 2014 due to the institution of a TS. Using a minimal standard estimate of $100,000 value for a life-year, a lifetime value of $2,365,000 per person was saved. This equates to an economic impact of the lives saved of almost $186 million annually, representing a 9-fold return on investment from the $20 million of annual state funding invested in the TS. CONCLUSIONS: The implementation of a TS in Arkansas during a 5-year period resulted in a reduction of the preventable death rate to 16% post-TS, and a 9-fold return on investment by the tax payer. Additional life-saving gains can be expected with ongoing financial support and additional system performance-improvement efforts.

Realities of rural emergency medical services disaster preparedness.

INTRODUCTION: Disaster preparedness is an area of major concern for the medical community that has been reinforced by recent world events. The emergency healthcare system must respond to all types of disasters, whether the incidents occur in urban or rural settings. Although the barriers and challenges are different in the rural setting, common areas of preparedness must be explored. PROBLEM: This study sought to answer several questions, including: (1) What are rural emergency medical services (EMS) organizations training for, compared to what they actually have seen during the last two years?; (2) What scale and types of events do they believe they are prepared to cope with?; and (3) What do they feel are priority areas for training and preparedness? METHODS: Data were gathered through a multi-region survey of 1801 EMS organizations in the US to describe EMS response experiences during specific incidents as well as the frequency with which these events occur. Respondents were asked a number of questions about local priorities. RESULTS: A total of 768 completed surveys were returned (43%). Over the past few years, training for commonly occurring types of crises and emergencies has declined in favor of terrorism preparedness. Many rural EMS organizations reported that events with 10 or fewer victims would overload them. Low priority was placed on interacting with other non-EMS disaster response agencies, and high priority was placed on basic staff training and retention. CONCLUSION: Maintaining viable, rural, emergency response capabilities and developing a community-wide response to natural or man-made events is crucial to mitigate long-term effects of disasters on a local healthcare system. The assessment of preparedness activities accomplished in this study will help to identify common themes to better prioritize preparedness activities and maximize the response capabilities of an EMS organization.

OOSTT: a Resource for Analyzing the Organizational Structures of Trauma Centers and Trauma Systems.

Organizational structures of healthcare organizations has increasingly become a focus of medical research. In the CAFÉ project we aim to provide a web-service enabling ontology-driven comparison of the organizational characteristics of trauma centers and trauma systems. Trauma remains one of the biggest challenges to healthcare systems worldwide. Research has demonstrated that coordinated efforts like trauma systems and trauma centers are key components of addressing this challenge. Evaluation and comparison of these organizations is essential. However, this research challenge is frequently compounded by the lack of a shared terminology and the lack of effective information technology solutions for assessing and comparing these organizations. In this paper we present the Ontology of Organizational Structures of Trauma systems and Trauma centers (OOSTT) that provides the ontological foundation to CAFÉ's web-based questionnaire infrastructure. We present the usage of the ontology in relation to the questionnaire and provide the methods that were used to create the ontology.

Analysis of prior health system contacts as a harbinger of subsequent fatal injury in American Indians.

CONTEXT: Many American Indian nations, tribes, and bands are at an elevated risk for premature death from unintentional injury. Previous research has documented a relationship between alcohol-related injury and subsequent injury death among predominately urban samples. The presence or nature of such a relationship has not been documented among American Indians living in the northern plains. PURPOSE: The purpose of this study was to identify and characterize any association between prior injury and/or alcohol use contacts with the Indian Health Service (IHS) and subsequent alcohol-related injury death that may suggest opportunities for mitigation. METHODS: Death certificates of American Indians who died from injury (ICD-9-E 800-999) in a rural IHS area over 6 consecutive years were linked to IHS acute-care facility records and toxicology reports. Deaths and prior IHS contacts were stratified by alcohol use as a contributing factor. Of the 526 injury deaths involving American Indians in the IHS area studied, 411 (78%) were successfully linked to IHS records. One hundred fifty-two of these cases met the inclusion criteria, with an additional 98 cases identified as a comparison group. FINDINGS: No differences in alcohol use at time of death between groups with and without prior health care contact (for injury or alcohol) could be determined (81% vs 73%). A significant relationship was found between previous visits for acute or chronic alcohol use and subsequent alcohol-related fatalities (P =.01). CONCLUSIONS: Based on these findings, injury-prevention activities in the population studied should be initiated at the time of any health-system contact in which alcohol use is identified. Intervention strategies should be developed that convey the immediate risk of death from injury in these patients.

A general systems approach to suicide prevention: lessons from cardiac prevention and control.

The pathology of cardiac disease includes genetic, physical, biochemical, psychological, social, and environmental vectors. Factors contributing to suicide have been identified in these same areas. Survival from an acute cardiac event requires a systematized and multisectoral response. Communities that do not have systematized response capabilities to acute cardiac events have poorer survival outcomes. Suicide prevention and control may also be responsive to an integrated community response system. This paper examines the development of a community cardiac care model, explores potential parallels for a community suicide prevention and control model, and outlines a general systems theory framework for a suicide prevention and control system.

Effect of JumpSTART training on immediate and short-term pediatric triage performance.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of JumpSTART training in changing prehospital care personnel and/or school nursing personnel performance in triaging pediatric patients involved in a multiple casualty incident immediately posttraining and at a 3- to 4-month follow-up interval. METHODS: This research involved a traditional pretest, training, posttest, and follow-up test format. However, since the variable of interest was performance rather than cognition, the measures were the individual student's ability to triage 10 children with simulated injuries into 1 of 4 possible categories within a 5-minute time window. A convenience sample of participants was selected from 3 divergent geographic locations. Standardized training and performance evaluation measures were employed. RESULTS: Significant performance improvements in pediatric triage were noted immediately following a 1-hour lecture, discussion, and case review. Changes in performance were maintained over a 3-month posttraining period. Prehospital personnel and school nurses benefited equally from pediatric triage training. CONCLUSIONS: Structured training results in triage performance improvement among prehospital and nursing personnel. This improvement is maintained for a period of at least 3 months. Additional research pertaining to the length of time between necessary retraining and/or refresher is warranted. Additionally, the relationship between staged scenario performance and responses to actual multiple casualty incidents needs to be established.

A randomized, prospective, multisite comparison of pediatric prehospital training methods.

OBJECTIVE: Results of prehospital pediatric continuing education using train-the-trainer and CD-ROM training methods were compared to each other and to a control group. The null hypothesis was that no differences would be found in pretraining and posttraining measurements of knowledge and performance by either training method. METHODS: This was a prospective trial involving 12 sites. Random selections were made from ambulance service lists provided by 3-state emergency medical services (EMS) agencies. Preintervention and postintervention (12-month) measurements included a written examination and 2 performance scenarios videotaped for independent panel evaluation. Training was either an interactive CD-ROM or standard classroom instruction using a train-the-trainer model. Mean differences in written, performance, and combined scores were analyzed. RESULTS: Differences were noted in the combined and performance scores for the CD-ROM intervention group. No differences were noted in written measurements between or among the groups. CONCLUSION: In this small sample, interactive CD-ROM training shows promise for improving performance. The research design, with additional guards against sample size attrition, may provide a model for multisite EMS education research.