Modified Shock Index as a Predictor of Admission and In-hospital Mortality in Emergency Departments; an Analysis of a US National Database.

Introduction: The modified shock index (MSI) is the ratio of heart rate to mean arterial pressure. It is used as a predictive and prognostic marker in a variety of disease states. This study aimed to derive the optimal MSI cut-off that is associated with increased likelihood (likelihood ratio, LR) of admission and in-hospital mortality in patients presenting to emergency department (ED). Methods: We retrospectively reviewed data from the National Hospital Ambulatory Medical Care Survey between 2005 and 2010. Adults>18 years of age were included regardless of chief complaint. Basic patient demographics, initial vital signs, and outcomes were recorded for each patient. Then the optimal MSI cut-off for prediction of admission and in-hospital mortality in ED was calculated. LR ≥ 5 was considered clinically significant. Results: 567,994,402 distinct weighted adult ED patient visits were included in the analysis. 15.7% and 2.4% resulted in admissions and in-hospital mortality, respectively. MSI > 1.7 was associated with a moderate increase in the likelihood of both admission (Positive LR (+LR) = 6.29) and in-hospital mortality (+LR = 5.12). +LR for hospital admission at MSI >1.7 was higher for men (7.13; 95% CI 7.11-7.15) compared to women (5.49; 95% CI 5.47-5.50) and for non-white (7.92; 95% CI 7.88-7.95) compared to white patients (5.85; 95% CI 5.84-5.86). For MSI <0.7, the +LRs were not clinically significant for admission (+LR = 1.07) or in-hospital mortality (LR = 0.75). Conclusion: In this largest retrospective study, to date, on MSI in the undifferentiated ED population, we demonstrated that an MSI >1.7 on presentation is predictive of admission and in-hospital mortality. The use of MSI could help guide accurate acuity designation, resource allocation, and disposition.

Shock index as a predictor of hospital admission and inpatient mortality in a US national database of emergency departments.

STUDY OBJECTIVES: The shock index (SI), defined as the ratio of the heart rate (HR) to the systolic blood pressure (BP), is used as a prognostic tool in trauma and in specific disease states. However, there is scarcity of data about the utility of the SI in the general emergency department (ED)population. Our goal was to use a large national database of EDs in the United States (US) to determine whether the likelihood of inpatient mortality and hospital admission was associated with initial SI at presentation. METHODS: Data from the National Hospital Ambulatory Medical Care Survey were retrospectively reviewed to obtain a weighted sample of all US ED visits between 2005 and 2010. All adults >18 years old who survived the ED visit were included, regardless of their chief complaint. Likelihood ratios (LR) were calculated for a range of SI values, in order to determine SI thresholds most predictive of hospital admission and inpatient mortality. +LRs >5 were considered to be clinically significant. RESULTS: A total of 526 455 251 adult patient encounters were included in the analysis. 56.9% were women, 73.9% were white and 53.2% were between the ages of 18 and 44 years. 88 326 638 (15.7%) unique ED visits resulted in hospital admission and 1 927 235 (2.6%) visits resulted in inpatient mortality. SI>1.3 was associated with a clinically significant increase in both the likelihood of hospital admission (+LR=6.64) and inpatient mortality (+LR=5.67). SI>0.7 and >0.9, the traditional cited cut-offs, were only associated with marginal increases (+LR= 1.13; 1.54 for SI>0.7 and +LR=1.95; 2.59 for SI>0.9 for hospital admission and inpatient mortality, respectively). CONCLUSIONS: In this largest retrospective study to date on SI in the general ED population, we demonstrated that initial SI at presentation to the ED could potentially be useful in predicting the likelihood of hospital admission and inpatient mortality, which could help guide rapid and accurate acuity designation, resource allocation and disposition.

The Emergency Department Crash Cart: A systematic review and suggested contents.

BACKGROUND: As the field of Emergency Medicine grows worldwide, the importance of an Emergency Department Crash Cart (EDCC) has long been recognized. Yet, there is paucity of relevant peer-reviewed literature specifically discussing EDCCs or proposing detailed features for an EDCC suitable for both adult and pediatric patients. METHODS: The authors performed a systematic review of EDCC-specific literature indexed in Pubmed and Embase on December 20, 2016. In addition, the authors reviewed the 2015 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, the 2015 European Resuscitation Council (ERC) guidelines for resuscitation, and the 2013 American College of Surgeons (ACS) Advanced Trauma Life Support (ATLS) 9th edition. RESULTS: There were a total of 277 results, with 192 unique results and 85 duplicates. After careful review by two independent reviewers, all but four references were excluded. None of the four included articles described comprehensive contents of equipment and medications for both the adult and pediatric populations. This article describes in detail the final four articles specific to EDCC, and proposes a set of suggested contents for the EDCC. CONCLUSION: Our systematic review shows the striking paucity of such a high impact indispensable item in the ED. We hope that our EDCC content suggestions help enhance the level of response of EDs in the resuscitation of adult and pediatric populations, and encourage the implementation of and adherence to the latest evidence-based resuscitation guidelines.

Do End-of-Rotation and End-of-Shift Assessments Inform Clinical Competency Committees' (CCC) Decisions?

INTRODUCTION: Clinical Competency Committees (CCC) require reliable, objective data to inform decisions regarding assignment of milestone proficiency levels, which must be reported to the Accreditation Council for Graduate Medical Education. After the development of two new assessment methods, the end-of-shift (EOS) assessment and the end-of-rotation (EOR) assessment, we sought to evaluate their performance. We report data on the concordance between these assessments, as well as how each informs the final proficiency level determined in biannual CCC meetings. We hypothesized that there would be a high concordance level between the two assessment methods, including concordance of both the EOS and EOR with the final proficiency level designation by the CCC. METHODS: The residency program is an urban academic four-year emergency medicine residency with 48 residents. After their shifts in the emergency department (ED), residents handed out EOS assessment forms asking about individual milestones from 15 subcompetencies to supervising physicians, as well as triggered electronic EOR-doctor (EORd) assessments to supervising doctors and EOR-nurse (EORn) to nurses they had worked with after each two-week ED block. EORd assessments contained the full proficiency level scale from 16 subcompetencies, while EORn assessments contained four subcompetencies. Data reports were generated after each six-month assessment period and data was aggregated. We calculated Spearman's rank order correlations for correlations between assessment types and between assessments and final CCC proficiency levels. RESULTS: Over 24 months, 5,234 assessments were completed. The strongest correlations with CCC proficiency levels were the EORd for the immediate six-month assessment period prior (rs 0.71-0.84), and the CCC proficiency levels from the previous six-months (rs 0.83-0.92). EOS assessments had weaker correlations (rs 0.49 to 0.62), as did EORn (rs 0.4 to 0.73). CONCLUSION: End-of-rotation assessments completed by supervising doctors are most highly correlated with final CCC proficiency level designations, while end-of-shift assessments and end-of-rotation assessments by nurses did not correlate strongly with final CCC proficiency levels, both with overestimation of levels noted. Every level of proficiency the CCC assigned appears to be highly correlated with the designated level in the immediate six-month period, perhaps implying CCC members are biased by previous level assignments.

Hospital Surge Capacity: A Web-Based Simulation Tool for Emergency Planners.

The National Center for the Study of Preparedness and Catastrophic Event Response (PACER) has created a publicly available simulation tool called Surge (accessible at http://www.pacerapps.org) to estimate surge capacity for user-defined hospitals. Based on user input, a Monte Carlo simulation algorithm forecasts available hospital bed capacity over a 7-day period and iteratively assesses the ability to accommodate disaster patients. Currently, the tool can simulate bed capacity for acute mass casualty events (such as explosions) only and does not specifically simulate staff and supply inventory. Strategies to expand hospital capacity, such as (1) opening unlicensed beds, (2) canceling elective admissions, and (3) implementing reverse triage, can be interactively evaluated. In the present application of the tool, various response strategies were systematically investigated for 3 nationally representative hospital settings (large urban, midsize community, small rural). The simulation experiments estimated baseline surge capacity between 7% (large hospitals) and 22% (small hospitals) of staffed beds. Combining all response strategies simulated surge capacity between 30% and 40% of staffed beds. Response strategies were more impactful in the large urban hospital simulation owing to higher baseline occupancy and greater proportion of elective admissions. The publicly available Surge tool enables proactive assessment of hospital surge capacity to support improved decision-making for disaster response. (Disaster Med Public Health Preparedness. 2018;12:513-522).

Clinical metrics in emergency medicine: the shock index and the probability of hospital admission and inpatient mortality.

STUDY OBJECTIVES: The shock index (SI), defined as the ratio of HR to systolic BP, has been studied as an alternative prognostic tool to traditional vital signs in specific disease states and subgroups of patients. However, literature regarding its utility in the general ED population is lacking. Our main objective was to determine the probability of admission and inpatient mortality based on the first measured SI at initial presentation in the general adult ED population in our tertiary care centre. METHODS: A retrospective chart review of all adult patients (≥18 years old) presenting to the ED at our tertiary care centre over a 12-month period was conducted. Likelihood ratios (LRs) were calculated in order to determine the optimal SI cut-off for predicting hospital admission and inpatient mortality. RESULTS: We reviewed 58 336 ED patient encounters occurring between 1 October 2012 and 30 September 2013. SI >1.2 was associated with a large increase in the likelihood of hospital admission, with a positive LR (+LR) of 11.69 (95% CI 9.50 to 14.39) and a moderate increase in the likelihood of inpatient mortality with a +LR of 5.82 (95% CI 4.31 to 7.85). SI >0.7 and >0.9, the traditional 'normal' cut-offs cited in the literature, were only associated with minimal to small increases in the likelihood of admission and inpatient mortality. CONCLUSIONS: In our single-centre study, the initial SI recorded in the ED shows promise as a clinical metric in the general adult ED population, increasing the probability of both hospital admission and inpatient mortality, specifically at a threshold of SI >1.2.

Pediatric Emergency Department Return: A Literature Review of Risk Factors and Interventions.

BACKGROUND AND OBJECTIVE: Children discharged from emergency departments (EDs) are often at risk for ED return. The objective was to identify risk factors and interventions to mitigate or prevent ED return among this patient population. METHODS: Structured literature review of PubMed and clinicaltrials.gov was conducted to identify relevant studies. Inclusion criteria were studies evaluating ED returns by identifying risk factors and interventions in the pediatric population. Emergency department return was defined as returning to the ED within 1 year after initial visit. Abstract and full text articles were reviewed, and data were abstracted by 2 independent authors. RESULTS: A total of 963 articles were screened and yielded 42 potential relevant articles involving pediatric population. After full text review, a total of 12 articles were included in the final analysis (6 on risk factors and 6 on interventions). Risk factors for pediatric ED return included behavioral/psychiatric problems, younger age, acuity of illness, medical history of asthma, and social factors. Interventions included computer-generated instructions, postdischarge telephone coaching, ED-made appointments, case management, and home environment intervention. Emergency department-made appointments and postdischarge telephone coaching plus monetary incentive improved outpatient follow-up rate but not ED return. Home environment assessment coupled with case management reduced ED returns specifically among asthma patients. CONCLUSIONS: Several patient and visit characteristics can help predict children at risk for ED return. Although some interventions are successful at improving postdischarge follow-up, most did not reduce ED returns.

Disaster Metrics: Evaluation of de Boer's Disaster Severity Scale (DSS) Applied to Earthquakes.

INTRODUCTION: Quantitative measurement of the medical severity following multiple-casualty events (MCEs) is an important goal in disaster medicine. In 1990, de Boer proposed a 13-point, 7-parameter scale called the Disaster Severity Scale (DSS). Parameters include cause, duration, radius, number of casualties, nature of injuries, rescue time, and effect on surrounding community. Hypothesis This study aimed to examine the reliability and dimensionality (number of salient themes) of de Boer's DSS scale through its application to 144 discrete earthquake events. METHODS: A search for earthquake events was conducted via National Oceanic and Atmospheric Administration (NOAA) and US Geological Survey (USGS) databases. Two experts in the field of disaster medicine independently reviewed and assigned scores for parameters that had no data readily available (nature of injuries, rescue time, and effect on surrounding community), and differences were reconciled via consensus. Principle Component Analysis was performed using SPSS Statistics for Windows Version 22.0 (IBM Corp; Armonk, New York USA) to evaluate the reliability and dimensionality of the DSS. RESULTS: A total of 144 individual earthquakes from 2003 through 2013 were identified and scored. Of 13 points possible, the mean score was 6.04, the mode = 5, minimum = 4, maximum = 11, and standard deviation = 2.23. Three parameters in the DSS had zero variance (ie, the parameter received the same score in all 144 earthquakes). Because of the zero contribution to variance, these three parameters (cause, duration, and radius) were removed to run the statistical analysis. Cronbach's alpha score, a coefficient of internal consistency, for the remaining four parameters was found to be robust at 0.89. Principle Component Analysis showed uni-dimensional characteristics with only one component having an eigenvalue greater than one at 3.17. The 4-parameter DSS, however, suffered from restriction of scoring range on both parameter and scale levels. CONCLUSION: Jan de Boer's DSS in its 7-parameter format fails to hold statistically in a dataset of 144 earthquakes subjected to analysis. A modified 4-parameter scale was found to quantitatively assess medical severity more directly, but remains flawed due to range restriction on both individual parameter and scale levels. Further research is needed in the field of disaster metrics to develop a scale that is reliable in its complete set of parameters, capable of better fine discrimination, and uni-dimensional in measurement of the medical severity of MCEs.

Troponin elevations only detected with a high-sensitivity assay: clinical correlations and prognostic significance.

OBJECTIVES: With clinical use of high-sensitivity troponin I (hsTnI), more frequent troponin elevations will occur. However, the burden and implications of these elevations are not well understood. The authors quantified the prevalence of elevated hsTnI in patients presenting with possible acute coronary syndrome (ACS) who do not have elevated troponin with a current generation assay (cardiac troponin I [cTnI]) and determined the association of these newly detected elevations with a composite of all-cause mortality and subsequent cardiac hospitalization. METHODS: This was a prospective observational study of 808 subjects evaluated for possible ACS and followed for up to 1 year. Troponin values were measured with hsTnI (Abbott Laboratories) and cTnI (Abbott and Beckman Coulter). Cardiac hospitalization was defined as hospitalization for ACS, revascularization, acute heart failure (AHF), or tachy/brady arrhythmia that occurred after the index emergency department (ED) visit or hospital discharge. RESULTS: Forty subjects (5%) were diagnosed with ACS (26 myocardial infarction and 14 unstable angina). On the initial sample, the prevalence of elevated hsTnI among subjects with nonelevated cTnI was 9.2% using a gender-neutral cutoff (95% confidence interval [CI] = 7.1% to 11.4%) and 11.1% using a gender-specific cutoff (95% CI = 8.8% to 13.4%). Adjudicated diagnoses for subjects whose initial samples had elevated hsTnI but nonelevated cTnI (gender-neutral cutoff) were as follows: three (4.6%) ACS, 15 (23.1%) AHF, three (4.6%) volume overload etiology unclear/noncardiac, three (4.6%) cardiac (non-ACS), and 41 (63.1%) other. Of the 65 patients whose initial samples had hsTnI but nonelevated cTnI, eight developed cTnI elevation on subsequent serial sampling. After traditional cardiovascular risk factors and renal function were adjusted for, subjects with elevated initial hsTnI but nonelevated cTnI (initial and serial sampling) had a higher risk of all-cause mortality and subsequent cardiac hospitalization than subjects with both nonelevated hsTnI and nonelevated cTnI (hazard ratio [HR] = 1.91, 95% CI = 1.14 to 3.19). CONCLUSIONS: On the initial sample, 9% to 11% of subjects without cTnI elevation had hsTnI elevation. Although the majority of the patients with these newly detected hsTnI elevations did not have ACS, they had a higher risk for all-cause mortality and subsequent cardiac hospitalization.

Availability and diversity of training programs for responders to international disasters and complex humanitarian emergencies.

INTRODUCTION: Volunteers and members of relief organizations increasingly seek formal training prior to international field deployment. This paper identifies training programs for personnel responding to international disasters and complex humanitarian emergencies, and provides concise information - if available- regarding the founding organization, year established, location, cost, duration of training, participants targeted, and the content of each program. METHODS: An environmental scan was conducted through a combination of a peer-reviewed literature search and an open Internet search for the training programs. Literature search engines included EMBASE, Cochrane, Scopus, PubMed, Web of Science databases using the search terms "international," "disaster," "complex humanitarian emergencies," "training," and "humanitarian response". Both searches were conducted between January 2, 2013 and September 12, 2013. RESULTS: 14 peer-reviewed articles mentioned or described eight training programs, while open Internet search revealed 13 additional programs. In total, twenty-one training programs were identified as currently available for responders to international disasters and CHE. Each of the programs identified has different goals and objectives, duration, expenses, targeted trainees and modules. Each of the programs identified has different goals and objectives, duration, expenses, targeted trainees and modules. Seven programs (33%) are free of charge and four programs (19%) focus on the mental aspects of disasters. The mean duration for each training program is 5 to 7 days. Fourteen of the trainings are conducted in multiple locations (66%), two in Cuba (9%) and two in Australia (9%). The cost-reported in US dollars- ranges from $100 to $2,400 with a mean cost of $480 and a median cost of $135. Most of the programs are open to the public, but some are only available by invitation only, such as the International Mobilization Preparation for Action (IMPACT) and the United Nations Humanitarian Civil-Military Coordination (UN-CMCoord) Field Course. CONCLUSIONS: A variety of training programs are available for responders to disasters and complex humanitarian emergencies. These programs vary in their objectives, audiences, modules, geographical locations, eligibility and financial cost. This paper presents an overview of available programs and serves as a resource for potential responders interested in capacity-building training prior to deployment.

Fellowships in international emergency medicine in the USA: a comparative survey of program directors' and fellows' perspectives on the curriculum.

OBJECTIVE: Experts have proposed core curriculum components for international emergency medicine (IEM) fellowships. This study examined perceptions of program directors (PDs) and fellows on whether IEM fellowships cover these components, whether their perspectives differ and the barriers preventing fellowships from covering them. METHODS: From 1 November 2011 to 30 November 2011, a survey was administered to PDs, current fellows and recent graduates of the 34 US IEM fellowships. Respondents quantified their fellowship experience in six proposed core curriculum areas: emergency medicine (EM) systems development, EM education, humanitarian assistance, public health, emergency medical services and disaster medicine. Analysis was performed regarding what per cent of programmes fulfil the six curriculum areas. A paired t test determined the difference between PDs' and fellows' responses. Agreement between PDs and fellows within the same programme was determined using a κ statistic. RESULTS: Only 1/18 (6%) (according to fellows) to 2/24 (8%) (according to PDs) of programmes expose fellows to all six components. PDs consistently reported higher exposure than fellows. The difference in mean score between PDs and fellows was statistically significant (p<0.05) in three of the 6 (50%) core curriculum elements: humanitarian aid, public health and disaster medicine. Per cent agreement between PDs and fellows within each programmes ranged from poor to fair. CONCLUSIONS: While IEM fellowships have varying structure, this study highlights the importance of further discussion between PDs and fellows regarding delineation and objectives of core curriculum components. Transparent curricula and open communication between PDs and fellows may reduce differences in reported experiences.

Comparing the accuracy of syndrome surveillance systems in detecting influenza-like illness: GUARDIAN vs. RODS vs. electronic medical record reports.

BACKGROUND: A highly sensitive real-time syndrome surveillance system is critical to detect, monitor, and control infectious disease outbreaks, such as influenza. Direct comparisons of diagnostic accuracy of various surveillance systems are scarce. OBJECTIVE: To statistically compare sensitivity and specificity of multiple proprietary and open source syndrome surveillance systems to detect influenza-like illness (ILI). METHODS: A retrospective, cross-sectional study was conducted utilizing data from 1122 patients seen during November 1­7, 2009 in the emergency department of a single urban academic medical center. The study compared the Geographic Utilization of Artificial Intelligence in Real-time for Disease Identification and Alert Notification (GUARDIAN) system to the Complaint Coder (CoCo) of the Real-time Outbreak Detection System (RODS), the Symptom Coder (SyCo) of RODS, and to a standardized report generated via a proprietary electronic medical record (EMR) system. Sensitivity, specificity, and accuracy of each classifier's ability to identify ILI cases were calculated and compared to a manual review by a board-certified emergency physician. Chi-square and McNemar's tests were used to evaluate the statistical difference between the various surveillance systems.ResultsThe performance of GUARDIAN in detecting ILI in terms of sensitivity, specificity, and accuracy, as compared to a physician chart review, was 95.5%, 97.6%, and 97.1%, respectively. The EMR-generated reports were the next best system at identifying disease activity with a sensitivity, specificity, and accuracy of 36.7%, 99.3%, and 83.2%, respectively. RODS (CoCo and SyCo) had similar sensitivity (35.3%) but slightly different specificity (CoCo = 98.9%; SyCo = 99.3%). The GUARDIAN surveillance system with its multiple data sources performed significantly better compared to CoCo (χ2 = 130.6, p < 0.05), SyCo (χ2 = 125.2, p < 0.05), and EMR-based reports (χ2 = 121.3, p < 0.05). In addition, similar significant improvements in the accuracy (>12%) and sensitivity (>47%) were observed for GUARDIAN with only chief complaint data as compared to RODS (CoCo and SyCo) and EMR-based reports. CONCLUSION: In our study population, the GUARDIAN surveillance system, with its ability to utilize multiple data sources from patient encounters and real-time automaticity, demonstrated a more robust performance when compared to standard EMR-based reports and the RODS systems in detecting ILI. More large-scale studies are needed to validate the study findings, and to compare the performance of GUARDIAN in detecting other infectious diseases.

Interventions to mitigate emergency department and hospital crowding during an infectious respiratory disease outbreak: results from an expert panel.

OBJECTIVE: To identify and prioritize potential Emergency Department (ED) and hospital-based interventions which could mitigate the impact of crowding during patient surge from a widespread infectious respiratory disease outbreak and determine potential data sources that may be useful for triggering decisions to implement these high priority interventions. DESIGN: Expert panel utilizing Nominal Group Technique to identify and prioritize interventions, and in addition, determine appropriate "triggers" for implementation of the high priority interventions in the context of four different infectious respiratory disease scenarios that vary by patient volumes (high versus low) and illness severity (high versus low). SETTING: One day in-person conference held November, 2011. PARTICIPANTS: Regional and national experts representing the fields of public health, disease surveillance, clinical medicine, ED operations, and hospital operations. MAIN OUTCOME MEASURE: Prioritized list of potential interventions to reduce ED and hospital crowding, respectively. In addition, we created a prioritized list of potential data sources which could be useful to trigger interventions. RESULTS: High priority interventions to mitigate ED surge included standardizing admission and discharge criteria and instituting infection control measures. To mitigate hospital crowding, panelists prioritized mandatory vaccination and an algorithm for antiviral use. Data sources identified for triggering implementation of these interventions were most commonly ED and hospital utilization metrics. CONCLUSIONS: We developed a prioritized list of potentially useful interventions to mitigate ED and hospital crowding in various outbreak scenarios. The data sources identified to "trigger" the implementation of these high priority interventions consist mainly of sources available at the local, institutional level.

The Rush University advanced trauma training program, a novel approach for military trauma training.

Nearly 90% of combat deaths occur on the battlefield before the casualty reaches a treatment facility. It has been shown that early intervention in trauma patients improves morbidity and mortality. Hence, the training of military health care providers in lifesaving measures is imperative to saving lives on the battlefield. To date, few courses exist to provide skills in combat-zone trauma stabilization and treatment. Even fewer offer training in the identification and treatment of post-traumatic stress disorders and traumatic brain injury. We set out to develop a multidisciplinary, comprehensive course to include didactic lectures as well as hands-on training and observational modules. Ten courses have been delivered to date. Thus far, feedback from military personnel and course participants has revealed the positive impact of the training program. In this manuscript, we present the layout of the program and its contents.

State of virtual reality based disaster preparedness and response training.

The advent of technologically-based approaches to disaster response training through Virtual Reality (VR) environments appears promising in its ability to bridge the gaps of other commonly established training formats. Specifically, the immersive and participatory nature of VR training offers a unique realistic quality that is not generally present in classroom-based or web-based training, yet retains considerable cost advantages over large-scale real-life exercises and other modalities and is gaining increasing acceptance. Currently, numerous government departments and agencies including the U.S. Department of Homeland Security (DHS), the Centers for Disease Control and Prevention (CDC) as well as academic institutions are exploring the unique advantages of VR-based training for disaster preparedness and response. Growing implementation of VR-based training for disaster preparedness and response, conducted either independently or combined with other training formats, is anticipated. This paper reviews several applications of VR-based training in the United States, and reveals advantages as well as potential drawbacks and challenges associated with the implementation of such training platform.

Improving knowledge and process for international emergency medicine fellowship applicants: a call for a uniform application.

Background. There are currently 34 International Emergency Medicine (IEM) fellowship programs. Applicants and programs are increasing in number and diversity. Without a standardized application, applicants have a difficulty approaching programs in an informed and an organized method; a streamlined application system is necessary. Objectives. To measure fellows' knowledge of their programs' curricula prior to starting fellowship and to determine what percent of fellows and program directors would support a universal application system. Methods. A focus group of program directors, recent, and current fellows convened to determine the most important features of an IEM fellowship application process. A survey was administered electronically to a convenience sample of 78 participants from 34 programs. Respondents included fellowship directors, fellows, and recent graduates. Results. Most fellows (70%) did not know their program's curriculum prior to starting fellowship. The majority of program directors and fellows support a uniform application service (81% and 67%, resp.) and deadline (85% for both). A minority of program directors (35%) and fellows (30%) support a formal match. Conclusions. Program directors and fellows support a uniform application service and deadline, but not a formalized match. Forums for disseminating IEM fellowship information and for administering a uniform application service and deadline are currently in development to improve the process.

Prehospital emergency medical services in Lebanon: overview and prospects.

Prehospital emergency medical services in Lebanon are based on volunteer systems with multiple agencies. In this article, a brief history of the development of prehospital care in Lebanon is presented with a description of existing services. Also explored are the different aspects of prehospital care in Lebanon, including funding, public access and dispatch, equipment and supplies, provider training and certification, medical direction, and associated hospital-based emergency care.

Critical resources for hospital surge capacity: an expert consensus panel.

BACKGROUND: Hospital surge capacity (HSC) is dependent on the ability to increase or conserve resources. The hospital surge model put forth by the Agency for Healthcare Research and Quality (AHRQ) estimates the resources needed by hospitals to treat casualties resulting from 13 national planning scenarios. However, emergency planners need to know which hospital resource are most critical in order to develop a more accurate plan for HSC in the event of a disaster. OBJECTIVE: To identify critical hospital resources required in four specific catastrophic scenarios; namely, pandemic influenza, radiation, explosive, and nerve gas. METHODS: We convened an expert consensus panel comprised of 23 participants representing health providers (i.e., nurses and physicians), administrators, emergency planners, and specialists. Four disaster scenarios were examined by the panel. Participants were divided into 4 groups of five or six members, each of which were assigned two of four scenarios. They were asked to consider 132 hospital patient care resources- extracted from the AHRQ's hospital surge model- in order to identify the ones that would be critical in their opinion to patient care. The definition for a critical hospital resource was the following: absence of the resource is likely to have a major impact on patient outcomes, i.e., high likelihood of untoward event, possibly death. For items with any disagreement in ranking, we conducted a facilitated discussion (modified Delphi technique) until consensus was reached, which was defined as more than 50% agreement. Intraclass Correlation Coefficients (ICC) were calculated for each scenario, and across all scenarios as a measure of participant agreement on critical resources. For the critical resources common to all scenarios, Kruskal-Wallis test was performed to measure the distribution of scores across all scenarios. RESULTS: Of the 132 hospital resources, 25 were considered critical for all four scenarios by more than 50% of the participants. The number of hospital resources considered to be critical by consensus varied from one scenario to another; 58 for the pandemic influenza scenario, 51 for radiation exposure, 41 for explosives, and 35 for nerve gas scenario. Intravenous crystalloid solution was the only resource ranked by all participants as critical across all scenarios. The agreement in ranking was strong in nerve agent and pandemic influenza (ICC= 0.7 in both), and moderate in explosives (ICC= 0.6) and radiation (ICC= 0.5). CONCLUSION: In four disaster scenarios, namely, radiation, pandemic influenza, explosives, and nerve gas scenarios; supply of as few as 25 common resources may be considered critical to hospital surge capacity. The absence of any these resources may compromise patient care. More studies are needed to identify critical hospital resources in other disaster scenarios.

Earthquake-related injuries in the pediatric population: a systematic review.

BACKGROUND: Children are a special population, particularly susceptible to injury. Registries for various injury types in the pediatric population are important, not only for epidemiological purposes but also for their implications on intervention programs. Although injury registries already exist, there is no uniform injury classification system for traumatic mass casualty events such as earthquakes. OBJECTIVE: To systematically review peer-reviewed literature on the patterns of earthquake-related injuries in the pediatric population. METHODS: On May 14, 2012, the authors performed a systematic review of literature from 1950 to 2012 indexed in Pubmed, EMBASE, Scopus, Web of Science, and Cochrane Library. Articles written in English, providing a quantitative description of pediatric injuries were included. Articles focusing on other types of disasters, geological, surgical, conceptual, psychological, indirect injuries, injury complications such as wound infections and acute kidney injury, case reports, reviews, and non-English articles were excluded. RESULTS: A total of 2037 articles were retrieved, of which only 10 contained quantitative earthquake-related pediatric injury data. All studies were retrospective, had different age categorization, and reported injuries heterogeneously. Only 2 studies reported patterns of injury for all pediatric patients, including patients admitted and discharged. Seven articles described injuries by anatomic location, 5 articles described injuries by type, and 2 articles described injuries using both systems. CONCLUSIONS: Differences in age categorization of pediatric patients, and in the injury classification system make quantifying the burden of earthquake-related injuries in the pediatric population difficult. A uniform age categorization and injury classification system are paramount for drawing broader conclusions, enhancing disaster preparation for future disasters, and decreasing morbidity and mortality.