Strokes Averted by Intravenous Thrombolysis: A Secondary Analysis of a Prospective, Multicenter, Controlled Trial of Mobile Stroke Units.

OBJECTIVE: This study was undertaken to examine averted stroke in optimized stroke systems. METHODS: This secondary analysis of a multicenter trial from 2014 to 2020 compared patients treated by mobile stroke unit (MSU) versus standard management. The analytical cohort consisted of participants with suspected stroke treated with intravenous thrombolysis. The main outcome was a tissue-defined averted stroke, defined as a final diagnosis of stroke with resolution of presenting symptoms/signs by 24 hours attributed to thrombolysis and no acute infarction/hemorrhage on imaging. An additional outcome was stroke with early symptom resolution, defined as a final diagnosis of stroke with resolution of presenting symptoms/signs by 24 hours attributed to thrombolysis. RESULTS: Among 1,009 patients with a median last known well to thrombolysis time of 87 minutes, 159 (16%) had tissue-defined averted stroke and 276 (27%) had stroke with early symptom resolution. Compared with standard management, MSU care was associated with more tissue-defined averted stroke (18% vs 11%, adjusted odds ratio [aOR] = 1.82, 95% confidence interval [CI] = 1.13-2.98) and stroke with early symptom resolution (31% vs 21%, aOR = 1.74, 95% CI = 1.12-2.61). The relationships between thrombolysis treatment time and averted/early recovered stroke appeared nonlinear. Most models indicated increased odds for stroke with early symptom resolution but not tissue-defined averted stroke with earlier treatment. Additionally, younger age, female gender, hyperlipidemia, lower National Institutes of Health Stroke Scale, lower blood pressure, and no large vessel occlusion were associated with both tissue-defined averted stroke and stroke with early symptom resolution. INTERPRETATION: In optimized stroke systems, 1 in 4 patients treated with thrombolysis recovered within 24 hours and 1 in 6 had no demonstrable brain injury on imaging. ANN NEUROL 2024;95:347-361.

Agency factors associated with first response systems that improve out-of-hospital cardiac arrest outcomes.

BACKGROUND: Data are conflicting regarding the association between first responder (FR) intervention and improved outcomes after out-of-hospital cardiac arrest (OHCA). We evaluated characteristics of agencies that have positive associations between FR interventions and outcomes. METHODS: We analyzed the 2016-2021 national Cardiac Arrest Registry to Enhance Survival (CARES). We defined the exposures as FR CPR and AED. The outcome was survival with favorable neurologic status. We used logistic regression models to evaluate the association between FR interventions with OHCA outcome for each agency, stratifying agencies into positive association (95% confidence interval above 1) and no/inverse association (95% confidence below or including 1). We compared characteristics between cohorts. RESULTS: For the association between FR CPR and outcomes, 21 agencies caring for 42,856 OHCAs had a positive association; 371 agencies caring for 449,824 OHCAs had no association. For FR AED, 47 agencies caring for 103,120 OHCAs had a positive association; 262 agencies caring for 327,761 OHCAs had no association. Comparing agency characteristics for FR CPR, agencies with a positive association had more annual OHCAs (+300), lower FR CPR rate (-11.3%), and lower FR AED rate (-10.8%). Comparing FR AED, agencies with a positive association had more OHCAs per year (+150.5), lower FR CPR rate (-6.8%), lower FR AED rate (-13.3%), lower response time (-0.6 minutes), and more OHCAs from high-income neighborhoods (+3.7%). CONCLUSION: FR AED more commonly had a positive association with outcomes than FR CPR. Agencies with better outcomes from FR interventions treated more OHCAs and had lower rates of FR intervention.

Public Health Interventions Guided by Houston's Wastewater Surveillance Program During the COVID-19 Pandemic.

Since the start of the COVID-19 pandemic, wastewater surveillance has emerged as a powerful tool used by public health authorities to track SARS-CoV-2 infections in communities. In May 2020, the Houston Health Department began working with a coalition of municipal and academic partners to develop a wastewater monitoring and reporting system for the city of Houston, Texas. Data collected from the system are integrated with other COVID-19 surveillance data and communicated through different channels to local authorities and the general public. This information is used to shape policies and inform actions to mitigate and prevent the spread of COVID-19 at municipal, institutional, and individual levels. Based on the success of this monitoring and reporting system to drive public health protection efforts, the wastewater surveillance program is likely to become a standard part of the public health toolkit for responding to infectious diseases and, potentially, other disease-causing outbreaks.

Outcomes of patients with pre-existing disability managed by mobile stroke units: A sub-analysis of the BEST-MSU study.

BACKGROUND: Few data exist on acute stroke treatment in patients with pre-existing disability (PD) since they are usually excluded from clinical trials. A recent trial of mobile stroke units (MSUs) demonstrated faster treatment and improved outcomes, and included PD patients. AIM: To determine outcomes with tissue plasminogen activator (tPA), and benefit of MSU versus management by emergency medical services (EMS), for PD patients. METHODS: Primary outcomes were utility-weighted modified Rankin Scale (uw-mRS). Linear and logistic regression models compared outcomes in patients with versus without PD, and PD patients treated by MSU versus standard management by EMS. Time metrics, safety, quality of life, and health-care utilization were compared. RESULTS: Of the 1047 tPA-eligible ischemic stroke patients, 254 were with PD (baseline mRS 2-5) and 793 were without PD (baseline mRS 0-1). Although PD patients had worse 90-day uw-mRS, higher mortality, more health-care utilization, and worse quality of life than non-disabled patients, 53% returned to at least their baseline mRS, those treated faster had better outcome, and there was no increased bleeding risk. Comparing PD patients treated by MSU versus EMS, 90-day uw-mRS was 0.42 versus 0.36 (p = 0.07) and 57% versus 46% returned to at least their baseline mRS. There was no interaction between disability status and MSU versus EMS group assignment (p = 0.67) for 90-day uw-mRS. CONCLUSION: PD did not prevent the benefit of faster treatment with tPA in the BEST-MSU study. Our data support inclusion of PD patients in the MSU management paradigm.

First Responder CPR and Survival Differences in Texas Minority and Lower Socioeconomic Status Neighborhoods.

INTRODUCTION: First responder (FR) cardiopulmonary resuscitation (CPR) is an important component of out-of-hospital cardiac arrest (OHCA) care. However, little is known about FR CPR disparities. METHODS: We linked the 2014-2021 Texas Cardiac Arrest Registry to Enhance Survival (TX-CARES) database to census tract data. We included non-traumatic OHCAs that were not witnessed by 9-1-1 responders and did not receive bystander CPR. We defined census tracts as having >50% of a race/ethnicity: White, Black, or Hispanic/Latino. We also stratified patients into quartiles based on socioeconomic status (SES): household income, high school graduation, and unemployment. We also combined race/ethnicity and income to create a total of five mixed strata, comparing lower income and minority census tracts to high income White census tracts. We created mixed model logistic regression models, adjusting for confounders and modeling census tract as a random intercept. Using the models, we compared FR CPR rates for census race/ethnicity (Black and Hispanic/Latino compared to White), and SES quartiles (2nd, 3rd, and 4th quartiles compared to 1st quartiles). Secondarily, we evaluated the association between FR CPR and survival for all strata. RESULTS: We included 21,966 OHCAs, and 57.4% had FR CPR. Evaluating the association between census tract characteristic and FR CPR, majority Black (aOR 0.30, 95% CI 0.22-0.41) had a lower bystander CPR rate when compared to majority White. The lowest income quartile had a lower rate of bystander CPR (aOR 0.80, 95% CI 0.65-0.98). The worst unemployment quartile was also associated with a lower rate of FR CPR (aOR 0.75, 95% CI 0.61-0.92). Combining race/ethnicity and income, middle income majority Black (30.0%; aOR 0.27, 95% CI 0.17-0.46) and low income >80% Black (31.8%; aOR 0.27, 95% CI 0.10-0.68) had lower rates of FR CPR in comparison to high income majority White. There were no associations between Hispanic or lower high school graduation and lower rates of FR CPR. We found no association between FR CPR and survival for all three strata. CONCLUSION: While we identified disparities in FR CPR in low SES and majority Black census tracts, we identified no association between FR CPR and survival in Texas.

Geospatial Analysis of Prehospital Triage and Early Potential Preventable Traumatic Deaths.

Severely injured patients often depend on prompt prehospital triage for survival. This study aimed to examine the under-triage of preventable or potentially preventable traumatic deaths. A retrospective review of Harris County, TX, revealed 1848 deaths within 24 hours of injury, with 186 being preventable or potentially preventable (P/PP). The analysis evaluated the geospatial relationship between each death and the receiving hospital. Out of the 186 P/PP deaths, these were more commonly male, minority, and penetrating mechanisms when compared with NP deaths. Of the 186 PP/P, 97 patients were transported to hospital care, 35 (36%) were transported to Level III, IV, or non-designated hospitals. Geospatial analysis revealed an association between the location of initial injury and proximity to receiving Level III, IV, and non-designated centers. Geospatial analysis supports proximity to the nearest hospital as one of the primary reasons for under-triage.

Wastewater surveillance of SARS-CoV-2 and influenza in preK-12 schools shows school, community, and citywide infections.

Wastewater surveillance is a passive and efficient way to monitor the spread of infectious diseases in large populations and high transmission areas such as preK-12 schools. Infections caused by respiratory viruses in school-aged children are likely underreported, particularly because many children may be asymptomatic or mildly symptomatic. Wastewater monitoring of SARS-CoV-2 has been studied extensively and primarily by sampling at centralized wastewater treatment plants, and there are limited studies on SARS-CoV-2 in preK-12 school wastewater. Similarly, wastewater detections of influenza have only been reported in wastewater treatment plant and university manhole samples. Here, we present the results of a 17-month wastewater monitoring program for SARS-CoV-2 (n = 2176 samples) and influenza A and B (n = 1217 samples) in 51 preK-12 schools. We show that school wastewater concentrations of SARS-CoV-2 RNA were strongly associated with COVID-19 cases in schools and community positivity rates, and that influenza detections in school wastewater were significantly associated with citywide influenza diagnosis rates. Results were communicated back to schools and local communities to enable mitigation strategies to stop the spread, and direct resources such as testing and vaccination clinics. This study demonstrates that school wastewater surveillance is reflective of local infections at several population levels and plays a crucial role in the detection and mitigation of outbreaks.

Management and Control Issues Related to Two Mumps Outbreaks in Houston: Future Implications.

BACKGROUND: Mumps is a highly contagious disease spread by airborne droplets, making control especially difficult in congregate, crowded settings such as shelters and jails. A mumps outbreak in Honduras, starting in 2018 among adults who were unvaccinated, spread northward with Central Americans migrating to the United States. We describe 2 mumps outbreaks in Houston during 2019 among migrants at the Houston Contract Detention Facility (HCDF) and among inmates at the Harris County Jail (HCJ). METHODS: We investigated cases of acute onset parotitis. Three or more mumps cases in a facility was considered an outbreak. Confirmed cases had positive polymerase chain reactions (PCR). Probable cases were linked epidemiologically to a confirmed case in the same unit and a positive serology for serum anti-mumps immunoglobulin M (IgM) antibody. Outbreak control measures included enhanced surveillance, isolation of housing units, educational outreach, and immunization with Measles, Mumps, Rubella (MMR) vaccine. RESULTS: At HCDF, during a 10-month period, we investigated 42 possible cases. Of the possible cases, 28 were lab-confirmed with 9 probable, 4 ruled out, and 1 vaccine reaction. All were migrants. At HCJ, during a 3-month period, we investigated 60 suspect cases; 20 cases were lab-confirmed, 13 probable and 27 ruled out. All but 2 were inmates. Only about a third of those offered MMR vaccination accepted. CONCLUSIONS: Successful outbreak resolution required close cooperation with HCDF and HCJ with ongoing surveillance, isolation of units with cases and MMR vaccination. Such facilities will have outbreaks; regular communications with local public health could improve response.

Citywide wastewater SARS-CoV-2 levels strongly correlated with multiple disease surveillance indicators and outcomes over three COVID-19 waves.

Public health surveillance systems for COVID-19 are multifaceted and include multiple indicators reflective of different aspects of the burden and spread of the disease in a community. With the emergence of wastewater disease surveillance as a powerful tool to track infection dynamics of SARS-CoV-2, there is a need to integrate and validate wastewater information with existing disease surveillance systems and demonstrate how it can be used as a routine surveillance tool. A first step toward integration is showing how it relates to other disease surveillance indicators and outcomes, such as case positivity rates, syndromic surveillance data, and hospital bed use rates. Here, we present an 86-week long surveillance study that covers three major COVID-19 surges. City-wide SARS-CoV-2 RNA viral loads in wastewater were measured across 39 wastewater treatment plants and compared to other disease metrics for the city of Houston, TX. We show that wastewater levels are strongly correlated with positivity rate, syndromic surveillance rates of COVID-19 visits, and COVID-19-related general bed use rates at hospitals. We show that the relative timing of wastewater relative to each indicator shifted across the pandemic, likely due to a multitude of factors including testing availability, health-seeking behavior, and changes in viral variants. Next, we show that individual WWTPs led city-wide changes in SARS-CoV-2 viral loads, indicating a distributed monitoring system could be used to enhance the early-warning capability of a wastewater monitoring system. Finally, we describe how the results were used in real-time to inform public health response and resource allocation.

Efficacy of defibrillator pads placement during ventricular arrhythmias, a before and after analysis.

BACKGROUND: European resuscitation guidelines describe several acceptable placements of defibrillator pads during resuscitation of cardiac arrest. However, no clinical trial has compared defibrillation efficacy between any of the different pad placements. Houston Fire Department emergency medical system (EMS) used anterior-posterior (AP) defibrillator pad placement before becoming a study site in the circulation improving resuscitation care trial (CIRC). During CIRC, Houston Fire EMS used sternal-apical (SA) pad placement. METHODS: Data from electronic defibrillator records was compared between a pre-CIRC dataset and patients in the CIRC trial receiving manual cardiopulmonary resuscitation (CPR). Only shocks from patients with initial ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) were included. Measured outcome was defibrillation efficacy, defined as termination of VF/VT. The general estimatingequations model was used to study the association between defibrillation efficacy rates in the AP vs SA group. RESULTS: In the pre-CIRC dataset, 207 included patients received 1023 shocks with AP pad placement, compared with 277 patients from the CIRC trial who received 1020 shocks with SA pad placement. There was no significant difference in defibrillation efficacy between AP and SA pads placement (82.1 % vs 82.2 %, p = 0.98). CONCLUSION: No difference was observed in defibrillation efficacy between AP and SA pad placement in this study. A randomized clinical trial may be indicated.

Community Variations in Out-of-Hospital Cardiac Arrest Care and Outcomes in Texas.

Background: Large and unacceptable variation exists in cardiac resuscitation care and outcomes across communities. Texas is the second most populous state in the US with wide variation in community and emergency response infrastructure. We utilized the Texas-CARES registry to perform the first Texas state analysis of out-of-hospital cardiac arrest (OHCA) in Texas, evaluating for variations in incidence, care, and outcomes.Methods: We analyzed the Texas-CARES registry, including all adult, non-traumatic OHCAs from 1/1/2014 through 12/31/2018. We analyzed the incidence and characteristics of OHCA care and outcome, overall and stratified by community. Utilizing mixed models accounting for clustering by community, we characterized variations in bystander CPR, bystander AED in public locations, and survival to hospital discharge across communities, adjusting for age, gender, race, location of arrest, and rate of witnessed arrest (bystander and 911 responder witnessed).Results: There were a total of 26,847 (5,369 per year) OHCAs from 13 communities; median 2,762 per community (IQR 444-2,767, min 136, max 9161). Texas care and outcome characteristics were: bystander CPR (43.3%), bystander AED use (9.1%), survival to discharge (9.1%), and survival with good neurological outcomes (4.0%). Bystander CPR rate ranged from 19.2% to 55.0%, and there were five communities above and five below the adjusted 95% confidence interval. Bystander AED use ranged from 0% to 19.5%, and there was one community below the adjusted 95% confidence interval. Survival to hospital discharge ranged from 6.7% to 14.0%, and there were three communities above and two below the adjusted 95% confidence interval.Conclusion: While overall OHCA care and outcomes were similar in Texas compared to national averages, bystander CPR, bystander AED use, and survival varied widely across communities in Texas. These variations signal opportunities to improve OHCA care and outcomes in Texas.

Prospective, Multicenter, Controlled Trial of Mobile Stroke Units.

BACKGROUND: Mobile stroke units (MSUs) are ambulances with staff and a computed tomographic scanner that may enable faster treatment with tissue plasminogen activator (t-PA) than standard management by emergency medical services (EMS). Whether and how much MSUs alter outcomes has not been extensively studied. METHODS: In an observational, prospective, multicenter, alternating-week trial, we assessed outcomes from MSU or EMS management within 4.5 hours after onset of acute stroke symptoms. The primary outcome was the score on the utility-weighted modified Rankin scale (range, 0 to 1, with higher scores indicating better outcomes according to a patient value system, derived from scores on the modified Rankin scale of 0 to 6, with higher scores indicating more disability). The main analysis involved dichotomized scores on the utility-weighted modified Rankin scale (≥0.91 or <0.91, approximating scores on the modified Rankin scale of ≤1 or >1) at 90 days in patients eligible for t-PA. Analyses were also performed in all enrolled patients. RESULTS: We enrolled 1515 patients, of whom 1047 were eligible to receive t-PA; 617 received care by MSU and 430 by EMS. The median time from onset of stroke to administration of t-PA was 72 minutes in the MSU group and 108 minutes in the EMS group. Of patients eligible for t-PA, 97.1% in the MSU group received t-PA, as compared with 79.5% in the EMS group. The mean score on the utility-weighted modified Rankin scale at 90 days in patients eligible for t-PA was 0.72 in the MSU group and 0.66 in the EMS group (adjusted odds ratio for a score of ≥0.91, 2.43; 95% confidence interval [CI], 1.75 to 3.36; P<0.001). Among the patients eligible for t-PA, 55.0% in the MSU group and 44.4% in the EMS group had a score of 0 or 1 on the modified Rankin scale at 90 days. Among all enrolled patients, the mean score on the utility-weighted modified Rankin scale at discharge was 0.57 in the MSU group and 0.51 in the EMS group (adjusted odds ratio for a score of ≥0.91, 1.82; 95% CI, 1.39 to 2.37; P<0.001). Secondary clinical outcomes generally favored MSUs. Mortality at 90 days was 8.9% in the MSU group and 11.9% in the EMS group. CONCLUSIONS: In patients with acute stroke who were eligible for t-PA, utility-weighted disability outcomes at 90 days were better with MSUs than with EMS. (Funded by the Patient-Centered Outcomes Research Institute; BEST-MSU ClinicalTrials.gov number, NCT02190500.).

Population-Based Estimates of SARS-CoV-2 Seroprevalence in Houston, Texas as of September 2020.

BACKGROUND: In contrast to studies that relied on volunteers or convenience sampling, there are few population-based severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroprevalence investigations and most were conducted early in the pandemic. The health department of the fourth largest US city recognized that sound estimates of viral impact were needed to inform decision making. METHODS: Adapting standardized disaster research methodology, in September 2020 the city was divided into high and low strata based on reverse-transcriptase polymerase chain reaction (RT-PCR) positivity rates; census block groups within each stratum were randomly selected with probability proportional to size, followed by random selection of households within each group. Using 2 immunoassays, the proportion of infected individuals was estimated for the city, by positivity rate and sociodemographic and other characteristics. The degree of underascertainment of seroprevalence was estimated based on RT-PCR-positive cases. RESULTS: Seroprevalence was estimated to be 14% with near 2-fold difference in areas with high (18%) versus low (10%) RT-PCR positivity rates and was 4 times higher compared to case-based surveillance data. CONCLUSIONS: Seroprevalence was higher than previously reported and greater than estimated from RT-PCR data. Results will be used to inform public health decisions about testing, outreach, and vaccine rollout.

Patterns and risk factors of opioid-suspected EMS overdose in Houston metropolitan area, 2015-2019: A Bayesian spatiotemporal analysis.

BACKGROUND: Opioid-related overdose deaths are the top accidental cause of death in the United States, and development of regional strategies to address this epidemic should begin with a better understanding of where and when overdoses are occurring. METHODS AND FINDINGS: In this study, we relied on emergency medical services data to investigate the geographical and temporal patterns in opioid-suspected overdose incidents in one of the largest and most ethnically diverse metropolitan areas (Houston Texas). Using a cross sectional design and Bayesian spatiotemporal models, we identified zip code areas with excessive opioid-suspected incidents, and assessed how the incidence risks were associated with zip code level socioeconomic characteristics. Our analysis suggested that opioid-suspected overdose incidents were particularly high in multiple zip codes, primarily south and central within the city. Zip codes with high percentage of renters had higher overdose relative risk (RR = 1.03; 95% CI: [1.01, 1.04]), while crowded housing and larger proportion of white citizens had lower relative risks (RR = 0.9; 95% CI: [0.84, 0.96], RR = 0.97, 95% CI: [0.95, 0.99], respectively). CONCLUSIONS: Our analysis illustrated the utility of Bayesian spatiotemporal models in assisting the development of targeted community strategies for local prevention and harm reduction efforts.

A Framework for EMS Outreach for Drug Overdose Survivors: A Case Report of the Houston Emergency Opioid Engagement System.

OBJECTIVE: Fatalities from drug-induced overdoses in the United States have taken greater than 292,000 lives in the last five years, and nearly two-thirds of these are opioid-related. The burden on prehospital emergency medical services (EMS) to respond to these incidents is growing. The standard of care typically involves overdose reversal and rapid transport, although a few agencies have begun to use community paramedicine to more proactively follow-up, initiate treatment, and refer patients to addiction medicine providers. Methods: In this manuscript we share the details of an outreach case study to serve as a blueprint for other agencies and municipalities to adopt and refine. The University of Texas Health Science Center, in partnership with the Houston Fire Department and other local first responder agencies, developed a program in Houston, Texas based on rapid response to post-overdose survivors using available incident data from the primary municipal agencies. Results: The Houston Emergency Opioid Engagement System (HEROES) was created to more comprehensively address the opioid epidemic. By utilizing data extracted from the patient care record system, a team comprised of a peer recovery coach and a paramedic is dispatched to the home location of a recent overdose (OD) incident to provide outreach. Conclusions: Outreach dialog and motivational interviewing techniques are used to provide awareness of treatment options and to engage individuals into a treatment program. A case report of this program and recommendations for broader adoption are presented.

Enhanced dispatch and rendezvous doubles the catchment area and number of patients treated on a mobile stroke unit.

INTRODUCTION: Mobile Stroke Units (MSUs) deliver acute stroke treatment on-scene in coordination with Emergency Medical Services (EMS). One criticism of the MSU approach is the limited range of a single MSU. The Houston MSU is evaluating MSU implementation, and we developed a rendezvous approach as an innovative solution to expand the range and number of patients treated. METHODS: In addition to direct 911 dispatch of our MSU to the scene within our 7-mile catchment area, we empowered more distant EMS units to activate the MSU. We also monitored EMS radio communications to identify possible patients. For these distant patients, the MSU met the EMS unit en route to the stroke center and treated the patient at that intermediate location. The distribution of the distance from MSU base station to site of stroke and time from 911 alert to tissue plasminogen activator (tPA) bolus were compared between patients treated on-scene and by rendezvous using Wilcoxon rank sum test. RESULTS: Over 4 years, 338 acute ischemic stroke patients were treated with tPA on our MSU. Of these, 169 (50%) were treated on-scene after MSU dispatch at a median of 6.4 miles (IQR 6.4 miles) from MSU base station. 169 (50%) were treated by 'rendezvous' pathway with assessment and treatment of stroke a median of 12.4 miles from base (IQR 5.5 miles) (p< 0.0001). Time (min) from MSU alert to tPA bolus did not differ: 36.0 ± 10.0 for on-scene vs 37.0 ± 10.0 with rendezvous (p=0.65). 13% of patients alerted via direct 911 dispatch were treated vs 44% of rendezvous patients. CONCLUSION: Adding a rendezvous approach to an MSU dispatch pathway doubles the range of operations and the number of patients treated by an MSU in an urban area, without incurring delay.

Bleeding to death in a big city: An analysis of all trauma deaths from hemorrhage in a metropolitan area during 1 year.

BACKGROUND: Hemorrhage is the most common cause of potentially preventable trauma deaths, but no studies have focused on all civilian traumatic deaths from hemorrhage, so we describe a year of these deaths from a large county to identify opportunities for preventing hemorrhagic deaths. METHODS: All trauma-related deaths in Harris County, Texas, in 2014 underwent examination by the medical examiner; patients were excluded if hemorrhage was not their primary reason for death. Deaths were then categorized as preventable/potentially preventable hemorrhage (PPH) or nonpreventable hemorrhage. These categories were compared across mechanism of injury, death location, and anatomic locations of hemorrhage to determine significant differences. RESULTS: A total of 1,848 deaths were reviewed, and 305 were from uncontrolled hemorrhage. One hundred thirty-seven (44.9%) of these deaths were PPH. Of these PPH, 49 (35.8%) occurred prehospital and an additional 28 (20.4%) died within 1 hour of arriving at an acute care setting. Of the 83 PPH who arrived at a hospital, 21 (25.3%) died at a center not designated as level 1. Isolated truncal bleeding was the source of hemorrhage in 102 (74.5%) of the PPH. Of those who died with truncal PPH, the distribution was 22 chest (21.6%), 39 chest and abdomen (38.2%), 16 abdomen (15.7%), and 25 all other combinations (24.5%). When patients who died within 1 hour of arrival to a hospital were combined with the 168 deaths that occurred prehospital, 223 (74.3%) of 300 deaths occurred before spending 1 hour in a hospital and 77 (34.5%) of 223 of these deaths were PPH. CONCLUSION: In a well-developed, urban trauma system, 34.5% of patients died from PPH in the prehospital setting or within an hour of hospitalization. Earlier, more effective prehospital resuscitation and truncal hemorrhage control strategies are needed to decrease deaths from PPH. LEVEL OF EVIDENCE: Therapeutic/Care management, level IV.

Design of a home-based intervention for Houston-area African-American adults with asthma: Methods and lessons learned from a pragmatic randomized trial.

A growing body of evidence demonstrates that home-based, multicomponent interventions can effectively reduce exposures to asthma triggers and decrease asthma symptoms. However, few of these studies have targeted adults. To address this and other research gaps, we designed and implemented a pragmatic randomized clinical trial, the Houston Home-based Integrated Intervention Targeting Better Asthma Control (HIITBAC) for African Americans, to assess the effectiveness of a home-based intervention to improve asthma control and quality of life in African-American adults-a population disproportionately affected by asthma. The primary goals were to help participants reduce allergens and irritants in their homes and better manage their disease through knowledge, improved medication use, and behavior change. HIITBAC had two groups: clinic-only and home-visit groups. Both groups received enhanced clinical care, but the home-visit group also received a detailed home assessment and four additional home visits spaced over roughly one year. We recruited 263 participants. Of these, 152 (57.8%) were recruited through electronic health record data, 51 (19.4%) through Emergency Medical Services data, and 60 (22.8%) through other efforts (e.g., emergency departments, community events, outreach). Seventy participants (26.6%) were lost to follow up, substantially more in the home-visit than in the clinic-only group. We describe the HIITBAC methodology and cohort, discuss lessons learned about recruitment and retention, and highlight adaptations we implemented to address these lessons.

Establishing a Regional Trauma Preventable/Potentially Preventable Death Rate.

OBJECTIVE: To establish a trauma preventable/potentially preventable death rate (PPPDR) within a heavily populated county in Texas. SUMMARY: The National Academies of Sciences estimated the trauma preventable death rate in the United States to be 20%, issued a call for zero preventable deaths, while acknowledging that an accurate preventable death rate was lacking. In this absence, effective strategies to improve quality of care across trauma systems will remain difficult. METHODS: A retrospective review of death-related records that occurred during 2014 in Harris County, TX, a diverse population of 4.4 million. Patient demographics, mechanism of injury, cause, timing, and location of deaths were assessed. Deaths were categorized using uniform criteria and recorded as preventable, potentially preventable or nonpreventable. RESULTS: Of 1848 deaths, 85% had an autopsy and 99.7% were assigned a level of preventability, resulting in a trauma PPPDR of 36.2%. Sex, age, and race/ethnicity varied across preventability categories (P < 0.01). Of 847 prehospital deaths, 758 (89.5%) were nonpreventable. Among 89 prehospital preventable/potentially preventable (P/PP) deaths, hemorrhage accounted for 55.1%. Of the 657 initial acute care setting deaths, 292 (44.4%) were P/PP; of these, hemorrhage, sepsis, and traumatic brain injury accounted for 73.3%. Of 339 deaths occurring after initial hospitalization, 287 (84.7%) were P/PP, of these 117 resulted from sepsis and 31 from pulmonary thromboembolism, accounted for 51.6%. CONCLUSIONS: The trauma PPPDR was almost double that estimated by the National Academies of Sciences. Data regarding P/PP deaths offers opportunity to target research, prevention, intervention, and treatment corresponding to all phases of the trauma system.

Establishing a regional pediatric trauma preventable/potentially preventable death rate.

PURPOSE: Although trauma is the leading cause of death for the pediatric population, few studies have addressed the preventable/potentially preventable death rate (PPPDR) attributable to trauma. METHODS: This is a retrospective study of trauma-related death records occurring in Harris County, Texas in 2014. Descriptive and Chi-squared tests were conducted for two groups, pediatric and adult trauma deaths in relation to demographic characteristics, mechanism of injury, death location and survival time. RESULTS: There were 105 pediatric (age < 18 years) and 1738 adult patients. The PPPDR for the pediatric group was 21.0%, whereas the PPPDR for the adult group was 37.2% (p = 0.001). Analysis showed fewer preventable/potentially preventable (P/PP) deaths resulting from any blunt trauma mechanism in the pediatric population than in the adult population (19.6% vs. 48.4%, p < 0.001). Amongst the pediatric population, P/PP traumatic brain injury (TBI) were more common in the youngest age range (age 0-5) vs. the older (6-12 years) pediatric and adolescent (13-17 years) patients. CONCLUSION: Our results identify areas of opportunities for improving pediatric trauma care. Although the overall P/PP death rate is lower in the pediatric population than the adult, opportunities for improving initial acute care, particularly TBI, exist.