Homicide as a medical outcome: racial disparity in deaths from assault in US Level I and II trauma centers.

BACKGROUND: Since 1900, thousands of medical journal articles have been published on the topic of racial disparities in health and medical outcomes in the United States, including overlapping disparities based on health insurance status. But research on the question of such disparities in the medical treatment of injury from assault-matters of public safety, considerable public expense, and policy debate-is lacking. METHODS: To determine differences by race and insurance status on death from intentional injury by others on and after trauma center arrival, propensity score matching is used to estimate adjusted mortality risk ratios by race and medical insurance controlling for facility, case, and injury characteristics. Analysis is based on a nationally representative sample of 100 Level I and II US trauma centers (National Trauma Data Bank 2005-2008) and includes 137,618 black and white assault cases aged 15 years and older: 35% white, and 65% black, with 46% of the whites and 60% of the blacks coded as uninsured. RESULTS: Black patients showed higher overall raw mortality rates from assault than whites (8.9% vs. 5.1%), but after propensity score matching, the black to white adjusted risk ratio for death from assault (homicide) dropped significantly across firearm, cutting/piercing, and blunt injuries. After adjustment, estimated black deaths were 29% in excess of white deaths for firearm injuries, 36% in excess for cutting/piercing injuries, and 61% in excess for blunt injuries. Uninsured blacks comprised 76% of all excess trauma center deaths from assault. CONCLUSIONS: Along with insurance status, and after excluding on-scene deaths, among patients brought to the Level I and II trauma centers, race is a substantial independent predictor of who dies from assault. Blacks, especially the uninsured, have significantly worse outcomes overall, but there is some evidence that this pattern is minimized at higher levels of injury severity. LEVEL OF EVIDENCE: I, prognostic study.

Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine.

BACKGROUND: The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote "best practices" and to improve patient outcomes. OBJECTIVE: 2007 update of the 2002 American College of Critical Care Medicine Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock. PARTICIPANTS: Society of Critical Care Medicine members with special interest in neonatal and pediatric septic shock were identified from general solicitation at the Society of Critical Care Medicine Educational and Scientific Symposia (2001-2006). METHODS: The Pubmed/MEDLINE literature database (1966-2006) was searched using the keywords and phrases: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation (ECMO), and American College of Critical Care Medicine guidelines. Best practice centers that reported best outcomes were identified and their practices examined as models of care. Using a modified Delphi method, 30 experts graded new literature. Over 30 additional experts then reviewed the updated recommendations. The document was subsequently modified until there was greater than 90% expert consensus. RESULTS: The 2002 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and AHA sanctioned recommendations. Centers that implemented the 2002 guidelines reported best practice outcomes (hospital mortality 1%-3% in previously healthy, and 7%-10% in chronically ill children). Early use of 2002 guidelines was associated with improved outcome in the community hospital emergency department (number needed to treat = 3.3) and tertiary pediatric intensive care setting (number needed to treat = 3.6); every hour that went by without guideline adherence was associated with a 1.4-fold increased mortality risk. The updated 2007 guidelines continue to recognize an increased likelihood that children with septic shock, compared with adults, require 1) proportionally larger quantities of fluid, 2) inotrope and vasodilator therapies, 3) hydrocortisone for absolute adrenal insufficiency, and 4) ECMO for refractory shock. The major new recommendation in the 2007 update is earlier use of inotrope support through peripheral access until central access is attained. CONCLUSION: The 2007 update continues to emphasize early use of age-specific therapies to attain time-sensitive goals, specifically recommending 1) first hour fluid resuscitation and inotrope therapy directed to goals of threshold heart rates, normal blood pressure, and capillary refill 70% and cardiac index 3.3-6.0 L/min/m.