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.

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.

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.

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.

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.

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.

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.

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.

Inter-hospital communications and transport: turning one-way funnels into two-way networks.

The Inter-hospital Communications and Transport workgroup was charged with exploring the current status, barriers, and data necessary to optimize the initial destination and subsequent transfer of patients between and among acute care settings. The subtitle, "Turning Funnels Into Two-way Networks," is descriptive of the approach that the workgroup took by exploring how and when smaller facilities in suburban, rural, and frontier areas can contribute to the daily business of caring for emergency patients across the lower-acuity spectrum-in some instances with consultant support from academic medical centers. It also focused on the need to identify high-acuity patients and expedite triage and transfer of those patients to facilities with specialty resources. Draft research recommendations were developed through an iterative writing process and presented to a breakout session of Academic Emergency Medicine's 2010 consensus conference, "Beyond Regionalization: Integrated Networks of Emergency Care." Priority research areas were determined by informal consensus of the breakout group. A subsequent iterative writing process was undertaken to complete this article. A number of broad research questions are presented.

Ambulance Crash Characteristics in the US Defined by the Popular Press: A Retrospective Analysis.

Ambulance crashes are a significant risk to prehospital care providers, the patients they are carrying, persons in other vehicles, and pedestrians. No uniform national transportation or medical database captures all ambulance crashes in the United States. A website captures many significant ambulance crashes by collecting reports in the popular media (the website is mentioned in the introduction). This report summaries findings from ambulance crashes for the time period of May 1, 2007 to April 30, 2009. Of the 466 crashes examined, 358 resulted in injuries to prehospital personnel, other vehicle occupants, patients being transported in the ambulance, or pedestrians. A total of 982 persons were injured as a result of ambulance crashes during the time period. Prehospital personnel were the most likely to be injured. Provider safety can and should be improved by ambulance vehicle redesign and the development of improved occupant safety restraints. Seventy-nine (79) crashes resulted in fatalities to some member of the same groups listed above. A total of 99 persons were killed in ambulance crashes during the time period. Persons in other vehicles involved in collisions with ambulances were the most likely to die as a result of crashes. In the urban environment, intersections are a particularly dangerous place for ambulances.

Characterizing job satisfaction and intent to leave among nationally registered emergency medical technicians: an analysis of the 2005 LEADS survey.

The primary purpose of this study was to characterize job satisfaction with opportunities for advancement, job satisfaction with pay and benefits, and intent to leave the EMS profession among Nationally Registered EMT-Basics and EMT-Paramedics. A secondary data analysis was performed on the National Registry of EMTs Longitudinal Emergency Medical Technician Attributes and Demographic Study Project (LEADS) 2005 core survey. We used chi-square and multiple logistic regression analyses to test for differences in job satisfaction with opportunities for advancement, job satisfaction with pay and benefits, and intent to leave the EMS profession across years of experience and work location. Among 11 measures of job satisfaction, NREMT-Basics and NREMT-Paramedics were least satisfied with opportunities for advancement and pay and benefits (67.8 and 55.2%, respectively). Nearly 6% of respondents reported intentions of leaving the profession within 12 months. In univariate analyses, job satisfaction with advancement opportunities varied across years of experience and work location. Job satisfaction with pay and benefits varied across years of experience and work location. The proportion reporting intentions of leaving the profession did not vary across the two independent variables of interest. In multivariable logistic regression, statistical differences observed in univariate analyses were attenuated to non-significance across all outcome models. Income, personal health, level of EMS certification, and type of EMS work were significant in several outcome models. EMS workforce research is at its infancy, thus our study adds to a limited but growing body of knowledge. In future and replicated research, one will need to consider different person and organizational variables in predicting different measures of job satisfaction among EMS personnel.

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.

An assessment of the impact of trauma systems consultation on the level of trauma system development.

BACKGROUND: Studies have shown that trauma systems decrease morbidity and mortality after injury. Despite these findings, overall progress in system development has been slow and inconsistent. The American College of Surgeons Committee on Trauma (COT) has developed a process to provide expert consultation to facilitate regional trauma system development. This study evaluated the progress that occurred after COT consultation visits in six regional systems. STUDY DESIGN: All six trauma systems undergoing COT consultation between January 1, 2004 and September 1, 2006 were included in the study. Using a set of 16 objective indicators, preconsultation status was retrospectively assessed by members of the original consultation team using data from the final consultation reports. Postconsultation status was assessed by directed telephone conference, conducted by members of the original consultation team with current key representatives from each system. Progress was assessed by comparing changes in both aggregate and individual indicator scores. RESULTS: This study showed a statistically significant increase in aggregate indicator scores after consultation. The largest gains were seen in systems with the longest time interval between the two assessments. Individual indicators related to system planning and quality assurance infrastructure showed the most improvement. Little or no change was seen in indicators related to system funding. CONCLUSIONS: The COT consultation process appears to be effective in facilitating regional trauma system development. In this short-term followup study, progress was seen primarily in areas related to planning and system design. Consultation was not effective in helping systems secure stable funding.

Contributing factors and issues associated with rural ambulance crashes: literature review and annotated bibliography.

Ambulance crashes occur with greater frequency and severity than crashes involving vehicles of similar size and weight characteristics. Crashes in rural areas tend to be more severe in terms of injury or death to vehicle occupants. The purpose of this article was to examine the extant literature, as well as summarize and discuss the overlapping findings of that body of literature. A stepwise literature search was conducted using the following MeSH search terms ambulance; accident, traffic; emergency medical technician; occupational health; and rural in descending combination. MEDLINE was used as the primary database but was augmented by searches of Academic Search Premier, Comprehensive Index of Nursing, Allied Health Literature, and ProQuest Dissertation International. The search resulted in 32 article citations, and of these, 28 were included. An annotated bibliography is followed by a discussion and conclusion that identify opportunities for prevention activities in the areas of education, enforcement, and engineering.

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.