O. John Ma

Validation of length of hospital stay as a surrogate measure for injury severity and resource use among injury survivors.

OBJECTIVESnWhile hospital length of stay (LOS) has been used as a surrogate injury outcome when more detailed outcomes are unavailable, it has not been validated. This project sought to validate LOS as a proxy measure of injury severity and resource use in heterogeneous injury populations.nnnMETHODSnThis observational study used four retrospective cohorts: patients presenting to 339 California emergency departments (EDs) with a primary International Classification of Diseases, Ninth Revision (ICD-9), injury diagnosis (years 2005-2006); California hospital injury admissions (a subset of the ED population); trauma patients presenting to 48 Oregon EDs (years 1998-2003); and injured Medicare patients admitted to 171 Oregon and Washington hospitals (years 2001-2002). In-hospital deaths were excluded, as they represent adverse outcomes regardless of LOS. Duration of hospital stay was defined as the number of days from ED admission to hospital discharge. The primary composite outcome (dichotomous) was serious injury (Injury Severity Score [ISS] >or= 16 or ICD-9 ISS <or= 0.90) or resource use (major surgery, blood transfusion, or prolonged ventilation). The discriminatory accuracy of LOS for identifying the composite outcome was evaluated using receiver operating characteristic (ROC) analysis. Analyses were also stratified by age (0-14, 15-64, and >or=65 years), hospital type, and hospital annual admission volume.nnnRESULTSnThe four cohorts included 3,989,409 California ED injury visits (including admissions), 236,639 California injury admissions, 23,817 Oregon trauma patients, and 30,804 Medicare injury admissions. Composite outcome rates for the four cohorts were 2.1%, 29%, 27%, and 22%, respectively. Areas under the ROC curves for overall LOS were 0.88 (California ED), 0.74 (California admissions), 0.82 (Oregon trauma patients), and 0.68 (Medicare patients). In general, the discriminatory value of LOS was highest among children, tertiary trauma centers, and higher volume hospitals, although this finding differed by the injury population and outcome assessed.nnnCONCLUSIONSnHospital LOS may be a reasonable proxy for serious injury and resource use among injury survivors when more detailed outcomes are unavailable, although the discriminatory value differs by age and the injury population being studied.

The Optimum Follow-Up Period for Assessing Mortality Outcomes in Injured Older Adults

OBJECTIVES: To compare mortality rates of hospitalized injured aged 67 and older across commonly used follow‐up periods (e.g., in‐hospital, 30‐day, 1‐year) and to determine the postinjury time after which mortality rates stabilize.

The 2011 model of the clinical practice of emergency medicine

The 2011 Model of the Clinical Practice of Emergency Medicine.

Soft Tissue Infections and Emergency Department Disposition: Predicting the Need for Inpatient Admission

OBJECTIVESnLittle empiric evidence exists to guide emergency department (ED) disposition of patients presenting with soft tissue infections. This studys objective was to generate a clinical decision rule to predict the need for greater than 24-hour hospital admission for patients presenting to the ED with soft tissue infection.nnnMETHODSnThis was a retrospective cohort study of consecutive patients presenting to a tertiary care hospital ED with diagnosis of nonfacial soft tissue infection. Standardized chart review was used to collect 29 clinical variables. The primary outcome was >24-hour hospital admission (either general admission or ED observation unit), regardless of initial disposition. Patients initially discharged home and later admitted for more than 24 hours were included in the outcome. Data were analyzed using classification and regression tree (CART) analysis and multivariable logistic regression.nnnRESULTSnA total of 846 patients presented to the ED with nonfacial soft tissue infection. After merging duplicate records, 674 patients remained, of which 81 (12%) required longer than 24-hour admission. Using CART, the strongest predictors of >24-hour admission were patient temperature at ED presentation and mechanism of infection. In the multivariable logistic regression model, initial patient temperature (odds ratio [OR] for each degree over 37 degrees C = 2.91, 95% confidence interval [CI] = 1.65 to 5.12) and history of fever (OR = 3.02, 95% CI = 1.41 to 6.43) remained the strongest predictors of hospital admission. Despite these findings, there was no combination of factors that reliably identified more than 90% of target patients.nnnCONCLUSIONSnAlthough we were unable to generate a high-sensitivity decision rule to identify ED patients with soft tissue infection requiring >24-hour admission, the presence of a fever (either by initial ED vital signs or by history) was the strongest predictor of need for >24-hour hospital stay. These findings may help guide disposition of patients presenting to the ED with nonfacial soft tissue infections.

Patient Choice in the Selection of Hospitals by 9-1-1 Emergency Medical Services Providers in Trauma Systems

OBJECTIVESnReasons for undertriage (transporting seriously injured patients to nontrauma centers) and the apparent lack of benefit of trauma centers among older adults remain unclear; understanding emergency medical services (EMS) provider reasons for selecting certain hospitals in trauma systems may provide insight to these issues. In this study, the authors evaluated reasons cited by EMS providers for selecting specific hospital destinations for injured patients, stratified by age, injury severity, field triage status, and prognosis.nnnMETHODSnThis was a retrospective cohort study of injured children and adults transported by 61 EMS agencies to 93 hospitals (trauma and nontrauma centers) in five regions of the western United States from 2006 through 2008. Hospital records were probabilistically linked to EMS records using trauma registries, state discharge data, and emergency department data. The seven standardized reasons cited by EMS providers for selecting hospital destinations included closest facility, ambulance diversion, physician choice, law enforcement choice, patient or family choice, specialty resource center, and other. Serious injury was defined as an Injury Severity Score (ISS) ≥ 16, and unadjusted in-hospital mortality was considered as a marker of prognosis. All analyses were stratified by age in 10-year increments, and descriptive statistics were used to characterize the findings.nnnRESULTSnA total of 176,981 injured patients were evaluated and transported by EMS over the 3-year period, of whom 5,752 (3.3%) had ISS ≥ 16 and 2,773 (1.6%) died. Patient or family choice (50.6%), closest facility (20.7%), and specialty resource center (15.2%) were the most common reasons indicated by EMS providers for selecting destination hospitals; these frequencies varied substantially by patient age. The frequency of patient or family choice increased with increasing age, from 36.4% among 21- to 30-year-olds to 75.8% among those older than 90xa0years. This trend paralleled undertriage rates and persisted when restricted to patients with serious injuries. Older patients with the worst prognoses were preferentially transported to major trauma centers, a finding that was not explained by field triage protocols.nnnCONCLUSIONSnEmergency medical services transport patterns among injured patients are not random, even after accounting for field triage protocols. The selection of hospitals appears to be heavily influenced by patient or family choice, which increases with patient age and involves inherent differences in patient prognosis.

Is futile care in the injured elderly an important target for cost savings

BACKGROUND This study proposes a definition of futile care and quantifies its cost in injured elders. METHODS This was a retrospective study of Medicare patients with an International Classification of Diseases-9 injury diagnosis admitted to 171 Oregon and Washington facilities from January 1, 2001, through December 31, 2002, who died within 6 months of admission. Futile care was defined as death within 7 days of discharge from a hospitalization of at least 14 days. We compared health care costs in the last 6 months of life with those who did and did not meet our definition of futility. To simulate predicting and preventing futility early in the hospital course, we examined the effect of reducing spending on the futile care cohort to the level of those who survived 7 to 10 days after injury. RESULTS There were 6,832 elders who died within 6 months of injury, of whom 230 (3.4%) met our definition of futility. The median cost of care in the last 6 months of life was

The Academic RVU: Ten Years Developing a Metric for and Financially Incenting Academic Productivity at Oregon Health & Science University

33,373 for those not meeting our definition of futility and

Physician Age and Performance on the American Board of Emergency Medicine ConCert Examination

87,391 for the futile care group (p < 0.001). The 3.4% receiving futile care incurred 8.9% of total costs. Reducing expenditures in the futile care group to the level of those who died from 7 to 10 days after injury (median,

Development and implementation of an emergency department telephone follow-up system

25,633) would result in an overall cost savings of 6.5%. CONCLUSION End-of-life health care costs were significantly higher for those who received futile care. However, even aggressive reductions in futile care would result in small savings overall. LEVEL OF EVIDENCE Economic analysis, level III.

Using Press Ganey Provider Feedback to Improve Patient Satisfaction: A Pilot Randomized Controlled Trial

Purpose Established metrics reward academic faculty for clinical productivity. Few data have analyzed a bonus model to measure and reward academic productivity. This study’s objective was to describe development and use of a departmental academic bonus system for incenting faculty scholarly and educational productivity. Method This cross-sectional study analyzed a departmental bonus system among emergency medicine academic faculty at Oregon Health & Science University, including growth from 2005 to 2015. All faculty members with a primary appointment were eligible for participation. Each activity was awarded points based on a predetermined education or scholarly point scale. Faculty members accumulated points based on their activity (numerator), and the cumulative points of all faculty were the denominator. Variables were individual faculty member (deidentified), academic year, bonus system points, bonus amounts awarded, and measures of academic productivity. Data were analyzed using descriptive statistics, including measures of variance. Results The total annual financial bonus pool ranged from