Thomas D. Kirsch

Use of advanced radiology during visits to US emergency departments for injury-related conditions, 1998-2007.

CONTEXT Excessive use of medical imaging increases health care costs and exposure to ionizing radiation (a potential carcinogen) without yielding significant benefits to all patients. OBJECTIVE To determine whether there has been a change in the prevalence of emergency department visits for injury-related conditions for which computed tomography (CT) or magnetic resonance imaging (MRI) was obtained and whether there has been a change in the diagnosis of life-threatening conditions and patient disposition. DESIGN, SETTING, AND PARTICIPANTS Retrospective cross-sectional analysis of emergency department visits using data from the National Hospital Ambulatory Medical Care Survey (1998-2007). Sampled visits were weighted to produce estimates for the United States. MAIN OUTCOMES MEASURES Proportion of visits for injury-related conditions during which a CT or MRI was obtained, a life-threatening condition was diagnosed (eg, cervical spine fracture, skull fracture, intracranial bleeding, liver and spleen laceration), and which resulted in hospital and intensive care unit admission. RESULTS The prevalence of CT or MRI use during emergency department visits for injury-related conditions increased from 6% (95% confidence interval [CI], 5%-7%) (257 of 5237 visits) in 1998 to 15% (95% CI, 14%-17%) (981 of 6567 visits) in 2007 (P < .001 for trend). There was a small increase in the prevalence of life-threatening conditions (1.7% [95% CI, 1.2%-2.2%; 89 of 5237 visits] in 1998 and 2.0% [95% CI, 1.6%-2.5%; 142 of 6567 visits] in 2007; P=.04 for trend) [corrected].There was no change in prevalence of visits during which patients were either admitted to the hospital (5.9% [95% CI, 4.9%-6.9%] in 1998 and 5.5% [95% CI, 4.7%-6.5%] in 2007; P = .50 for trend) or to an intensive care unit (0.62% [95% CI, 0.40%-1.00%] in 1998 and 0.80% [95% CI, 0.53%-1.21%] in 2007; P = .14 for trend). Visits during which CT or MRI was obtained lasted 126 minutes (95% CI, 123-131 minutes) longer than those for which CT or MRI was not obtained. CONCLUSION From 1998 to 2007, the prevalence of CT or MRI use during emergency department visits for injury-related conditions increased significantly, without an equal increase in the prevalence of life-threatening conditions.

The human impact of earthquakes: a historical review of events 1980-2009 and systematic literature review

Introduction. Although rare, tsunamis have the potential to cause considerable loss of life and injury as well as widespread damage to the natural and built environments. The objectives of this review were to describe the impact of tsunamis on human populations in terms of mortality, injury, and displacement and, to the extent possible, identify risk factors associated with these outcomes. This is one of five reviews on the human impact of natural disasters. Methods. Data on the impact of tsunamis were compiled using two methods, a historical review from 1900 to mid 2009 of tsunami events from multiple databases and a systematic literature review to October 2012 of publications. Analysis included descriptive statistics and bivariate tests for associations between tsunami mortality and characteristics using STATA 11. Findings. There were 255,195 deaths (range 252,619-275,784) and 48,462 injuries (range 45,466-51,457) as a result of tsunamis from 1900 to 2009. The majority of deaths (89%) and injuries reported during this time period were attributed to a single event –the 2004 Indian Ocean tsunami. Findings from the systematic literature review indicate that the primary cause of tsunami-related mortality is drowning, and that females, children and the elderly are at increased mortality risk. The few studies that reported on tsunami-related injury suggest that males and young adults are at increased injury-risk. Conclusions. Early warning systems may help mitigate tsunami-related loss of life.

Seventy-two-hour Returns May Not be a Good Indicator of Safety in the Emergency Department: A National Study

OBJECTIVES The objective was to measure the association between returns to an emergency department (ED) within 72 hours and resource utilization, severity of illness, mortality, and admission rate. METHODS This was a retrospective, cross-sectional analysis of ED visits using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1998 to 2006. Cohorts were patients who had been seen in the ED within the past 72 hours versus those without the prior visit. A multivariate model was created to predict adjusted-resource utilization and mortality or admission rate. RESULTS During the study period, there were 218,179 ED patient visits and a 3.2% 72-hour return rate. Patients with Medicare (3.5%) and without insurance (3.5%) were more likely to return within 72 hours. Visits associated with alcohol (4.1%), low triage acuity (4.0%), or dermatologic conditions (5.9%) were more likely to return. Seventy-two-hour return visits used fewer resources (5.0 [±0.1] vs. 5.5 [±0.1] tests, medications, procedures), were less likely to be Level I triage acuity (17% vs. 20%), and had a similar admission rate (13% vs. 13%) as those not seen within 72 hours. The sample size was too small to evaluate mortality. CONCLUSIONS Patients who return to the ED within 72 hours do not use more resources, are not more severely ill, and do not have a higher hospital admission rate than those who had not been previously seen. These findings do not support the use of 72-hour returns as a quality or safety indicator. A more refined variation such as 72-hour returns resulting in admission may have more value.

Computed Tomography Scan Utilization in Emergency Departments: A Multi-State Analysis

BACKGROUND Increased utilization of computed tomography (CT) in emergency departments (EDs) has become a concern due to its expense and the potential risks associated with radiation exposure. OBJECTIVE To describe the predictors of CT utilization based on patient, provider, and ED characteristics. METHODS There were 3,217,396 ED patient visits during a 12-month period that were included in this retrospective analysis of a database from a single billing company that included 227 EDs in 41 states. Data were collected between January 1, 2006 and December 31, 2006 and included patient visit information, CT use for each patient visit, patient demographics, ED provider information, and ED volume. RESULTS The CT utilization rate was 16.7% (95% confidence interval [CI] 16.7-16.8%) for adults, whereas in pediatric patients (< 18 years of age) it was 5.3% (95% CI 5.3-5.4%). The adult CT utilization rate ranged from 11.3% (95% CI 11.2-11.4%) at age 20-29 years to 24.6% (95% CI 24.5-24.8%) for those>65 years of age. For the admitted patients, the CT utilization rate was 27.8% (95% CI 27.6-27.9%); for the patients transferred out of the hospital, the CT utilization rate was 23.2% (95% CI 22.9-23.6%). Discharged patients had a rate of 11.3% (95% CI 11.2-11.3%) and patients who left against medical advice had a scan rate of 20.2% (95% CI 19.6-20.7%). The CT utilization rate was 9.3% (95% CI 9.2-9.4%) in EDs with<20,000 annual visits and increased to 17.8% (95% CI 17.7-17.9%) in EDs with volumes of>40,000. The CT utilization rate was 16.1% (95% CI 16.1-16.2%) for emergency medicine boarded physicians vs. 11.3% (95% CI 11.3-11.4%) for non-emergency-medicine boarded physicians. CONCLUSIONS CT utilization by EDs seems to vary by a number of parameters, including patient age, ED volume, training background of the provider, and disposition status of the patient.

Epidemiology and Practice of Emergency Medicine in a Developing Country

STUDY OBJECTIVE To analyze the emergency medicine system in a developing country and identify areas of need and potential collaboration. DESIGN Convenience sample surveys of all emergency visits over a 2-week period, hospital admission and health department statistics, and interviews with government officials, health providers, and EMS managers. SETTING Port of Spain General Hospital, Trinidad and Tobago. RESULTS The ED has more than 100,000 visits per year. No records are kept. No physician in this study had emergency medicine training; only one had completed any residency. The survey included 3,710 patients: 40.5% were admitted, and .3% died. Injuries accounted for 41.6% of all visits, asthma 7.8%. The mean time elapsed before a patient was seen was .5 hour; mean time to discharge, 1.9 hours. In only 9% of patients were laboratory tests performed. Prehospital providers had limited equipment and training. CONCLUSION The ED and prehospital systems provide high-volume and often high-acuteness care. Barriers to improved care include limited specialized training and lack of medical records.

The human impact of tropical cyclones: a historical review of events 1980-2009 and systematic literature review

Background. Cyclones have significantly affected populations in Southeast Asia, the Western Pacific, and the Americas over the past quarter of a century. Future vulnerability to cyclones will increase due to factors including population growth, urbanization, increasing coastal settlement, and global warming. The objectives of this review were to describe the impact of cyclones on human populations in terms of mortality, injury, and displacement and, to the extent possible, identify risk factors associated with these outcomes. This is one of five reviews on the human impact of natural disasters. Methods. Data on the impact of cyclones were compiled using two methods, a historical review from 1980 to 2009 of cyclone events from multiple databases and a systematic literature review of publications ending in October 2012. Analysis included descriptive statistics and bivariate tests for associations between cyclone characteristics and mortality using Stata 11.0. Findings. There were 412,644 deaths, 290,654 injured, and 466.1 million people affected by cyclones between 1980 and 2009, and the mortality and injury burden was concentrated in less developed nations of Southeast Asia and the Western Pacific. Inconsistent reporting suggests this is an underestimate, particularly in terms of the injured and affected populations. The primary cause of cyclone-related mortality is drowning; in developed countries male gender was associated with increased mortality risk, whereas females experienced higher mortality in less developed countries. Conclusions. Additional attention to preparedness and early warning, particularly in Asia, can lessen the impact of future cyclones.

Guidelines for Evaluation of International Emergency Medicine Assistance and Development Projects

Interest in the development of the specialty of emergency medicine and of emergency health care systems has greatly increased worldwide in the last few years. The guidelines in this article were developed in an effort to assist others in design and evaluation of all types of emergency medicine projects.

Pediatric injuries presenting to an emergency department in a developing country.

Purpose: To describe the causes and outcomes of pediatric injuries using the emergency departments (ED) as a surveillance site. Method: Prospective, 14-day surveys of all injuries were conducted in the EDs of the two national trauma referral hospitals of Trinidad and Tobago. Data on patient demographics, type, cause, and outcome of injuries were collected. The %2 test for significance was used for categorical variables. Results: Pediatric patients (<20 years) accounted for 41.5% (714/1722) of injury visits. Of these, 62.6% were male and 17.4% were <four years old, 26.2% four to nine years, 31.1% 10 to 14 years, and 25.4% were 15 to 19 years old. Three patients (0.4%) died, 68.6% were discharged, and 31.0% admitted. Intentional injuries accounted for 13.9% of injuries. Of the intentional injuries, the assailant was significantly more likely to be known than not (P<0.01). The most common causes of all injuries were: falls, 44.4%; blunt objects, 12.3%; sharp objects, 11.8%; motor vehicle (including pedestrians), 7.4%; poison, 3.6%; and burns, 1.7%. Injuries occurring in the home accounted for 46.2%; in school, 25.5%; sports/recreation, 11.1%; and at work, 4.5%. The most common injuries were: lacerations, 30.8%, contusions/abrasions, 26.7%, fractures, 18.8%; and sprains/dislocations, 9.4%. Conclusion: Pediatric injuries are a significant cause of morbidity and mortality in this country, accounting for almost one third of injured patients. Because of the low frequency of pediatric injury deaths, ED surveillance may be a more effective means of identifying high risk groups and activities for injuries. Data from EDs may be useful in other developing countries to develop injury prevention programs.

A Comparative Analysis of Two External Health Care Disaster Responses Following Hurricane Katrina

Objective. Hurricane Katrina severely disrupted the health services in the U.S. Gulf Coast, necessitating an external health care response. The types andneeds of patients following such an extensive event have not been well described. The objective of this study was to analyze the types of patients treated in two temporary clinics andto identify differences between them. Methods. Two temporary sites were established: a disaster medical assistance team–based site in Mississippi anda volunteer-based site near New Orleans. Data were abstracted from patient charts for the two days of simultaneous operation: September 11 and12, 2005. Each patients age group, disposition, andprimary discharge diagnosis was categorized andanalyzed with descriptive andcomparative statistics. Results. There were a total of 501 patient encounters. The most common presentation overall was for chronic health conditions such as medication refills (20.6%), immunizations (11.0%), obtaining community resources (6.0%). andmanagement of acute exacerbation of chronic hypertension (4.6%). There were important differences; the Mississippi site treated more acute conditions than the Louisiana site, including lacerations (13.7% vs. 0%; p < 0.001), musculosketal injuries (9.4% vs. 2.6%; p < 0.001), andother nonspecified injuries (3.0% vs. 0.4%; p = 0.020). Conclusions. With extensive damage to a health care system, these temporary clinics staffed by out-of-state volunteers provided needed health care. The most common health problems were related to chronic disease, primary health care, androutine emergency care, not to the direct impact of the hurricane. In addition to treating minor injuries, disaster planners should prepare to provide primary health care, administer vaccinations, andprovide missing long-term medications. Key words: disaster medicine; emergency medicine; emergency medical services; public health.

Resilience of the Canterbury Hospital System to the 2011 Christchurch Earthquake

The paper analyzes the performance of a hospital system using a holistic and multidisciplinary approach. Data on impacts to the hospital system were collected using a standardized survey tool. A fault-tree analysis method is adopted to assess the functionality of critical hospital services based on three main contributing factors: staff, structure, and stuff. Damage to utility networks and to nonstructural components was found to have the most significant effect on hospital functionality. The functional curve is integrated over time to estimate the resilience of the regional acute-care hospital with and without the redistribution of its major services. The ability of the hospital network to offer redundancies in services after the earthquake increased the resilience of the Christchurch Hospital by 12%. The resilience method can be used to assess future performance of hospitals, and to quantify the effectiveness of seismic retrofits, hospital safety legislation, and new seismic preparedness strategies.