Bio


Dr. Nancy Ewen Wang is a Professor of Emergency Medicine and Pediatrics. She was Associate Director of Pediatric Emergency Medicine at the Stanford University School of Medicine for more than 20 years. Her career has been committed to serving vulnerable populations as well as decreasing health disparities locally as well as globally. She founded the Stanford section in Social Emergency Medicine, a field which uses the perspective of the Emergency Department (ED) to identify patient social needs which contribute to disease and to develop solutions to decrease health disparities. As such, she directed the Social Emergency Medicine fellowship and was medical director for a student-run group which screened ED patients for social needs (Stanford Health Advocates and Research in the ED (SHAR(ED)). She has worked clinically and educated trainees and faculty globally, including at sites in Chiapas, Mexico; Borneo Indonesia and Galapagos, Ecuador. Her current research and advocacy includes investigating disparities in specialty care access and quality, including trauma and mental health and the impact of the Covid-19 pandemic on Asian American populations. She has been a medical expert for the Flores Settlement Agreement witnessing the conditions of detention for unaccompanied immigrant children. Dr. Wang received a Stanford Impact Lab Fellowship to provide wraparound social and medical services for unaccompanied immigrant children who have settled in the US. Most recently, she has been appointed as Faculty Director of the new REACH MD/MS Program in Health Equity Research at the Stanford School of Medicine. Dr. Wang completed an Emergency Medicine Residency at Stanford and then a Pediatric Emergency Medicine Fellowship between LPCH and Children's Oakland.

Academic Appointments


Current Research and Scholarly Interests


Dr. Nancy Ewen Wang is a Professor of Emergency Medicine and Pediatrics. She was Associate Director of Pediatric Emergency Medicine at the Stanford University School of Medicine for more than 20 years. Her career has been committed to serving vulnerable populations as well as decreasing health disparities locally as well as globally. She founded the Stanford section in Social Emergency Medicine, a field which uses the perspective of the Emergency Department (ED) to identify patient social needs which contribute to disease and to develop solutions to decrease health disparities. As such, she directed the Social Emergency Medicine fellowship and was medical director for a student-run group which screened ED patients for social needs (Stanford Health Advocates and Research in the ED (SHAR(ED)). She has worked clinically and educated trainees and faculty globally, including at sites in Chiapas, Mexico; Borneo Indonesia and Galapagos, Ecuador. Her current research and advocacy includes investigating disparities in specialty care access and quality, including trauma and mental health and the impact of the Covid-19 pandemic on Asian American populations. She has been a medical expert for the Flores Settlement Agreement witnessing the conditions of detention for unaccompanied immigrant children. Dr. Wang received a Stanford Impact Lab Fellowship to provide wraparound social and medical services for unaccompanied immigrant children who have settled in the US. Most recently, she has been appointed as Faculty Director of the new REACH MD/MS Program in Health Equity Research at the Stanford School of Medicine. Dr. Wang completed an Emergency Medicine Residency at Stanford and then a Pediatric Emergency Medicine Fellowship between LPCH and Children's Oakland.

All Publications


  • Proceedings from the 2021 SAEM Consensus Conference: Research Priorities for Interventions to Address Social Risks and Needs Identified in Emergency Department Patients. The western journal of emergency medicine Kraynov, L., Quarles, A., Kerrigan, A., Mayes, K. D., Mahmoud-Werthmann, S., Fockele, C. E., Duber, H. C., Doran, K. M., Lin, M. P., Cooper, R. J., Wang, N. E. 2023; 24 (2): 295-301

    Abstract

    Emergency departments (ED) function as a health and social safety net, regularly taking care of patients with high social risk and need. Few studies have examined ED-based interventions for social risk and need.Focusing on ED-based interventions, we identified initial research gaps and priorities in the ED using a literature review, topic expert feedback, and consensus-building. Research gaps and priorities were further refined based on moderated, scripted discussions and survey feedback during the 2021 SAEM Consensus Conference. Using these methods, we derived six priorities based on three identified gaps in ED-based social risks and needs interventions: 1) assessment of ED-based interventions; 2) intervention implementation in the ED environment; and 3) intercommunication between patients, EDs, and medical and social systems.Using these methods, we derived six priorities based on three identified gaps in ED-based social risks and needs interventions: 1) assessment of ED-based interventions, 2) intervention implementation in the ED environment, and 3) intercommunication between patients, EDs, and medical and social systems. Assessing intervention effectiveness through patient-centered outcome and risk reduction measures should be high priorities in the future. Also noted was the need to study methods of integrating interventions into the ED environment and to increase collaboration between EDs and their larger health systems, community partners, social services, and local government.The identified research gaps and priorities offer guidance for future work to establish effective interventions and build relationships with community health and social systems to address social risks and needs, thereby improving the health of our patients.

    View details for DOI 10.5811/westjem.2022.11.57293

    View details for PubMedID 36976612

    View details for PubMedCentralID PMC10047718

  • Disparities in COVID-19 testing and outcomes among Asian American and Pacific Islanders: an observational study in a large health care system. BMC public health Li, J., Chhoa, D., Palaniappan, L., Hays, K. J., Pressman, A., Wang, N. E. 2023; 23 (1): 251

    Abstract

    BACKGROUND: The COVID-19 pandemic has disproportionately impacted racial and ethnic minorities in the United States, including Asian Americans, Native Hawaiians and Pacific Islanders (Asian Americans and NH/PIs). However, few studies have highlighted nor disaggregated these disparities by Asian Americans and NH/PIs ethnic subgroups.METHODS: This retrospective, cross-sectional observational study aimed to assess variation of Asian Americans and NH/PIs COVID-19 testing and outcomes compared to non-Hispanic Whites (NHW). The study utilized data from the electronic health records (EHR) and the COVID-19 Universal Registry for Vital Evaluations (CURVE) from all patients tested for SARS-CoV-2 (n=556,690) at a large, health system in Northern and Central California between February 20, 2020 and March 31, 2021. Chi-square tests were used for testing differences in the severity of COVID-19 (hospitalization, ICU admission, death) and patient demographic and clinical characteristics across the Asian Americans and NH/PIs subgroups and NHW. Unadjusted and adjusted Odds Ratios (ORs) were estimated for measuring effect of race ethnicity on severity of COVID-19 using multivariable logistic regression.RESULTS: Of the entire tested population, 70,564/556,690 (12.7%) tested positive for SARS-CoV-2. SARS-CoV-2 positivity of Asian subgroups varied from 4% in the Chinese and Korean populations, to 11.2%, 13.5%, and 12.5% for Asian Indian, Filipino, and "other Asian" populations respectively. Pacific Islanders had the greatest subgroup test positivity at 20.1%. Among Asian Americans and NH/PIs patients with COVID-19 disease, Vietnamese (OR=2.06, 95% CI=1.30-3.25), "Other Asian" (OR=2.13, 95% CI=1.79-2.54), Filipino (OR=1.78, 95% CI=1.34-2.23), Japanese (OR=1.78, 95% CI=1.10-2.88), and Chinese (OR=1.73, 95% CI=1.34-2.23) subgroups had almost double the odds of hospitalization compared to NHW. Pacific Islander (OR=1.58, 95% CI=1.19-2.10) and mixed race subgroups (OR=1.55, 95% CI=1.10-2.20) had more than one and a half times odds of hospitalization compared to NHW. Adjusted odds of ICU admission or death among hospitalized patients by different Asian subgroups varied but were not statistically significant.CONCLUSIONS: Variation of COVID-19 testing and hospitalization by Asian subgroups was striking in our study. A focus on the Asian Americans and NH/PIs population with disaggregation of subgroups is crucial to understand nuances of health access, utilization, and outcomes among subgroups to create health equity for these underrepresented populations.

    View details for DOI 10.1186/s12889-023-15089-w

    View details for PubMedID 36747155

  • Computed tomography rates in pediatric trauma patients among emergency medicine and pediatric emergency medicine physicians. Journal of pediatric surgery Pariaszevski, A., Wang, N. E., Lee, M. O., Brown, I., Imler, D., Lowe, J., Fang, A. 2022

    Abstract

    Pediatric trauma patients undergo fewer computed tomography (CT) scans when evaluated at pediatric trauma centers (PTC) versus adult trauma centers (ATC) with no change in clinical outcome. Factors contributing to this difference are unclear. We sought to identify whether the training background of physicians, specifically emergency medicine (EM) versus pediatric emergency medicine (PEM), affected the CT rate of pediatric trauma patients within one institution.A single-center retrospective study of CT utilization based on attending physicians' training in trauma patients <18 years between November 2018 and November 2020. Attendings were categorized into two groups: EM residency with no PEM fellowship, or pediatrics/EM residency with PEM fellowship. Primary outcomes measured were the proportion of patients receiving a CT and CT positivity rate.Of 463 study patients, CTs were obtained in 145/228 (64%) patients by EM, and 130/235 (55%) by PEM (p=.07). CT positivity rate was 21% and 19% in EM and PEM, respectively (p=.46). The mean number of CTs per patient in EM was 2.8 compared to 2.1 in PEM (p<.01), and for patients with an injury severity score (ISS) >15, mean number of CTs per patient increased to 4.9 in EM versus 2.4 in PEM (p=.01).The mean number of CTs ordered per patient was statistically higher for EM attendings. The differences between CT rates highlight future opportunities for ongoing development of pediatric trauma imaging guidelines and radiation exposure reduction.Retrospective Study, Level III.

    View details for DOI 10.1016/j.jpedsurg.2022.10.042

    View details for PubMedID 36418201

  • A lasting impact? Exploring the immediate and longitudinal impact of an emergency department service learning help desk program AEM EDUCATION AND TRAINING Cohen, A., Hu, S., Bellon, M., Wang, N., Sebok-Syer, S. S. 2022; 6 (3)

    View details for DOI 10.1002/aet2.10760

    View details for Web of Science ID 000808017100001

  • A lasting impact? Exploring the immediate and longitudinal impact of an emergency department service learning help desk program. AEM education and training Cohen, A. S., Hu, S., Bellon, M., Wang, N. E., Sebok-Syer, S. S. 2022; 6 (3): e10760

    Abstract

    The emergency department (ED) help desk is an undergraduate-run service learning program that screens ED patients for social needs, connects them to community resources, and follows-up to promote connections with resources. Students accepted to the program participate in a didactic course on the fundamentals of social emergency medicine as well as available community resources. Students also receive training around interviewing patients and use of screening software. Students commit to at least three quarters of service, during which they attend weekly team meetings.This qualitative study explores the impact of this service learning experience for students. Current and former students were identified by the director of the program. Purposive and snowball sampling was used to select a sample of participants that participated in a semistructured interview. Our codebook was developed inductively using thematic analysis. Themes were presented and discussed with the entire research team for further analysis and refinement. Data collection and analysis used a constant comparative approach, and data collection ceased when saturation was achieved.Study participants consisted of current and former ED help desk student volunteers (n = 21). All participants believed that the ED help desk service learning experience prepared them for future careers by providing an experience that filled a gap in their education. We identified four main themes: (1) participants' perceived impact on patients, (2) learning from patients' experiences and differences, (3) appreciating patients' vulnerability and collaboratively addressing patients' needs, and (4) learning to navigate patients' social needs within the broader health care system.Our ED help desk service learning program offers a unique experience for students to learn about patients' social needs, participate in meaningfully interactions with patients, and empower themselves and patients to work together as coproducers of patients' care.

    View details for DOI 10.1002/aet2.10760

    View details for PubMedID 35707394

    View details for PubMedCentralID PMC9178399

  • "Could we have predicted this?" The association of a future mental health need in young people with a non-specific complaint and frequent emergency department visits. Journal of the American College of Emergency Physicians open Fang, A., Hersh, M., Birgisson, N., Saynina, O., Wang, N. E. 2021; 2 (5): e12556

    Abstract

    Objective: Mental health emergencies among young people are increasing. There is growing pressure for emergency departments to screen patients for mental health needs even when it is not their chief complaint. We hypothesized that young people with an initial non-specific condition and emergency department (ED) revisits have increased mental health needs.Methods: Retrospective, observational study of the California Office of Statewide Health Planning and Development Emergency Department Discharge Dataset (2010-2014) of young people (11-24 years) with an index visit for International Classification of Diseases, Ninth Revision diagnostic codes of "Symptoms, signs, and ill-defined conditions" (Non-Specific); "Diseases of the respiratory system" (Respiratory) and "Unintentional injury" (Trauma) who were discharged from a California ED. Patients were excluded if they had a prior mental health visit, chronic disease, or were pregnant. ED visit frequency was counted over 12 months. Regression models were created to analyze characteristics associated with a mental health visit.Results: Patients in the Non-Specific category compared to the Respiratory category had 1.2 times the odds of a future mental health visit (OR 1.20; 95% CI 1.17-1.24). Patients with ≥1 ED revisit, regardless of diagnostic category, had 1.3 times the odds of a future mental health visit. Patients with both a Non-Specific index visit and 1, 2, and 3 or more revisits with non-specific diagnoses had increasing odds of a mental health visit (OR 1.38; 95% CI 1.29-1.47; OR 1.70; 95% CI 1.46-1.98; OR 2.20; 95% CI 1.70-2.87, respectively.).Conclusions: Young people who go to the ED for non-specific conditions and revisits may benefit from targeted ED mental health screening.

    View details for DOI 10.1002/emp2.12556

    View details for PubMedID 34632448

  • A retrospective observational cohort study: Epidemiology and outcomes of pediatric unintentional falls in US emergency departments. Injury Nguyen, Q. P., Saynina, O., Pirrotta, E. A., Huffman, L. C., Wang, N. E. 2021

    Abstract

    The objective is to determine how outcomes from unintentional falls differ for children with and without developmental disabilities, with a sensitivity analysis specifically examining those with ADHD.This is a retrospective observational cohort study of 2010-2015 data from the Nationwide Emergency Department Sample (NEDS). The NEDS is a sampling of ED visits across 953 hospitals in 36 states. Unintentional falls for children with and without developmental disabilities were compared, adjusting for age, sex, payment source, income, mechanism, injury severity score (ISS). A sensitivity analysis was then performed for children with ADHD (n=139,642) and those without any developmental disabilities. A priori chosen outcomes included hospital admission, length of stay, intubation, and surgery. Logistic regression analysis estimated adjusted odds ratios for outcomes.Among children who presented to the ED with unintentional falls (n=13,217,237), there were 223,445 (1.7%) with developmental disabilities. The majority of those with developmental disabilities were male, ages 10-14 years. Compared to children without developmental disabilities, those with developmental disabilities were more likely to have an inpatient admission (aOR=2.27, 95% CI=2.10-2.44), length of stay more than 2 days (aOR=1.73, 95% CI=1.51-1.98), intubation (aOR=4.77, 95% CI=3.62-6.27) and surgery (aOR=2.11, 95% CI=1.93-2.32). A sensitivity analysis showed that 139,642 (1%) of children ages 5-17 years had ADHD. Of those with ADHD, the majority was also male, ages 10-14 years. Compared to children without ADHD, those with ADHD had a higher odds of inpatient admission (aOR=1.74, 95% CI=1.58-1.91), length of stay greater than 2 days (aOR=1.59, 95% CI=1.37-1.85), intubation (aOR=3.96, 95% CI=2.73-5.73), and surgery (aOR=1.82, 95% CI=1.60-2.06).Children with developmental disabilities, in particular those with ADHD, who experience falls are often older and male. They had greater odds of poor outcomes. These children need additional anticipatory guidance and attention to adequate treatment to prevent injuries from unintentional falls.

    View details for DOI 10.1016/j.injury.2021.05.017

    View details for PubMedID 34099243

  • Pain Assessment and Management in Pediatric Intensive Care Units Around the World, an International, Multicenter Study. Frontiers in pediatrics Grunauer, M., Mikesell, C., Bustamante, G., Cobo, G., Sánchez, S., Román, A. M., Icaza-Freire, A. P., Gavilanes, A. W., Wang, N. E. 2021; 9: 746489

    Abstract

    The adequate assessment and management of pain remains a challenging task in the Pediatric Intensive Care Unit (PICU). Our goal is to describe how pain is assessed and managed in PICUs around the world and to examine how human and material resources impact achievement of this goal. An international multicenter cross-sectional observational study was designed with the participation of 34 PICUs located in urban, suburban, and rural areas of 18 countries. We evaluated how PICUs around the world assessed and managed pain according to the Initiative for Pediatric Palliative Care recommendations, and how human and material resources impacted achievement of this goal. Data was collected for this study from 2016 to 2018 using questionnaires completed by medical doctors and nurses. In this paper, we focus on the indicators related to how pain is managed and assessed. The average achievement of the goal of pain relief across all centers was 72.2% (SD: 21.1). We found a statistically significant trend of more effective pain management scores, routine assessment, proper documentation, and involvement of pain management experts by increasing country income. While there are efforts being made worldwide to improve the knowledge in pain assessment and management, there is a lack of resources to do so appropriately in low-middle-income countries. There is a mismatch between the existing guidelines and policies, which are mainly designed in high income countries, and the resources available in lower resourced environments.

    View details for DOI 10.3389/fped.2021.746489

    View details for PubMedID 34778135

    View details for PubMedCentralID PMC8581242

  • Opportunities for Supporting Latino Immigrants in Emergency and Ambulatory Care Settings. Journal of community health Lee, J., Bruce, J., Wang, N. E. 2020

    Abstract

    Toughened immigration policies exacerbate barriers to public benefits and health care for immigrants. The objective of this study is to examine the impact of the immigration climate on the utilization of pediatric emergency and ambulatory care services and elucidate ways to best support Latino immigrant families. This is a cross-sectional study involving surveys and interviews with Latino parents (≥18years) in the pediatric emergency department. Forty-five parents completed surveys and 40 were interviewed. We identified two themes on health care utilization: fear of detention and deportation in health care settings, and barriers to pediatric primary care; and two themes on how pediatric providers can best support Latinos: information and guidance on immigration policies, and reassurance and safety during visits. Despite immigration fears, Latino parents continue to seek health care for their children. This highlights the unique access that pediatric providers have to this vulnerable population to address immigration fears and establish trust in the health care system. Health care providers are also perceived as trusted figures from whom Latino families want more information on the latest immigration policies, immigration resources, and education on legal rights during medical visits.

    View details for DOI 10.1007/s10900-020-00889-7

    View details for PubMedID 32700173

  • EPIDEMIOLOGY OF UNINTENTIONAL FALLS IN US EMERGENCY DEPARTMENTS: DOES ADHD PLAY A ROLE? Quynh Nguyen, Saynina, O., Huffman, L., Pirrotta, E., Wang, N. LIPPINCOTT WILLIAMS & WILKINS. 2020
  • Closing the gap: Improving access to trauma care in New Mexico (2007-2017) AMERICAN JOURNAL OF EMERGENCY MEDICINE Anderson, E. S., Greenwood-Ericksen, M., Wang, N., Dworkis, D. A. 2019; 37 (11): 2028–34
  • Teaching How to Teach in a Train-the-Trainer Program. Journal of graduate medical education Feltes, M. n., Becker, J. n., McCall, N. n., Mbanjumucyo, G. n., Sivasankar, S. n., Wang, N. E. 2019; 11 (4 Suppl): 202–4

    View details for DOI 10.4300/JGME-D-18-01014

    View details for PubMedID 31428287

    View details for PubMedCentralID PMC6697297

  • Increasing ambulatory treatment of pediatric minor burns-The emerging paradigm for burn care in children. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Kiwanuka, H., Maan, Z., Pirrotta, E., Curtin, C., Wang, N. E. 2018

    Abstract

    INTRODUCTION: Innovations in topical burn treatment along with a drive toward value-based care are steering burn care to the outpatient setting. Little is known regarding what characteristics predict outpatient treatment of pediatric minor burns and whether there is a temporal trend toward this treatment paradigm.METHODS: A retrospective cohort study was performed using California's Office of Statewide Health Planning and Development linked emergency department and inpatient database (2005-2013). All patients under 18years of age with a primary burn diagnosis were extracted. Using patient and facility level variables, we used regression modeling to evaluate predictors of outpatient burn treatment and temporal trends.RESULTS: There were 16,480 pediatric minor burn encounters during the period. 56.4% were male, 85.3% had <10% total body surface area (TBSA), 76.3% were scald or contact, and 77.3% were at deepest depth 2nd degree. Multiple variables predicted an increased likelihood of discharge home including older age(p<0.001), smaller TBSA(p<0.001), and superficial/partial thickness burns(<0.001). Children of Hispanic and Black race were less likely to be discharged home compared to White and Asian peers(p=<0.001). On Poisson modeling, the incidence rate ratio over the 9-year period for home discharge was 1.004 (95% CI 1.001-1.008, p=0.032).CONCLUSION: Older patients and those with more superficial burns were more likely to be treated as outpatients. Black and non-white Hispanic race was associated with inpatient admission. There is a growing trend toward ambulatory treatment of minor burns in the pediatric population. Further research is needed to assess whether outpatient treatment of pediatric minor burns results in greater readmissions.

    View details for PubMedID 30236815

  • Nationwide Assessment of Factors Associated with Nonoperative Management of Pediatric Splenic Injury. The American surgeon Hakim, I. S., Newton, C., Schoen, M. K., Pirrotta, E. A., Wang, N. E. 2018; 84 (5): 695-702

    Abstract

    To evaluate variation in care nationwide for children with splenic injuries at pediatric trauma, adult trauma, and nontrauma centers. We used the National Inpatient Sample from 2001 to 2010 to identify pediatric patients with splenic injury. We analyzed demographic, clinical, and hospital status characteristics. The primary objective was comparison of splenectomy rates at pediatric, adult, and nontrauma centers. We identified 34,599 patients with splenic injury. Throughout the study, 3,979 (11.5%) patients underwent splenectomy: 8.2 per cent of patients at pediatric trauma, 17.6 per cent at adult trauma, and 14.5 per cent at nontrauma centers. Multivariate regression analysis demonstrated patients had decreased odds of splenectomy at pediatric trauma centers compared with adult and nontrauma centers (OR = 0.42, P < 0.001). In addition, children aged 14 to 17 years (OR = 2.5) with injury severity score > 14 (OR = 5.8) had increased odds of undergoing splenectomy. In this nationwide sample, children with splenic injury treated at adult trauma and nontrauma centers had significantly higher rates of splenectomy compared with children treated at pediatric trauma centers. We highlight the need for interventions that ensure all injured children receive appropriate and high quality trauma care.

    View details for PubMedID 29966571

  • Rapid Retriage of Critically Injured Trauma Patients JAMA SURGERY Della Valle, J. M., Newton, C., Kline, R. A., Spain, D. A., Pirrotta, E., Wang, N. 2017; 152 (10): 981–83

    View details for PubMedID 28678987

    View details for PubMedCentralID PMC5831465

  • Association Between Insurance and Transfer of Injured Children From Emergency Departments. Pediatrics Huang, Y., Kissee, J. L., Dayal, P., Wang, N. E., Sigal, I. S., Marcin, J. P. 2017; 140 (4)

    Abstract

    To determine if injured children presenting to nondesignated trauma centers are more or less likely to be transferred relative to being admitted based on insurance status.We conducted a cross-sectional study by using the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample. Pediatric trauma patients receiving care in emergency departments (EDs) at nontrauma centers who were either admitted locally or transferred to another hospital were included. We performed logistic regression analysis adjusting for injury severity and other confounders and incorporated nationally representative weights to determine the association between insurance and transfer or admission.Nine thousand four hundred and sixty-one ED pediatric trauma events at 386 nontrauma centers met inclusion criteria. EDs that treated a higher proportion of patients with Medicaid had higher odds of transfer relative to admission (odds ratio [OR]: 1.2 per 10% increase in Medicaid; 95% confidence interval [CI]: 1.1-1.4), resulting in overall higher odds of transfer among patients with Medicaid compared with patients with private insurance (OR: 1.3; 95% CI: 1.0-1.5). A patient's insurance status was not associated with different odds of transfer relative to admission within individual EDs after adjusting for the ED's proportion of patients with Medicaid (Medicaid OR: 1.0; 95% CI: 0.8-1.1).Injured pediatric patients presenting to nondesignated trauma centers are slightly more likely to be transferred than admitted when the ED treats a higher proportion of Medicaid patients. In this study, ongoing concerns about inequities in the delivery of care among hospitals treating high proportions of children with Medicaid are reinforced.

    View details for DOI 10.1542/peds.2016-3640

    View details for PubMedID 28928288

  • Association Between Insurance and Transfer of Injured Children From Emergency Departments PEDIATRICS Huang, Y., Kissee, J. L., Dayal, P., Wang, N., Sigal, I. S., Marcin, J. P. 2017; 140 (4)
  • Pragmatic Firearm Advocacy for Pediatricians. Hospital pediatrics Sandberg, M., Wang, N. E. 2017; 7 (6): 361-363

    View details for DOI 10.1542/hpeds.2017-0038

    View details for PubMedID 28536189

  • Development and Validation of the Agency for Healthcare Research and Quality Measures of Potentially Preventable Emergency Department (ED) Visits: The ED Prevention Quality Indicators for General Health Conditions. Health services research Davies, S., Schultz, E., Raven, M., Wang, N. E., Stocks, C. L., Delgado, M. K., McDonald, K. M. 2017

    Abstract

    To develop and validate rates of potentially preventable emergency department (ED) visits as indicators of community health.Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project 2008-2010 State Inpatient Databases and State Emergency Department Databases.Empirical analyses and structured panel reviews.Panels of 14-17 clinicians and end users evaluated a set of ED Prevention Quality Indicators (PQIs) using a Modified Delphi process. Empirical analyses included assessing variation in ED PQI rates across counties and sensitivity of those rates to county-level poverty, uninsurance, and density of primary care physicians (PCPs).ED PQI rates varied widely across U.S. communities. Indicator rates were significantly associated with county-level poverty, median income, Medicaid insurance, and levels of uninsurance. A few indicators were significantly associated with PCP density, with higher rates in areas with greater density. A clinical and an end-user panel separately rated the indicators as having strong face validity for most uses evaluated.The ED PQIs have undergone initial validation as indicators of community health with potential for use in public reporting, population health improvement, and research.

    View details for DOI 10.1111/1475-6773.12687

    View details for PubMedID 28369814

  • Variations in Utilization of Inpatient Rehabilitation Services among Pediatric Trauma Patients. journal of pediatrics Nguyen, H. T., Newton, C., Pirrotta, E. A., Aguilar, C., Wang, N. E. 2017; 182: 342-348 e1

    Abstract

    To assess clinical and nonclinical characteristics associated with the use of pediatric inpatient rehabilitation services among children with traumatic injuries. We hypothesized there would be no nonclinical variations in the use of pediatric inpatient rehabilitation services.Retrospective analysis of 1139 patients who were injured seriously (0-18 years of age) from our institutional trauma registry (2004-2014). Patients' nonclinical and clinical characteristics were analyzed. We used a full matching technique to compare characteristics between those admitted to rehabilitation (cases) to those discharged home (controls). We matched patients by age category, sex, maximum Abbreviated Injury Scale, and body region of maximum Abbreviated Injury Scale. We used survey-based multivariate logistic regression to identify characteristics associated with inpatient rehabilitation services, controlling for multiple injuries, distance from home to rehabilitation center, year of service, hospital length of stay, and clinically relevant interactions.Ninety-eight patients (8.6%) were admitted to inpatient rehabilitation and 968 (85.0%) were discharged home. Black and other minority patients had increased odds of receiving inpatient rehabilitation compared with white patients (OR, 7.6 [P< .001] and OR, 1.6 [P= .03], respectively). Patients with private compared with public insurance had increased odds of receiving inpatient rehabilitation (OR, 2.4; P< .001).Pediatric inpatient rehabilitation beds are a scarce resource that should be available to those with the greatest clinical need. The mechanism creating differences in the use of inpatient rehabilitation based on nonclinical characteristics such as race/ethnicity or insurance status must be understood to prevent disparities in access to inpatient rehabilitation services.

    View details for DOI 10.1016/j.jpeds.2016.11.039

    View details for PubMedID 27939128

  • PREDICTORS OF NONDIAGNOSTIC ULTRASOUND FOR APPENDICITIS JOURNAL OF EMERGENCY MEDICINE Keller, C., Wang, N. E., Imler, D. L., Vasanawala, S. S., Bruzoni, M., Quinn, J. V. 2017; 52 (3): 318-323

    Abstract

    Ionizing radiation and cost make ultrasound (US), when available, the first imaging study for the diagnosis of suspected pediatric appendicitis. US is less sensitive and specific than computed tomography (CT) or magnetic resonance imaging (MRI) scans, which are often performed after nondiagnostic US.We sought to determine predictors of nondiagnostic US in order to guide efficient ordering of imaging studies.A prospective cohort study of consecutive patients 4 to 30 years of age with suspected appendicitis took place at an emergency department with access to 24/7 US, MRI, and CT capabilities. Patients with US as their initial study were identified. Clinical (i.e., duration of illness, highest fever, and right lower quadrant pain) and demographic (i.e., age and sex) variables were collected. Body mass index (BMI) was calculated based on Centers for Disease Control and Prevention criteria; BMI >85th percentile was categorized as overweight. Patients were followed until day 7. Univariate and stepwise multivariate logistic regression analysis was performed.Over 3 months, 106 patients had US first for suspected appendicitis; 52 (49%) had nondiagnostic US results. Eighteen patients had appendicitis, and there were no missed cases after discharge. On univariate analysis, male sex, a yearly increase in age, and overweight BMI were associated with nondiagnostic US (p < 0.05). In the multivariate model, only BMI (odds ratio 4.9 [95% CI 2.0-12.2]) and age (odds ratio 1.1 [95% CI 1.02-1.20]) were predictors. Sixty-eight percent of nondiagnostic US results occurred in overweight patients.Overweight and older patients are more likely to have a nondiagnostic US or appendicitis, and it may be more efficient to consider alternatives to US first for these patients. Also, this information about the accuracy of US to diagnose suspected appendicitis may be useful to clinicians who wish to engage in shared decision-making with the parents or guardians of children regarding imaging options for children with acute abdominal pain.

    View details for DOI 10.1016/j.jemermed.2016.07.101

    View details for Web of Science ID 000397089400023

  • MRI vs. Ultrasound as the initial imaging modality for pediatric and young adult patients with suspected appendicitis. Academic emergency medicine Imler, D., Keller, C., Sivasankar, S., Wang, N. E., Vasanawala, S., Bruzoni, M., Quinn, J. 2017

    Abstract

    While ultrasound (US), given its lack of ionizing radiation is currently the recommended initial imaging study of choice for the diagnosis of appendicitis in pediatric and young adult patients, it does have significant shortcomings. US is time intensive, operator dependent, and results in frequent inconclusive studies, thus necessitating further imaging, and admission for observation or repeat clinical visits. A rapid focused Magnetic Resonance Imaging (MRI) for appendicitis has been shown to have definitive sensitivity and specificity, similar to Computed tomography (CT) but without radiation and offers a potential alternative to US.In this single-center prospective cohort study, we sought to determine the difference in total length of stay and charges between rapid MRI and US as the initial imaging modality in pediatric and young adult patients presenting to the Emergency Department (ED) with suspected appendicitis. We hypothesized that rapid MRI would be more efficient and cost effective than US as the initial imaging modality in the ED diagnosis of appendicitis.A prospective randomized cohort study of consecutive patients was conducted in patients 2-30 years of age in an academic ED with access to both rapid MRI and US imaging modalities 24/7. Prior to the start of the study, the days of the week were randomized to either rapid MRI or US as the initial imaging modality. Physicians evaluated patients with suspected appendicitis per their usual manner. If the physician decided to obtain radiologic imaging, the pre-determined imaging modality for the day of the week was used. All decisions regarding other diagnostic testing and/or further imaging were left to the physician's discretion. Time intervals (min) between triage, order placement, start of imaging, end of imaging, image result and disposition (discharge vs. admission), as well as total charges (diagnostic testing, imaging and repeat ED visits) were recorded.Over a 100-day period, 82 patients were imaged to evaluate for appendicitis; 45/82 (55%) of patients were in the US first group; and 37/82 (45%) patients were in the rapid MRI first group. There were no differences in patient demographics or clinical characteristics between the groups and no cases of missed appendicitis in either group. 11/45 (24%) of US first patients had inconclusive studies, resulting in follow-up rapid MRI and 5 return ED visits contrasted with no inconclusive studies or return visits (p< 0.05) in the rapid MRI group. The rapid MRI compared to US group was associated with longer ED length of stay (mean difference 100 min; 95% CI 35-169) and increased ED charges (mean difference $4,887; 95% CI $1,821 - $8,513).In the diagnosis of appendicitis, US first imaging is more time efficient and less costly than rapid MRI despite inconclusive studies after US imaging. Unless the process of obtaining a rapid MRI becomes more efficient and less expensive, US should be the first line imaging modality for appendicitis in patients 2-30 years of age. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/acem.13180

    View details for PubMedID 28207968

  • Continuum of Care for HCV Among Patients Diagnosed in the Emergency Department Setting. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Anderson, E. S., Galbraith, J. W., Deering, L. J., Pfeil, S. K., Todorovic, T., Rodgers, J. B., Forsythe, J. M., Franco, R., Wang, H., Wang, N. E., White, D. A. 2017

    View details for DOI 10.1093/cid/cix163

    View details for PubMedID 28207069

  • Characterization of Young Adult Emergency Department Users: Evidence to Guide Policy JOURNAL OF ADOLESCENT HEALTH Burns, C., Wang, N. E., Goldstein, B. A., Hernandez-Boussard, T. 2016; 59 (6): 654-661

    Abstract

    The purpose of this study was to characterize young adult patients aged 19-25 years who are emergency department (ED) frequent users and study factors associated with frequent ED use.ED visits among 19- to 25-year olds were identified from administrative records in California, Florida, Iowa, Massachusetts, and New York, 2010. Patients were analyzed for 12 months to study the frequency of their ED utilization. ED visits were categorized according to primary diagnosis. Patients were stratified by frequency of ED use: one visit (single users), two to four visits (infrequent users), and five or more visits (frequent users) in a 1-year period.We identified 1,711,774 young adult patients who made 3,650,966 ED visits. Sixty-six percent of patients were single users, 29% were infrequent users, and 4.6% were frequent users. Frequent users accounted for a disproportionate 28.8% of visits within the population studied. Frequent users had the largest proportion of visits for complications of pregnancy (13.6%) compared to single users (6.1%) and Medicaid (42.6%) compared to private insurance (17.3%). There was an increased risk of frequent ED use associated with females (odds ratio [OR]: 1.77), Medicaid (OR: 3.21), and Medicare insurance (OR: 4.22) compared to private insurance, and diseases of the blood (OR: 3.36) and mental illness (OR: 1.99) compared to injury and poisoning.Frequent users comprise a significant portion of the young adult ED population and present with a large proportion of visits for complications of pregnancy. Policies targeting this population might focus on improved access to primary and urgent care, acute obstetric care, and better coordination of care.

    View details for DOI 10.1016/j.jadohealth.2016.07.011

    View details for Web of Science ID 000389534900008

    View details for PubMedID 27613220

  • Variation in the Intensity of Care for Patients with Uncomplicated Renal Colic Presenting to U.S. Emergency Departments. journal of emergency medicine Elder, J. W., Delgado, M. K., Chung, B. I., Pirrotta, E. A., Wang, N. E. 2016

    Abstract

    Renal colic results in > 1 million ED visits per year, yet there exists a gap in understanding how the majority of these visits, namely uncomplicated cases, are managed.We assessed patient- and hospital-level variation for emergency department (ED) management of uncomplicated kidney stones.We identified ED visits from non-elderly adults (aged 19-79 years) with a primary diagnosis indicating renal stone or colic from the 2011 Nationwide Emergency Department Sample. Patients with additional diagnostic codes indicating infection, sepsis, and abdominal aortic aneurysm were excluded. We used sample-weighted logistic regression to determine the association between hospital admission and having a urologic procedure with patient and hospital characteristics.Of the 1,061,462 ED visits for uncomplicated kidney stones in 2011, 8.0% of visits resulted in admission and 6.3% resulted in an inpatient urologic procedure. Uninsured patients compared to Medicaid insured patients were less likely to be admitted or have an inpatient urologic procedure (odds ratio [OR] = 0.72; 95% confidence interval [CI] 0.65-0.81 and OR = 0.80; 95% CI 0.72-0.87, respectively). Private- and Medicare-insured patients compared to Medicaid-insured patients were more likely to have an inpatient urologic procedure (OR = 1.20; 95% CI 1.11-1.30 and OR = 1.14; 95% CI 1.04-1.25, respectively).For patients with uncomplicated renal colic, there is variation in the management associated with nonclinical factors, namely insurance. No consensus guidelines exist yet to address when to admit or utilize inpatient urologic procedures.

    View details for DOI 10.1016/j.jemermed.2016.05.037

    View details for PubMedID 27720288

  • Predictors of Nondiagnostic Ultrasound for Appendicitis. journal of emergency medicine Keller, C., Wang, N. E., Imler, D. L., Vasanawala, S. S., Bruzoni, M., Quinn, J. V. 2016

    Abstract

    Ionizing radiation and cost make ultrasound (US), when available, the first imaging study for the diagnosis of suspected pediatric appendicitis. US is less sensitive and specific than computed tomography (CT) or magnetic resonance imaging (MRI) scans, which are often performed after nondiagnostic US.We sought to determine predictors of nondiagnostic US in order to guide efficient ordering of imaging studies.A prospective cohort study of consecutive patients 4 to 30 years of age with suspected appendicitis took place at an emergency department with access to 24/7 US, MRI, and CT capabilities. Patients with US as their initial study were identified. Clinical (i.e., duration of illness, highest fever, and right lower quadrant pain) and demographic (i.e., age and sex) variables were collected. Body mass index (BMI) was calculated based on Centers for Disease Control and Prevention criteria; BMI >85th percentile was categorized as overweight. Patients were followed until day 7. Univariate and stepwise multivariate logistic regression analysis was performed.Over 3 months, 106 patients had US first for suspected appendicitis; 52 (49%) had nondiagnostic US results. Eighteen patients had appendicitis, and there were no missed cases after discharge. On univariate analysis, male sex, a yearly increase in age, and overweight BMI were associated with nondiagnostic US (p < 0.05). In the multivariate model, only BMI (odds ratio 4.9 [95% CI 2.0-12.2]) and age (odds ratio 1.1 [95% CI 1.02-1.20]) were predictors. Sixty-eight percent of nondiagnostic US results occurred in overweight patients.Overweight and older patients are more likely to have a nondiagnostic US or appendicitis, and it may be more efficient to consider alternatives to US first for these patients. Also, this information about the accuracy of US to diagnose suspected appendicitis may be useful to clinicians who wish to engage in shared decision-making with the parents or guardians of children regarding imaging options for children with acute abdominal pain.

    View details for DOI 10.1016/j.jemermed.2016.07.101

    View details for PubMedID 27692650

  • Addressing Social Determinants of Health from the Emergency Department through Social Emergency Medicine. The western journal of emergency medicine Anderson, E. S., Lippert, S., Newberry, J., Bernstein, E., Alter, H. J., Wang, N. E. 2016; 17 (4): 487-489

    View details for DOI 10.5811/westjem.2016.5.30240

    View details for PubMedID 27429706

  • Cost-Effectiveness of Field Trauma Triage among Injured Adults Served by Emergency Medical Services JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Newgard, C. D., Yang, Z., Nishijima, D., McConnell, K. J., Trent, S. A., Holmes, J. F., Daya, M., Mann, N. C., Hsia, R. Y., Rea, T. D., Wang, N. E., Staudenmayer, K., Delgado, M. K. 2016; 222 (6): 1125-1137

    Abstract

    The American College of Surgeons Committee on Trauma sets national targets for the accuracy of field trauma triage at ≥95% sensitivity and ≥65% specificity, yet the cost-effectiveness of realizing these goals is unknown. We evaluated the cost-effectiveness of current field trauma triage practices compared with triage strategies consistent with the national targets.This was a cost-effectiveness analysis using data from 79,937 injured adults transported by 48 emergency medical services agencies to 105 trauma and nontrauma hospitals in 6 regions of the western United States from 2006 through 2008. Incremental differences in survival, quality-adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio (costs per QALY gained) were estimated for each triage strategy during a 1-year and lifetime horizon using a decision analytic Markov model. We considered an incremental cost-effectiveness ratio threshold of <$100,000 to be cost-effective.For these 6 regions, a high-sensitivity triage strategy consistent with national trauma policy (sensitivity 98.6%, specificity 17.1%) would cost $1,317,333 per QALY gained, and current triage practices (sensitivity 87.2%, specificity 64.0%) cost $88,000 per QALY gained, compared with a moderate sensitivity strategy (sensitivity 71.2%, specificity 66.5%). Refining emergency medical services transport patterns by triage status improved cost-effectiveness. At the trauma-system level, a high-sensitivity triage strategy would save 3.7 additional lives per year at a 1-year cost of $8.78 million, and a moderate sensitivity approach would cost 5.2 additional lives and save $781,616 each year.A high-sensitivity approach to field triage consistent with national trauma policy is not cost-effective. The most cost-effective approach to field triage appears closely tied to triage specificity and adherence to triage-based emergency medical services transport practices.

    View details for DOI 10.1016/j.jamcollsurg.2016.02.014

    View details for PubMedID 27178369

  • The Triage of Injured Patients: Mechanism of Injury, Regardless of Injury Severity, Determines Hospital Destination AMERICAN SURGEON Staudenmayer, K., Wang, N. E., Weiser, T. G., Maggio, P., Mackersie, R. C., Spain, D., Hsia, R. Y. 2016; 82 (4): 356-361

    Abstract

    The target rate for trauma undertriage is <5 per cent, but rates are as high as 30 to 40 per cent in many trauma systems. We hypothesized that high undertriage rates were due to the tendency to undertriage injured elderly patients and a growing elderly population. We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database over a 5-year period. All hospital admissions and emergency department visits associated with injury were longitudinally linked. The primary outcome was triage pattern. Triage patterns were stratified across three dimensions: age, mechanism of injury, and access to care. A total of 60,182 severely injured patients were included in the analysis. Fall-related injuries were frequently undertriaged compared with injuries from motor vehicle collisions (MVCs) and penetrating trauma (52% vs 12% and 10%, respectively). This pattern was true for all age groups. Conversely, MVCs and penetrating traumas were associated with high rates of overtriage (>70% for both). In conclusion, in contrast to our hypothesis, we found that triage is largely determined by mechanism of injury regardless of injury severity. High rates of undertriage are largely due to the undertriage of fall-related injuries, which occurs in both younger and older adults. Patients injured after MVCs and penetrating trauma victims are brought to trauma centers regardless of injury severity, resulting in high rates of overtriage. These findings suggest an opportunity to improve trauma system performance.

    View details for Web of Science ID 000377853800022

    View details for PubMedID 27097630

  • The 6-Minute Walk Test as a Predictor of Summit Success on Denali WILDERNESS & ENVIRONMENTAL MEDICINE Shea, K. M., Ladd, E. R., Lipman, G. S., Bagley, P., Pirrotta, E. A., Vongsachang, H., Wang, N. E., Auerbach, P. S. 2016; 27 (1): 19-24

    Abstract

    To test whether the 6-minute walk test (6MWT), including postexercise vital sign measurements and distance walked, predicts summit success on Denali, AK.This was a prospective observational study of healthy volunteers between the ages of 18 and 65 years who had been at 4267 m for less than 24 hours on Denali. Physiologic measurements were made after the 6MWT. Subjects then attempted to summit at their own pace and, at the time of descent, completed a Lake Louise Acute Mountain Sickness Questionnaire and reported maximum elevation reached.One hundred twenty-one participants enrolled in the study. Data were collected on 111 subjects (92% response rate), of whom 60% summited. On univariate analysis, there was no association between any postexercise vital sign and summit success. Specifically, there was no significant difference in the mean postexercise peripheral oxygen saturation (Spo2) between summiters (75%) and nonsummiters (74%; 95% CI, -3 to 1; P = .37). The distance a subject walked in 6 minutes (6MWTD) was longer in summiters (617 m) compared with nonsummiters (560 m; 95% CI, 7.6 to 106; P = .02). However, this significance was not maintained on a multivariate analysis performed to control for age, sex, and guide status (P = .08), leading to the conclusion that 6MWTD was not a robust predictor of summit success.This study did not show a correlation between postexercise oxygen saturation or 6MWTD and summit success on Denali.

    View details for Web of Science ID 000372379000005

  • Social determinants of health from the emergency department: The practice of social emergency medicine WestJEM Anderson, E. S., Lippert, S., Newberry, J. A., Bernstien, E., Alter, H. J., Wang, N. E. 2016: 487–89
  • A mobile-based healthcare utilization assessment in rural Ghana Vogel, L. D., Goertz, L., Shani, S. S., Boots, M., Dorval, L., Wang, N., Vidan, A., Shoag, D. ELSEVIER SCIENCE BV. 2016: 366–68
  • Mental Illness Drives Hospitalizations for Detained California Youth. journal of adolescent health Anoshiravani, A., Saynina, O., Chamberlain, L., Goldstein, B. A., Huffman, L. C., Wang, N. E., Wise, P. H. 2015; 57 (5): 455-461

    Abstract

    The purpose of the study was to describe inpatient hospitalization patterns among detained and nondetained youth in a large, total population of hospitalized adolescents in California.We examined the unmasked California Office of Statewide Health Planning and Development Patient Discharge Dataset from 1997 to 2011. We considered hospitalized youth aged 11-18 years "detained" if admitted to California hospitals from detention, transferred from hospital to detention, or both. We compared discharge diagnoses and length of stay between detained youth and their nondetained counterparts in the general population.There were 11,367 hospitalizations for detained youth. Hospitalizations differed for detained versus nondetained youth: 63% of all detained youth had a primary diagnosis of mental health disorder (compared with 19.8% of nondetained youth). Detained girls were disproportionately affected, with 74% hospitalized for a primary mental health diagnosis. Detained youth hospitalized for mental health disorder had an increased median length of stay compared with nondetained inpatient youth with mental illness (≥ 6 days vs. 5 days, respectively). This group difference was heightened in the presence of minority status, public insurance, and concurrent substance abuse. Hospitalized detained youth discharged to chemical dependency treatment facilities had the longest hospital stays (≥ 43 days).Detained juvenile offenders are hospitalized for very different reasons than the general adolescent population. Mental illness, often with comorbid substance abuse, requiring long inpatient stays, represents the major cause for hospitalization. These findings underscore the urgent need for effective, well-coordinated mental health services for youth before, during, and after detention.

    View details for DOI 10.1016/j.jadohealth.2015.05.006

    View details for PubMedID 26208862

  • Emergency department-based health insurance enrollment for children: does linkage lead to insurance retention and utilization? Pediatric emergency care Kanak, M., Rutman, L., Pirrotta, E. A., Giammona, M., Bermudez, M., Wang, N. E. 2015; 31 (3): 169-172

    Abstract

    Although 40% of emergency departments (EDs) report having an insurance linkage program, no studies have evaluated the long-term success of these programs. This study aimed to examine insurance retention and utilization by children initially referred to insurance by our ED insurance linkage program.We retrospectively examined insurance records of all uninsured children successfully enrolled in public insurance by the insurance linkage program established in our suburban academic ED between 2004 and 2009. Emergency department-enrolled children were matched by age, sex, program, and year of enrollment to a control group of children from the same county who were enrolled in non-ED settings. Wilcoxon signed rank and χ tests were used to compare enrollment and claims variables.Emergency department-enrolled children retained insurance for longer, had a higher reenrollment rate, and were higher users of insurance. The average length of enrollment for ED children was 734 days versus 597 days in the control group. Eighty percent of the ED cohort reenrolled in insurance after initial eligibility expiration versus 64% of the control group. Children enrolled via the ED averaged 26 claims (vs 12 claims) and $20,087 (vs $5216) in hospital charges per year of enrollment. This higher utilization was reflected in increased primary care, specialty care, ED visits, inpatient, and mental health claims in the ED group.Emergency department-based insurance enrollment programs have the potential to improve access to health care for children. Policies aimed at expanding insurance enrollment among the uninsured population, including the Affordable Care Act, may consider the ED's potential as an effective enrollment site.

    View details for DOI 10.1097/PEC.0000000000000340

    View details for PubMedID 25742607

  • Nonsurgical treatment of two cases of infantile facial growths in a resource-poor setting. Wilderness & environmental medicine Natawidjaja, R., Ewen Wang, N. 2015; 26 (1): 91-93

    View details for DOI 10.1016/j.wem.2014.08.002

    View details for PubMedID 25712300

  • Improved Management of Acute Asthma Among Pregnant Women Presenting to the ED CHEST Hasegawa, K., Cydulka, R. K., Sullivan, A. F., Langdorf, M. I., Nonas, S. A., Nowak, R. M., Wang, N. E., Camargo, C. A. 2015; 147 (2): 406-414

    Abstract

    A multicenter study in the late 1990s demonstrated suboptimal emergency asthma care for pregnant women in US EDs. After a decade, follow-up data are lacking. We aimed to examine changes in emergency asthma care of pregnant women since the 1990s.We combined data from four multicenter observational studies of ED patients with acute asthma performed in 1996 to 2001 (three studies) and 2011 to 2012 (one study). We restricted the data so that comparisons were based on the same 48 EDs in both time periods. We identified all pregnant patients aged 18 to 44 years with acute asthma. Primary outcomes were treatment with systemic corticosteroids in the ED and, among those sent home, at ED discharge.Of 4,895 ED patients with acute asthma, the analytic cohort comprised 125 pregnant women. Between the two time periods, there were no significant changes in patient demographics, chronic asthma severity, or initial peak expiratory flow. In contrast, ED systemic corticosteroid treatment increased significantly from 51% to 78% across the time periods (OR, 3.11; 95% CI, 1.27-7.60; P = .01); systemic corticosteroids at discharge increased from 42% to 63% (OR, 2.49; 95% CI, 0.97-6.37; P = .054). In the adjusted analyses, pregnant women in recent years were more likely to receive systemic corticosteroids, both in the ED (OR, 4.76; 95% CI, 1.63-13.9; P = .004) and at discharge (OR, 3.18; 95% CI, 1.05-9.61; P = .04).Between the two time periods, emergency asthma care in pregnant women significantly improved. However, with one in three pregnant women being discharged home without systemic corticosteroids, further improvement is warranted.

    View details for DOI 10.1378/chest.14-1874

    View details for PubMedID 25358070

  • Presentation of prescription and nonprescription opioid overdoses to US emergency departments. JAMA internal medicine Yokell, M. A., Delgado, M. K., Zaller, N. D., Wang, N. E., McGowan, S. K., Green, T. C. 2014; 174 (12): 2034-2037

    View details for DOI 10.1001/jamainternmed.2014.5413

    View details for PubMedID 25347221

  • Interhospital Facility Transfers in the United States: A Nationwide Outcomes Study. Journal of patient safety Hernandez-Boussard, T., Davies, S., McDonald, K., Wang, N. E. 2014: -?

    Abstract

    Patient transfers between hospitals are becoming more common in the United States. Disease-specific studies have reported varying outcomes associated with transfer status. However, even as national quality improvement efforts and regulations are being actively adopted, forcing hospitals to become financially accountable for the quality of care provided, surprisingly little is known about transfer patients or their outcomes at a population level. This population-wide study provides timely analyses of the characteristics of this particularly vulnerable and sizable inpatient population. We identified and compared characteristics and outcomes of transfer and nontransfer patients.With the use of the 2009 Nationwide Inpatient Sample, a nationally representative sample of U.S. hospitalizations, we examined patient characteristics, in-hospital adverse events, and discharge disposition for transfer versus nontransfer patients in this observational study.We identified 1,397,712 transfer patients and 31,692,211 nontransfer patients. Age, sex, race, and payer were significantly associated with odds of transfer (P < 0.05). Transfer patients had higher risk-adjusted inpatient mortality (4.6 versus 2.1, P < 0.01), longer length of stay (13.3 versus 4.5, P < 0.01), and fewer routine disposition discharges (53.6 versus 68.7, P < 0.01). In-hospital adverse events were significantly higher in transfer patients compared with nontransfer patients (P < 0.05).Our results suggest that transfer patients have inferior outcomes compared with nontransfer patients. Although they are clinically complex patients and assessing accountability as between the transferring and receiving hospitals is methodologically difficult, transfer patients must nonetheless be included in quality benchmark data to assess the potential impact this population has on hospital outcome profiles. With hospital accountability and value-based payments constituting an integral part of health care reform, documenting the quality of care delivered to transfer patients is essential before accurate quality assessment improvement efforts can begin in this patient population.

    View details for PubMedID 25397857

  • The Affordable Care Act reduces emergency department use by young adults: evidence from three States. Health affairs Hernandez-Boussard, T., Burns, C. S., Wang, N. E., Baker, L. C., Goldstein, B. A. 2014; 33 (9): 1648-1654

    Abstract

    The Affordable Care Act (ACA) extended eligibility for health insurance for young adults ages 19-25. This extension may have affected how young adults use emergency department (ED) care and other health services. To test the impact of the ACA on how young adults used ED services, we used 2009-11 state administrative records from California, Florida, and New York to compare changes in ED use in young adults ages 19-25 before and after the ACA provision was implemented with changes in the same period for people ages 26-31 (the control group). Following implementation of the ACA provision, the younger group had a decrease of 2.7 ED visits per 1,000 people compared to the older group-a relative change of -2.1 percent. The largest relative decreases were found in women (-3.0 percent) and blacks (-3.4 percent). This relative decrease in ED use implies a total reduction of more than 60,000 visits from young adults ages 19-25 across the three states in 2011. When we compared the probability of ever using the ED before and after implementation of the ACA provision, we found a minimal decrease (-0.4 percent) among the younger group compared to the older group. This suggests that the change in the number of visits was driven by fewer visits among ED users, not by changes in the number of people who ever visited the ED.

    View details for DOI 10.1377/hlthaff.2014.0103

    View details for PubMedID 25201671

  • Clinical Correlation Needed: What Do Emergency Physicians Do After an Equivocal Ultrasound for Pediatric Acute Appendicitis? JOURNAL OF CLINICAL ULTRASOUND Ramarajan, N., Krishnamoorthi, R., Gharahbaghian, L., Pirrotta, E., Barth, R. A., Wang, N. E. 2014; 42 (7): 385-394

    Abstract

    Although follow-up CT is recommended for pediatric appendicitis if initial ultrasound (US) is equivocal, many physicians observe the patient at home. There are limited data to understand currently how common or safe this practice is. Our objectives are to assess prevalence of acute appendicitis and outcomes in patients with equivocal US with and without follow-up CT and to identify variables associated with ordering a follow-up CT.Retrospective analysis of the prevalence of appendicitis and outcomes of patients 1-18 years old with an equivocal US at a pediatric emergency department from 2003 to 2008. Recursive partitioning analysis and multivariate logistic regression were used to identify variables associated with ordering follow-up CT.Fifty-five percent (340/620) of children with equivocal US did not receive CT, none of whom returned with a missed appendicitis. The prevalence of appendicitis in children with equivocal US was 12.5% (78/620). In children with follow-up CT, the prevalence was 22.1% (62/280); in those without follow-up CT, the prevalence was 4.7% (16/340). Recursive partitioning identified age >11 years, leukocytosis >15,000 cells/ml, and secondary signs predisposing toward acute appendicitis on US as significant predictors of CT.We view our study as a fundamental part of the incremental progress to understand how best to use US and CT imaging to diagnose pediatric appendicitis while minimizing ionizing radiation. Children at low risk for appendicitis with equivocal US are amenable to observation and reassessment prior to reimaging with US or CT.

    View details for DOI 10.1002/jcu.22153

    View details for Web of Science ID 000340536300001

    View details for PubMedID 24700515

  • Variations in Pediatric Trauma Transfer Patterns in Northern California Pediatric Trauma Centers (2001-2009) ACADEMIC EMERGENCY MEDICINE Vogel, L. D., Vongsachang, H., Pirrotta, E., Holmes, J. M., Sherck, J., Newton, C., D'Souza, P., Spain, D. A., Wang, N. E. 2014; 21 (9): 1023-1030

    Abstract

    Due to the scarcity of specialized resources for pediatric trauma, "regionalization," or a system designed to get "the right child, to the right place, at the right time," is vital to quality pediatric trauma care. In Northern California, four pediatric trauma centers serve 3.9 million children within a geographically diverse area of 113,630 square miles. A significant proportion of children with trauma is initially triaged to nontrauma hospitals and may require subsequent transfer to a specialty center. Trauma transfer patterns to a pediatric trauma center may provide insight into regional primary triage practices. Transfers from hospitals in close proximity to pediatric trauma centers might suggest that some children could have avoided transfer with minimal additional transport time. While pediatric trauma centers are scarce and serve as regional resources, transfers from beyond the regular catchment area of a trauma center could be an indication of clinical need.The objective of this study was to gain an understanding of patterns of pediatric trauma transfer to all pediatric trauma centers within the region as a first step in assessing the efficacy and efficiency of trauma triage. The authors examined three groups of transfer patients: transfers from within the same county as the pediatric trauma center (near transfers), transfers from counties adjacent to the pediatric trauma center (catchment transfers), and transfers from more distant counties (far transfers). The hypothesis was that catchment transfers would form the bulk of transfers, near transfers would compose < 10% of total transfers, and far transfers would be younger and more severely injured than catchment transfers.This was a retrospective analysis of institutional trauma registry data of children < 18 years from all pediatric trauma centers in Northern California from 2001 through 2009. Transfers were characterized by the location of the transfer hospital relative to the location of the pediatric trauma center. Characteristics associated with near transfer compared to primary triage to a pediatric trauma center were identified, as well as characteristics associated with far transfer compared to catchment transfer.A total of 2,852 of 11,952 (23.9%) pediatric trauma patients were transfers. Near transfers comprised 24.5% of cases, catchment transfers were 37.4%, and far transfers were 38.2%. After controlling for demographic, clinical, and geographic factors, younger age, higher Injury Severity Score (ISS), public versus private insurance, and an injury mechanism of "fall" were associated with near transfer rather than direct triage. Older age, higher ISS, and mechanism of "motor vehicle crash" were associated with far rather than catchment transfer.This analysis of patterns of transfer to all pediatric trauma centers within Northern California gives the most comprehensive population view of pediatric trauma triage to date, to the authors' knowledge. Trauma transfers comprise an important minority of patients cared for at pediatric trauma centers. The number of near transfers documented indicates the potential to improve the primary triage process of patients to pediatric trauma centers. The frequency of far transfers substantiates the well-known shortage of pediatric trauma expertise. Development of regionwide standardized transfer protocols and agreements between hospitals, as well as standardized monitoring of the process and outcomes, could increase efficiency of care.

    View details for DOI 10.1111/acem.12463

    View details for Web of Science ID 000342810800010

  • Interfacility transfer and mortality for patients with ruptured abdominal aortic aneurysm. Journal of vascular surgery Mell, M. W., Wang, N. E., Morrison, D. E., Hernandez-Boussard, T. 2014; 60 (3): 553-557

    Abstract

    Patients receiving interfacility transfer to a higher level of medical care for ruptured abdominal aortic aneurysms (rAAAs) are an important minority that are not well characterized and are typically omitted from outcomes and quality indicator studies. Our objective was to compare patients transferred for treatment of rAAAs with those treated without transfer, with particular emphasis on mortality and resource utilization.We linked longitudinal data from 2005 to 2010 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases and Emergency Department Databases from California, Florida, and New York. Patients were identified using International Classification of Diseases-Ninth Revision-Clinical Modification codes. Our main outcome variables were mortality, length of stay, and cost. Data included discharge information on the transfer-out and transfer-in hospital. We used univariate and multivariate analysis to identify variables independently associated with transfer and in-hospital mortality.Of 4439 rAAA patients identified with intent to treat, 847 (19.1%) were transferred before receiving operative repair. Of those transferred, 141 (17%) died without undergoing AAA repair. By multivariate analysis, increasing age in years (odds ratio [OR] 0.98; 95% confidence interval [CI], 0.97-0.99; P < .001), private insurance vs Medicare (OR, 0.62; 95% CI, 0.47-0.80; P < .001), and increasing comorbidities as measured by the Elixhauser Comorbidity Index (OR, 0.90; 95% CI, 0.86-0.95; P < .001) were negatively associated with transfer. Weekend presentation (OR, 1.23; 95% CI, 1.02-1.47; P = .03) was positively associated with transfer. Transfer was associated with a lower operative mortality (adjusted OR, 0.81; 95% CI, 0.68-0.97; P < .02) but an increased overall mortality when including transferred patients who died without surgery (OR, 1.30; 95% CI, 1.05-1.60; P = .01). Among the transferred patients, there was no significant difference in travel distance between those who survived and those who died (median, 28.7 vs 25.8 miles; P = .07). Length of stay (median, 10 vs 9 days; P = .008), and hospital costs ($161,000 vs $146,000; P = .02) were higher for those transferred.The survival advantage for patients transferred who received treatment was eclipsed by increased mortality of the transfer process. Including 17% of transferred patients who died without receiving definitive repair, mortality was increased for patients transferred for rAAA repair compared with those not transferred after adjusting for demographic, clinical, and hospital factors. Transferred patients used significantly more hospital resources. Improving systems and guidelines for interfacility transfer may further improve the outcomes for these patients and decrease associated hospital resource utilization.

    View details for DOI 10.1016/j.jvs.2014.02.061

    View details for PubMedID 24768368

  • Characteristics of United States Emergency Departments that Routinely Perform Alcohol Risk Screening and Counseling for Patients Presenting with Drinking-related Complaints. The western journal of emergency medicine Yokell, M. A., Camargo, C. A., Wang, N. E., Delgado, M. K. 2014; 15 (4): 438-445

    Abstract

    Emergency department (ED) screening and counseling for alcohol misuse have been shown to reduce at-risk drinking. However, barriers to more widespread adoption of this service remain unclear.We performed a secondary analysis of a nationwide survey of 277 EDs to determine the proportion of EDs that routinely perform alcohol screening and counseling among patients presenting with alcohol-related complaints and to identify potential institutional barriers and facilitators to routine screening and counseling. The survey was randomly mailed to 350 EDs sampled from the 2007 National Emergency Department Inventory (NEDI), with 80% of ED medical directors responding after receiving the mailing or follow-up fax/email. The survey asked about a variety of preventive services and ED directors' opinions regarding perceived barriers to offering preventive services in their EDs.Overall, only 27% of all EDs and 22% of Level I/II trauma center EDs reported routinely screening and counseling patients presenting with drinking-related complaints. Rates of routine screening and counseling were similar across geographic areas, crowding status, and urban-rural status. EDs that performed routine screening and counseling often offered other preventive services, such as tobacco cessation (P<0.01) and primary care linkage (P=0.01). EDs with directors who expressed concern about increased financial costs to the ED, inadequate follow-up, and diversion of nurse/physician time all had lower rates of screening and counseling and also more frequently reported lacking the perceived capacity to perform routine counseling and screening. Among EDs that did not routinely perform alcohol screening and counseling, more crowded than non-crowded (P<0.01) and more metro than rural (P<0.01) EDs reported lacking the capacity to perform routine screening and counseling. The capacity to perform routine screening also decreased as ED visit volume increased (P=0.04).To increase routine alcohol screening and counseling for patients presenting with alcohol-related complaints, ED directors' perceived barriers related to an ED's capacity to perform screening, such as limited financial and staff resources, should be addressed, as should directors' concerns regarding the implementation of preventive health services in EDs. Uniform reimbursement methods should be used to increase ED compensation for performing this important and effective service.

    View details for DOI 10.5811/westjem.2013.12.18833

    View details for PubMedID 25035750

    View details for PubMedCentralID PMC4100850

  • Availability of insurance linkage programs in u.s. Emergency departments. The western journal of emergency medicine Kanak, M., Delgado, M. K., Camargo, C. A., Wang, N. E. 2014; 15 (4): 529-535

    Abstract

    As millions of uninsured citizens who use emergency department (ED) services are now eligible for health insurance under the Affordable Care Act, the ED is ideally situated to facilitate linkage to insurance. Forty percent of U.S. EDs report having an insurance linkage program. This is the first national study to examine the characteristics of EDs that offer or do not offer these programs.This was a secondary analysis of data from the National Survey for Preventive Health Services in U.S. EDs conducted in 2008-09. We compared EDs with and without insurance programs across demographic and operational factors using univariate analysis. We then tested our hypotheses using multivariable logistic regression. We also further examined program capacity and priority among the sub-group of EDs with no insurance linkage program.After adjustment, ED-insurance linkage programs were more likely to be located in the West (RR= 2.06, 95% CI = 1.33 - 2.72). The proportion of uninsured patients in an ED, teaching hospital status, and public ownership status were not associated with insurance linkage availability. EDs with linkage programs also offer more preventive services (RR = 1.87, 95% CI = 1.37-2.35) and have greater social worker availability (RR = 1.71, 95% CI = 1.12-2.33) than those who do not. Four of five EDs with a patient mix of ≥25% uninsured and no insurance linkage program reported that they could not offer a program with existing staff and funding.Availability of insurance linkage programs in the ED is not associated with the proportion of uninsured patients served by an ED. Policy or hospital-based interventions to increase insurance linkage should first target the 27% of EDs with high rates of uninsured patients that lack adequate program capacity. Further research on barriers to implementation and cost effectiveness may help to facilitate increased adoption of insurance linkage programs.

    View details for DOI 10.5811/westjem.2014.4.20223

    View details for PubMedID 25035763

    View details for PubMedCentralID PMC4100863

  • Survival of a Patient With Tetanus in Bhutan Using a Magnesium Infusion Managed Only by Clinical Signs WILDERNESS & ENVIRONMENTAL MEDICINE Wangmo, K. P., Teng, M., Henker, R., Kinnear, S., Tshering, J., Wang, N. E. 2014; 25 (2): 194-197

    Abstract

    Tetanus is a life-threatening disease that continues to have a high prevalence in developing countries. Severe muscle spasms often require patients to receive tracheostomy, high-dose sedatives, and sometimes prolonged neuromuscular blockade. Magnesium sulfate (MgSO4) infusion has great promise as an adjunct treatment for severe tetanus, as it may allow clinicians to decrease the dose of other sedative medications. Although the mechanism of action of MgSO4 is not well understood, it appears to attenuate both the muscle spasms and autonomic instability associated with severe tetanus infections. However, MgSO4 infusions are often managed based on serial measurements of serum magnesium levels and other laboratory tests such as arterial blood gases, which can be difficult to obtain in resource-poor settings. We describe a case of severe tetanus in Bhutan managed through the use of magnesium infusion titrated solely to physical examination findings.

    View details for PubMedID 24792133

  • Factors associated with the disposition of severely injured patients initially seen at non–trauma center emergency departments: disparities by insurance status. JAMA surgery Delgado, M. K., Yokell, M. A., Staudenmayer, K. L., Spain, D. A., Hernandez-Boussard, T., Wang, N. E. 2014; 149 (5): 422-430

    Abstract

    IMPORTANCE Trauma is the leading cause of potential years of life lost before age 65 years in the United States. Timely care in a designated trauma center has been shown to reduce mortality by 25%. However, many severely injured patients are not transferred to trauma centers after initially being seen at non-trauma center emergency departments (EDs). OBJECTIVES To determine patient-level and hospital-level factors associated with the decision to admit rather than transfer severely injured patients who are initially seen at non-trauma center EDs and to ascertain whether insured patients are more likely to be admitted than transferred compared with uninsured patients. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of the 2009 Nationwide Emergency Department Sample. We included all ED encounters for major trauma (Injury Severity Score, >15) seen at non-trauma centers in patients aged 18 to 64 years. We excluded ED discharges and ED deaths. We quantified the absolute risk difference between admission vs transfer by insurance status, while adjusting for age, sex, mechanism of injury, Injury Severity Score, weekend admission and month of visit, and urban vs rural status and median household income of the home zip code, as well as annual ED visit volume and teaching status and US region. MAIN OUTCOMES AND MEASURES Inpatient admission vs transfer to another acute care facility. RESULTS In 2009, a total of 4513 observations from 636 non-trauma center EDs were available for analysis, representing a nationally weighted population of 19 312 non-trauma center ED encounters for major trauma. Overall, 54.5% in 2009 were admitted to the non-trauma center. Compared with patients without insurance, the adjusted absolute risk of admission vs transfer was 14.3% (95% CI, 9.2%-19.4%) higher for patients with Medicaid and 11.2% (95% CI, 6.9%-15.4%) higher for patients with private insurance. Other factors associated with admission vs transfer included severe abdominal injuries (risk difference, 15.9%; 95% CI, 9.4%-22.3%), urban teaching hospital vs non-teaching hospital (risk difference, 26.2%; 95% CI, 15.2%-37.2%), and annual ED visit volume (risk difference, 3.4%; 95% CI, 1.6%-5.3% higher for every additional 10 000 annual ED visits). CONCLUSIONS AND RELEVANCE Patients with severe injuries initially evaluated at non-trauma center EDs were less likely to be transferred if insured and were at risk of receiving suboptimal trauma care. Efforts in monitoring and optimizing trauma interhospital transfers and outcomes at the population level are warranted.

    View details for PubMedID 24554059

  • Factors Associated With the Disposition of Severely Injured Patients Initially Seen at Non-Trauma Center Emergency Departments Disparities by Insurance Status JAMA SURGERY Delgado, M. K., Yokell, M. A., Staudenmayer, K. L., Spain, D. A., Hernandez-Boussard, T., Wang, N. E. 2014; 149 (5): 422-430

    Abstract

    IMPORTANCE Trauma is the leading cause of potential years of life lost before age 65 years in the United States. Timely care in a designated trauma center has been shown to reduce mortality by 25%. However, many severely injured patients are not transferred to trauma centers after initially being seen at non-trauma center emergency departments (EDs). OBJECTIVES To determine patient-level and hospital-level factors associated with the decision to admit rather than transfer severely injured patients who are initially seen at non-trauma center EDs and to ascertain whether insured patients are more likely to be admitted than transferred compared with uninsured patients. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of the 2009 Nationwide Emergency Department Sample. We included all ED encounters for major trauma (Injury Severity Score, >15) seen at non-trauma centers in patients aged 18 to 64 years. We excluded ED discharges and ED deaths. We quantified the absolute risk difference between admission vs transfer by insurance status, while adjusting for age, sex, mechanism of injury, Injury Severity Score, weekend admission and month of visit, and urban vs rural status and median household income of the home zip code, as well as annual ED visit volume and teaching status and US region. MAIN OUTCOMES AND MEASURES Inpatient admission vs transfer to another acute care facility. RESULTS In 2009, a total of 4513 observations from 636 non-trauma center EDs were available for analysis, representing a nationally weighted population of 19 312 non-trauma center ED encounters for major trauma. Overall, 54.5% in 2009 were admitted to the non-trauma center. Compared with patients without insurance, the adjusted absolute risk of admission vs transfer was 14.3% (95% CI, 9.2%-19.4%) higher for patients with Medicaid and 11.2% (95% CI, 6.9%-15.4%) higher for patients with private insurance. Other factors associated with admission vs transfer included severe abdominal injuries (risk difference, 15.9%; 95% CI, 9.4%-22.3%), urban teaching hospital vs non-teaching hospital (risk difference, 26.2%; 95% CI, 15.2%-37.2%), and annual ED visit volume (risk difference, 3.4%; 95% CI, 1.6%-5.3% higher for every additional 10 000 annual ED visits). CONCLUSIONS AND RELEVANCE Patients with severe injuries initially evaluated at non-trauma center EDs were less likely to be transferred if insured and were at risk of receiving suboptimal trauma care. Efforts in monitoring and optimizing trauma interhospital transfers and outcomes at the population level are warranted.

    View details for DOI 10.1001/jamasurg.2013.4398

    View details for Web of Science ID 000337908600005

  • From 9-1-1 call to death: Evaluating traumatic deaths in seven regions for early recognition of high- risk patients JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Dean, D., Wetzel, B., White, N., Kuppermann, N., Wang, N. E., Haukoos, J. S., Hsia, R. Y., Mann, N. C., Barton, E. D., Newgard, C. D. 2014; 76 (3): 846-853

    Abstract

    This study aimed to characterize initial clinical presentations of patients served by emergency medical services (EMS) who die following injury, with particular attention to patients with occult ("talk-and-die") presentations.This was a population-based, multiregion, mixed-methods retrospective cohort study of fatally injured children and adults evaluated by 94 EMS agencies transporting to 122 hospitals in seven Western US regions from 2006 to 2008. Fatalities were divided into two main groups: occult injuries (talk-and-die; Glasgow Coma Scale [GCS] score ≥ 13, no cardiopulmonary arrest, and no intubation) versus overt injuries (all other patients). These groups were further subdivided by timing of death: early (<48 hours) versus late (>48 hours). We then compared demographic, physiologic, procedural, and injury patterns using descriptive statistics. We also used qualitative methods to analyze available EMS chart narratives for contextual information from the out-of-hospital encounter.During the 3-year study period, 3,358 persons served by 9-1-1 EMS providers died, with 1,225 (37.1%) in the field, 1,016 (30.8%) early in the hospital, and 1,060 (32.1%) late in the hospital. Of the 2,133 patients transported to a hospital, there were 612 (28.7%) talk-and-die patients, of whom 114 (18.6%) died early. Talk-and-die patients were older (median age, 81 years; interquartile range, 67-87 years), normotensive (median systolic blood pressure, 138 mm Hg; interquartile range, 116-160 mm Hg), commonly injured by falls (71.3%), and frequently (52.4%) died in nontrauma hospitals. Compared with overtly injured patients, talk-and-die patients had relatively fewer serious head injuries (13.7%) but more frequent extremity injuries (20.3% vs. 10.6%) and orthopedic interventions (25.3% vs. 5.0%). EMS personnel often found talk-and-die patients lying on the ground with hip pain or extremity injuries.Patients served by EMS who "talk-and-die" are typically older adults with falls, transported to nontrauma hospitals, with subtle clinical indications of the severity of their injuries. Improving recognition of talk-and-die patients may avoid fatal outcomes in a portion of these patients.Epidemiologic study, level III.

    View details for DOI 10.1097/TA.0b013e3182aafd9a

    View details for PubMedID 24553559

  • Djenkolism: case report and literature review. International medical case reports journal Bunawan, N. C., Rastegar, A., White, K. P., Wang, N. E. 2014; 7: 79-84

    Abstract

    Djenkolism is an uncommon but important cause of acute kidney injury. It sporadically occurs after an ingestion of the djenkol bean (Archidendron pauciflorum), which is native to Southeast Asia. The clinical features defining djenkolism include: spasmodic suprapubic and/or flank pain; urinary obstruction; and acute kidney injury. The precise pathogenesis of acute kidney injury following djenkol ingestion remains unknown. However, it is proposed that an interaction between the characteristics of the ingested beans and the host factors causes hypersaturation of djenkolic acid crystals within the urinary system, resulting in subsequent obstructive nephropathy with sludge, stones, or possible spasms. We report a case of djenkolism from our rural clinic in Borneo, Indonesia. Our systematic literature review identified 96 reported cases of djenkolism. The majority of patients recovered with hydration, bicarbonate therapy, and pain medication. Three patients required surgical intervention; one patient required ureteral stenting for the obstructing djenkolic acid stones. Four of the 96 reported patients died from acute kidney failure. We stress the importance of awareness of djenkolism to guide medical practitioners in the treatment of this rare disease in resource-poor areas in Southeast Asia.

    View details for DOI 10.2147/IMCRJ.S58379

    View details for PubMedID 24790471

  • School nurses' role in asthma management, school absenteeism, and cost savings: a demonstration project. journal of school health Rodriguez, E., Rivera, D. A., Perlroth, D., Becker, E., Wang, N. E., Landau, M. 2013; 83 (12): 842-850

    Abstract

    With increasing budget cuts to education and social services, rigorous evaluation needs to document school nurses' impact on student health, academic outcomes, and district funding.Utilizing a quasi-experimental design, we evaluated outcomes in 4 schools with added full-time nurses and 5 matched schools with part-time nurses in the San Jose Unified School District. Student data and logistic regression models were used to examine predictors of illness-related absenteeism for 2006-2007 and 2008-2009. We calculated average daily attendance (ADA) funding and parent wages associated with an improvement in illness-related absenteeism. Utilizing parent surveys, we also estimated the cost of services for asthma-related visits to the emergency room (ER; N = 2489).Children with asthma were more likely to be absent due to illness; however, mean absenteeism due to illness decreased when full-time nurses were added to demonstration schools but increased in comparison schools during 2008-2009, resulting in a potential savings of $48,518.62 in ADA funding (N = 6081). Parents in demonstration schools reported fewer ER visits, and the estimated savings in ER services and parent wages were significant.Full-time school nurses play an important role in improving asthma management among students in underserved schools, which can impact school absenteeism and attendance-related economic costs.

    View details for DOI 10.1111/josh.12102

    View details for PubMedID 24261518

  • Gunshot Injuries in Children Served by Emergency Services PEDIATRICS Newgard, C. D., Kuppermann, N., Holmes, J. F., Haukoos, J. S., Wetzel, B., Hsia, R. Y., Wang, N. E., Bulger, E. M., Staudenmayer, K., Mann, N. C., Barton, E. D., Wintemute, G. 2013; 132 (5): 862-870

    Abstract

    To describe the incidence, injury severity, resource use, mortality, and costs for children with gunshot injuries, compared with other injury mechanisms.This was a population-based, retrospective cohort study (January 1, 2006-December 31, 2008) including all injured children age ≤ 19 years with a 9-1-1 response from 47 emergency medical services agencies transporting to 93 hospitals in 5 regions of the western United States. Outcomes included population-adjusted incidence, injury severity score ≥ 16, major surgery, blood transfusion, mortality, and average per-patient acute care costs.A total of 49,983 injured children had a 9-1-1 emergency medical services response, including 505 (1.0%) with gunshot injuries (83.2% age 15-19 years, 84.5% male). The population-adjusted annual incidence of gunshot injuries was 7.5 cases/100,000 children, which varied 16-fold between regions. Compared with children who had other mechanisms of injury, those injured by gunshot had the highest proportion of serious injuries (23%, 95% confidence interval [CI] 17.6-28.4), major surgery (32%, 95% CI 26.1-38.5), in-hospital mortality (8.0%, 95% CI 4.7-11.4), and costs ($28,510 per patient, 95% CI 22,193-34,827).Despite being less common than other injury mechanisms, gunshot injuries cause a disproportionate burden of adverse outcomes in children, particularly among older adolescent males. Public health, injury prevention, and health policy solutions are needed to reduce gunshot injuries in children.

    View details for DOI 10.1542/peds.2013-1350

    View details for PubMedID 24127481

  • Cost-effectiveness of helicopter versus ground emergency medical services for trauma scene transport in the United States. Annals of emergency medicine Delgado, M. K., Staudenmayer, K. L., Wang, N. E., Spain, D. A., Weir, S., Owens, D. K., Goldhaber-Fiebert, J. D. 2013; 62 (4): 351-364 e19

    Abstract

    STUDY OBJECTIVE: We determine the minimum mortality reduction that helicopter emergency medical services (EMS) should provide relative to ground EMS for the scene transport of trauma victims to offset higher costs, inherent transport risks, and inevitable overtriage of patients with minor injury. METHODS: We developed a decision-analytic model to compare the costs and outcomes of helicopter versus ground EMS transport to a trauma center from a societal perspective during a patient's lifetime. We determined the mortality reduction needed to make helicopter transport cost less than $100,000 and $50,000 per quality-adjusted life-year gained compared with ground EMS. Model inputs were derived from the National Study on the Costs and Outcomes of Trauma, National Trauma Data Bank, Medicare reimbursements, and literature. We assessed robustness with probabilistic sensitivity analyses. RESULTS: Helicopter EMS must provide a minimum of a 17% relative risk reduction in mortality (1.6 lives saved/100 patients with the mean characteristics of the National Study on the Costs and Outcomes of Trauma cohort) to cost less than $100,000 per quality-adjusted life-year gained and a reduction of at least 33% (3.7 lives saved/100 patients) to cost less than $50,000 per quality-adjusted life-year. Helicopter EMS becomes more cost-effective with significant reductions in patients with minor injury who are triaged to air transport or if long-term disability outcomes are improved. CONCLUSION: Helicopter EMS needs to provide at least a 17% mortality reduction or a measurable improvement in long-term disability to compare favorably with other interventions considered cost-effective. Given current evidence, it is not clear that helicopter EMS achieves this mortality or disability reduction. Reducing overtriage of patients with minor injury to helicopter EMS would improve its cost-effectiveness.

    View details for DOI 10.1016/j.annemergmed.2013.02.025

    View details for PubMedID 23582619

  • Clinical and Demographic Characteristics Associated With Opioid Overdose Visits to United States Emergency Departments Yokell, M. A., Zaller, N. D., Delgado, M. K., Wang, N. E., McGowan, S. K., Green, T. C. MOSBY-ELSEVIER. 2013: S72
  • The effect of trauma center care on pediatric injury mortality in California, 1999 to 2011. journal of trauma and acute care surgery Wang, N. E., Saynina, O., Vogel, L. D., Newgard, C. D., Bhattacharya, J., Phibbs, C. S. 2013; 75 (4): 704-716

    Abstract

    Trauma centers (TCs) have been shown to decrease mortality in adults, but this has not been demonstrated at a population level in all children. We hypothesized that seriously injured children would have increased survival in a TC versus nontrauma center (nTC), but there would be no increased benefit from pediatric-designated versus adult TC care.This was a retrospective study of the unmasked California Office of Statewide Health and Planning Department patient discharge database (1999-2011). DRG International Classification of Diseases-9th Rev. (ICD-9) diagnostic codes indicating trauma were identified for children (0-18 years), and injury severity was calculated from ICD-9 codes using validated algorithms. To adjust for hospital case mix, we selected patients with ICD-9 codes that were capable of causing death and which appeared at both TCs and nTCs. Instrumental variable (IV) analysis using differential distance between the child's residence to a TC and to the nearest hospital was applied to further adjust for unobservable differences in TC and nTC populations. Instrumental variable regression models analyzed the association between mortality and TC versus nTC care as well as for pediatric versus adult TC designations, adjusting for demographic and clinical variables.Unadjusted mortality for the entire population of children with nontrivial trauma (n = 445,236) was 1.2%. In the final study population (n = 77,874), mortality was 5.3%, 3.8% in nTCs and 6.1% in TCs. IV regression analysis demonstrated a 0.79 percentage point (95% confidence interval, -0.80 to -0.30; p = 0.044) decrease in mortality for children cared for in TC versus nTC. No decrease in mortality was demonstrated for children cared for in pediatric versus adult TCs.Our IV TC outcome models use improved injury severity and case mix adjustment to demonstrate decreased mortality for seriously injured California children treated in TCs. These results can be used to take evidence-based steps to decrease disparities in pediatric access to, and subsequent outcomes for, trauma care.Therapeutic/care management, level III.

    View details for DOI 10.1097/TA.0b013e31829a0a65

    View details for PubMedID 24064887

  • A Population-Wide Study of Pediatric Access to Trauma Centers in California, 2005-2011 Vogel, L., Pirrotta, E., Wang, E. N. MOSBY-ELSEVIER. 2013: S67
  • The effect of trauma center care on pediatric injury mortality in California, 1999 to 2011. journal of trauma and acute care surgery Wang, N. E., Saynina, O., Vogel, L. D., Newgard, C. D., Bhattacharya, J., Phibbs, C. S. 2013; 75 (4): 704-716

    Abstract

    Trauma centers (TCs) have been shown to decrease mortality in adults, but this has not been demonstrated at a population level in all children. We hypothesized that seriously injured children would have increased survival in a TC versus nontrauma center (nTC), but there would be no increased benefit from pediatric-designated versus adult TC care.This was a retrospective study of the unmasked California Office of Statewide Health and Planning Department patient discharge database (1999-2011). DRG International Classification of Diseases-9th Rev. (ICD-9) diagnostic codes indicating trauma were identified for children (0-18 years), and injury severity was calculated from ICD-9 codes using validated algorithms. To adjust for hospital case mix, we selected patients with ICD-9 codes that were capable of causing death and which appeared at both TCs and nTCs. Instrumental variable (IV) analysis using differential distance between the child's residence to a TC and to the nearest hospital was applied to further adjust for unobservable differences in TC and nTC populations. Instrumental variable regression models analyzed the association between mortality and TC versus nTC care as well as for pediatric versus adult TC designations, adjusting for demographic and clinical variables.Unadjusted mortality for the entire population of children with nontrivial trauma (n = 445,236) was 1.2%. In the final study population (n = 77,874), mortality was 5.3%, 3.8% in nTCs and 6.1% in TCs. IV regression analysis demonstrated a 0.79 percentage point (95% confidence interval, -0.80 to -0.30; p = 0.044) decrease in mortality for children cared for in TC versus nTC. No decrease in mortality was demonstrated for children cared for in pediatric versus adult TCs.Our IV TC outcome models use improved injury severity and case mix adjustment to demonstrate decreased mortality for seriously injured California children treated in TCs. These results can be used to take evidence-based steps to decrease disparities in pediatric access to, and subsequent outcomes for, trauma care.Therapeutic/care management, level III.

    View details for DOI 10.1097/TA.0b013e31829a0a65

    View details for PubMedID 24064887

  • No Difference in Mortality After Inter-Facility Transfer for Patients with Ruptured Abdominal Aortic Aneurysm Mell, M. W., Wang, N. E., Morrison, D. E., Hernandez-Boussard, T. MOSBY-ELSEVIER. 2013: 562–62
  • The trade-offs in field trauma triage: A multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Newgard, C. D., Hsia, R. Y., Mann, N. C., Schmidt, T., Sahni, R., Bulger, E. M., Wang, N. E., Holmes, J. F., Fleischman, R., Zive, D., Staudenmayer, K., Haukoos, J. S., Kuppermann, N. 2013; 74 (5): 1298-1306

    Abstract

    BACKGROUND: National benchmarks for trauma triage sensitivity (≥95%) and specificity (≥50%) have not been rigorously evaluated across broad populations of injured patients. We evaluated the impact of different field triage schemes for identifying seriously injured patients across a range of sensitivity values. Impact metrics included specificity and number of undertriaged and overtriaged patients compared with current triage practices. METHODS: This was a retrospective cohort study of injured children and adults transported by 48 emergency medical service (EMS) agencies to 105 hospitals in 6 regions of the Western United States from 2006 through 2008. Hospital outcomes were probabilistically linked to EMS records through trauma registries, state discharge databases, and state emergency department databases. The primary outcome was an Injury Severity Score (ISS) of 16 or greater. We evaluated 40 field predictor variables, including 31 current field triage criteria, using classification and regression tree analysis and cross-validation to generate estimates for sensitivity and specificity. RESULTS: A total of 89,261 injured patients were evaluated and transported by EMS providers during the 3-year period, of whom 5,711 (6.4%) had ISS of 16 or greater. As the 95% sensitivity target for triage was approached (from the current value of 87.5%), decision tree complexity increased, specificity decreased (from 62.8% to 18.7%), and the number of triage-positive patients without serious injury doubled (67,927 vs. 31,104). Analyses restricted to children and older adults were similar. The most consistent modification to the current triage algorithm to increase sensitivity without a major decrease in specificity was altering the Glasgow Coma Scale (GCS) score cutoff point from 13 or less to 14 or less (sensitivity increase to 90.4%). CONCLUSION: Reaching the field triage sensitivity benchmark of 95% would require a large decrease in specificity (increase in overtriage). A 90% sensitivity target seems more realistic and may be obtainable by modest changes to the current triage algorithm. LEVEL OF EVIDENCE: Diagnostic test, level II.

    View details for DOI 10.1097/TA.0b013e31828b7848

    View details for PubMedID 23609282

  • VARIATION IN PREHOSPITAL USE AND UPTAKE OF THE NATIONAL FIELD TRIAGE DECISION SCHEME PREHOSPITAL EMERGENCY CARE Barnett, A. S., Wang, N. E., Sahni, R., Hsia, R. Y., Haukoos, J. S., Barton, E. D., Holmes, J. F., Newgard, C. D. 2013; 17 (2): 135-148

    Abstract

    The Field Triage Decision Scheme is a national guideline that has been implemented widely for prehospital emergency medical services (EMS) and trauma systems. However, little is known about the uptake, modification, or variation in field application of triage criteria between trauma systems.To describe and compare the use of field triage criteria by EMS personnel in six regions, including the timing of guideline uptake and the use of nonguideline criteria.This was a retrospective cohort study of injured children and adults transported by 48 EMS agencies to 105 hospitals (trauma centers and non-trauma centers) in six Western U.S. regions from 2006 through 2008. We used probabilistic linkage to match patient-level prehospital information from multiple sources, including EMS records, base-hospital phone communication records, and trauma registry data files. Triage criteria were evaluated individually and grouped by "steps" (physiologic, anatomic, mechanism, and special considerations). We used descriptive statistics to compare the frequency of triage criteria use (overall and between regions) and to evaluate the timing of guideline uptake across multiple versions of the guidelines.A total of 260,027 injured patients were evaluated and transported by EMS over the three-year study period, of whom 46,414 (18%) met at least one field triage criterion and formed the primary sample for analysis. The three most common criteria cited (of 33 in use) were EMS provider judgment (26%), age <5 or >55 years (10%), and Glasgow Coma Scale (GCS) score <14 (9%). Of the 33 criteria in use, five (15%) were previously retired from the guidelines and seven (21%) were never included in the guidelines. 11,048 (24%) patients had more than one criterion applied (range 1-21). There was large variation in the type and frequency of criteria used between systems, particularly among the nonphysiologic triage steps. Only one of six regions had translated the most recent guidelines into field use within two years after release.There is large variation between regions in the frequency and type of field triage criteria used. Field uptake of guideline revisions appears to be slow and variable, suggesting opportunities for improvement in dissemination and implementation of updated guidelines.

    View details for DOI 10.3109/10903127.2012.749966

    View details for PubMedID 23452003

  • Adverse events associated with procedural sedation in pediatric patients in the emergency department. Hospital pharmacy Cudny, M. E., Wang, N. E., Bardas, S. L., Nguyen, C. N. 2013; 48 (2): 134–42

    Abstract

    PURPOSE: To determine the agents used by emergency medicine (EM) physicians in pediatric procedural sedation and the associated adverse events (AEs) and to provide recommendations for optimizing drug therapy in pediatric patients.METHODS: We conducted a prospective study at Stanford Hospital's pediatric emergency department (ED) from April 2007 to April 2008 to determine the medications most frequently used in pediatric procedural sedation as well as their effectiveness and AEs. Patients, 18 years old or younger, who required procedural sedation in the pediatric ED were eligible for the study. The data collected included medical record number, sex, age, height, weight, procedure type and length, physician, and agents used. For each agent, the dose, route, time from administration to onset of sedation, duration of sedation, AEs, and sedation score were recorded. Use of supplemental oxygen and interventions during procedural sedation were also recorded.RESULTS: We found that in a convenience sample of 196 children (202 procedures) receiving procedural sedation in a university-based ED, 8 different medications were used (ketamine, etomidate, fentanyl, hydromorphone, methohexital, midazolam, pentobarbital, and thiopental). Ketamine was the most frequently used medication (88%), regardless of the procedure. Only twice in the study was the medication that was initially used for procedural sedation changed completely. Fracture reduction was the most frequently performed procedure (41%), followed by laceration/suture repair (32%). There were no serious AEs reported.CONCLUSION: EM-trained physicians can safely perform pediatric procedural sedation in the ED. In the pediatric ED, the most common procedure requiring conscious sedation is fracture reduction, with ketamine as the preferred agent.

    View details for DOI 10.1310/hpj4802-134.test

    View details for PubMedID 24421451

  • Characteristics Associated With Routine Use of Alcohol Screening in United States Emergency Departments Research Forum of the American-College-of-Emergency-Physicians (ACEP) Yokell, M. A., Camargo, J. C., Wang, N., Delgado, M. MOSBY-ELSEVIER. 2012: S134–S135
  • Predictors of Hospitalization After an Emergency Department Visit for California Youths With Psychiatric Disorders PSYCHIATRIC SERVICES Huffman, L. C., Wang, N. E., Saynina, O., Wren, F. J., Wise, P. H., Horwitz, S. M. 2012; 63 (9): 896-905

    Abstract

    This study examined patient, hospital, and county characteristics associated with hospitalization after emergency department visits for pediatric mental health problems.Retrospective analysis of emergency department encounters (N=324,997) of youths age five years to 17 years with psychiatric diagnoses was conducted with 2005-2009 California Office of Statewide Health Planning and Development emergency department statewide data.For youths with any psychiatric diagnosis, 23.4% of emergency department encounters resulted in hospitalization. In these cases, hospitalization largely was predicted by clinical need. Nonclinical factors that decreased the likelihood of hospitalization included demographic characteristics (such as younger age, lack of insurance, and rural residence) and resource characteristics (private hospital ownership, lack of psychiatric consultation in the emergency department, and lack of pediatric psychiatric beds). For youths with a significant psychiatric diagnosis plus a suicide attempt, 53.8% of emergency department encounters resulted in hospitalization. In these presumably more life-threatening cases, nonclinical factors that decreased the likelihood of hospitalization persisted: demographic characteristics (lack of insurance and rural residence) and resource characteristics (public hospital ownership, lack of psychiatric consultation, and lack of pediatric psychiatric beds).Mental health service delivery can improve only by addressing nonclinical demographic and resource obstacles that independently decrease the likelihood of hospitalization after an emergency department visit for a mental health issue; this is true even for the most severely ill youths-those with a suicide attempt as well as a serious psychiatric diagnosis.

    View details for DOI 10.1176/appi.ps.201000482

    View details for PubMedID 22710574

  • The association between insurance status and emergency department disposition of injured California children. Academic emergency medicine Arroyo, A. C., Ewen Wang, N., Saynina, O., Bhattacharya, J., Wise, P. H. 2012; 19 (5): 541-551

    Abstract

    This study examined the relationship between insurance status and emergency department (ED) disposition of injured California children.Multivariate regression models were built using data obtained from the 2005 through 2009 California Office of Statewide Health Planning and Development (OSHPD) data sets for all ED visits by injured children younger than 19 years of age.Of 3,519,530 injury-related ED visits, 52% were insured by private, and 36% were insured by public insurance, while 11% of visits were not insured. After adjustment for injury characteristics and demographic variables, publicly insured children had a higher likelihood of admission for mild, moderate, and severe injuries compared to privately insured children (mild injury adjusted odds ratio [AOR] = 1.36, 95% confidence interval [CI] = 1.34 to 1.39; moderate and severe injury AOR = 1.34, 95% CI = 1.28 to 1.41). However, uninsured children were less likely to be admitted for mild, moderate, and severe injuries compared to privately insured children (mild injury AOR = 0.63, 95% CI = 0.61 to 0.66; moderate and severe injury AOR = 0.50, 95% CI = 0.46 to 0.55). While publicly insured children with moderate and severe injuries were as likely as privately insured children to experience an ED death (AOR = 0.91, 95% CI = 0.70 to 1.18), uninsured children with moderate and severe injuries were more likely to die in the ED compared to privately insured children (AOR = 3.11, 95% CI = 2.38 to 4.06).Privately insured, publicly insured, and uninsured injured children have disparate patterns of ED disposition. Policy and clinical efforts are needed to ensure that all injured children receive equitable emergency care.

    View details for DOI 10.1111/j.1553-2712.2012.01356.x

    View details for PubMedID 22594358

    View details for PubMedCentralID PMC3443629

  • Deciphering the use and predictive value of "emergency medical services provider judgment" in out-of-hospital trauma triage: A multisite, mixed methods assessment JOURNAL OF TRAUMA AND ACUTE CARE SURGERY Newgard, C. D., Kampp, M., Nelson, M., Holmes, J. F., Zive, D., Rea, T., Bulger, E. M., Liao, M., Sherck, J., Hsia, R. Y., Wang, N. E., Fleischman, R. J., Barton, E. D., Daya, M., Heineman, J., Kuppermann, N. 2012; 72 (5): 1239-1248

    Abstract

    "Emergency medical services (EMS) provider judgment" was recently added as a field triage criterion to the national guidelines, yet its predictive value and real world application remain unclear. We examine the use and independent predictive value of EMS provider judgment in identifying seriously injured persons.We analyzed a population-based retrospective cohort, supplemented by qualitative analysis, of injured children and adults evaluated and transported by 47 EMS agencies to 94 hospitals in five regions across the Western United States from 2006 to 2008. We used logistic regression models to evaluate the independent predictive value of EMS provider judgment for Injury Severity Score ≥ 16. EMS narratives were analyzed using qualitative methods to assess and compare common themes for each step in the triage algorithm, plus EMS provider judgment.213,869 injured patients were evaluated and transported by EMS over the 3-year period, of whom 41,191 (19.3%) met at least one of the field triage criteria. EMS provider judgment was the most commonly used triage criterion (40.0% of all triage-positive patients; sole criterion in 21.4%). After accounting for other triage criteria and confounders, the adjusted odds ratio of Injury Severity Score ≥ 16 for EMS provider judgment was 1.23 (95% confidence interval, 1.03-1.47), although there was variability in predictive value across sites. Patients meeting EMS provider judgment had concerning clinical presentations qualitatively similar to those meeting mechanistic and other special considerations criteria.Among this multisite cohort of trauma patients, EMS provider judgment was the most commonly used field trauma triage criterion, independently associated with serious injury, and useful in identifying high-risk patients missed by other criteria. However, there was variability in predictive value between sites.

    View details for DOI 10.1097/TA.0b013e3182468b51

    View details for PubMedID 22673250

  • Evaluating the Use of Existing Data Sources, Probabilistic Linkage, and Multiple Imputation to Build Population-based Injury Databases Across Phases of Trauma Care ACADEMIC EMERGENCY MEDICINE Newgard, C., Malveau, S., Staudenmayer, K., Wang, N. E., Hsia, R. Y., Mann, N. C., Holmes, J. F., Kuppermann, N., Haukoos, J. S., Bulger, E. M., Dai, M., Cook, L. J. 2012; 19 (4): 469-480

    Abstract

    The objective was to evaluate the process of using existing data sources, probabilistic linkage, and multiple imputation to create large population-based injury databases matched to outcomes.This was a retrospective cohort study of injured children and adults transported by 94 emergency medical systems (EMS) agencies to 122 hospitals in seven regions of the western United States over a 36-month period (2006 to 2008). All injured patients evaluated by EMS personnel within specific geographic catchment areas were included, regardless of field disposition or outcome. The authors performed probabilistic linkage of EMS records to four hospital and postdischarge data sources (emergency department [ED] data, patient discharge data, trauma registries, and vital statistics files) and then handled missing values using multiple imputation. The authors compare and evaluate matched records, match rates (proportion of matches among eligible patients), and injury outcomes within and across sites.There were 381,719 injured patients evaluated by EMS personnel in the seven regions. Among transported patients, match rates ranged from 14.9% to 87.5% and were directly affected by the availability of hospital data sources and proportion of missing values for key linkage variables. For vital statistics records (1-year mortality), estimated match rates ranged from 88.0% to 98.7%. Use of multiple imputation (compared to complete case analysis) reduced bias for injury outcomes, although sample size, percentage missing, type of variable, and combined-site versus single-site imputation models all affected the resulting estimates and variance.This project demonstrates the feasibility and describes the process of constructing population-based injury databases across multiple phases of care using existing data sources and commonly available analytic methods. Attention to key linkage variables and decisions for handling missing values can be used to increase match rates between data sources, minimize bias, and preserve sampling design.

    View details for DOI 10.1111/j.1553-2712.2012.01324.x

    View details for PubMedID 22506952

    View details for PubMedCentralID PMC3334286

  • A Multisite Assessment of the American College of Surgeons Committee on Trauma Field Triage Decision Scheme for Identifying Seriously Injured Children and Adults JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Newgard, C. D., Zive, D., Holmes, J. F., Bulger, E. M., Staudenmayer, K., Liao, M., Rea, T., Hsia, R. Y., Wang, N. E., Fleischman, R., Jui, J., Mann, N. C., Haukoos, J. S., Sporer, K. A., Gubler, K. D., Hedges, J. R. 2011; 213 (6): 709-721

    Abstract

    The American College of Surgeons Committee on Trauma (ACSCOT) has developed and updated field trauma triage protocols for decades, yet the ability to identify major trauma patients remains unclear. We estimate the diagnostic value of the Field Triage Decision Scheme for identifying major trauma patients (Injury Severity Score [ISS] ≥ 16) in a large and diverse multisite cohort.This was a retrospective cohort study of injured children and adults transported by 94 emergency medical services (EMS) agencies to 122 hospitals in 7 regions of the Western US from 2006 through 2008. Patients who met any of the field trauma triage criteria (per EMS personnel) were considered triage positive. Hospital outcomes measures were probabilistically linked to EMS records through trauma registries, state discharge data, and emergency department data. The primary outcome defining a "major trauma patient" was ISS ≥ 16.There were 122,345 injured patients evaluated and transported by EMS over the 3-year period, 34.5% of whom met at least 1 triage criterion and 5.8% had ISS ≥ 16. The overall sensitivity and specificity of the criteria for identifying major trauma patients were 85.8% (95% CI 85.0% to 86.6%) and 68.7% (95% CI 68.4% to 68.9%), respectively. Triage sensitivity and specificity, respectively, differed by age: 84.1% and 66.4% (0 to 17 years); 89.5% and 64.3% (18 to 54 years); and 79.9% and 75.4% (≥55 years). Evaluating the diagnostic value of triage by hospital destination (transport to Level I/II trauma centers) did not substantially improve these findings.The sensitivity of the Field Triage Decision Scheme for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders.

    View details for DOI 10.1016/j.jamcollsurg.2011.09.012

    View details for PubMedID 22107917

  • Effectiveness of a Staged US and CT Protocol for the Diagnosis of Pediatric Appendicitis: Reducing Radiation Exposure in the Age of ALARA RADIOLOGY Krishnamoorthi, R., Ramarajan, N., Wang, N. E., Newman, B., Rubesova, E., Mueller, C. M., Barth, R. A. 2011; 259 (1): 231-239

    Abstract

    To evaluate the effectiveness of a staged ultrasonography (US) and computed tomography (CT) imaging protocol for the accurate diagnosis of suspected appendicitis in children and the opportunity for reducing the number of CT examinations and associated radiation exposure.This retrospective study was compliant with HIPAA, and a waiver of informed consent was approved by the institutional review board. This study is a review of all imaging studies obtained in children suspected of having appendicitis between 2003 and 2008 at a suburban pediatric emergency department. A multidisciplinary staged US and CT imaging protocol for the diagnosis of appendicitis was implemented in 2003. In the staged protocol, US was performed first in patients suspected of having appendicitis; follow-up CT was recommended when US findings were equivocal. Of 1228 pediatric patients who presented to the emergency department for suspected appendicitis, 631 (287 boys, 344 girls; age range, 2 months to 18 years; median age, 10 years) were compliant with the imaging pathway. The sensitivity, specificity, negative appendectomy rate (number of appendectomies with normal pathologic findings divided by the number of surgeries performed for suspected appendicitis), missed appendicitis rate, and number of CT examinations avoided by using the staged protocol were analyzed.The sensitivity and specificity of the staged protocol were 98.6% and 90.6%, respectively. The negative appendectomy rate was 8.1% (19 of 235 patients), and the missed appendicitis rate was less than 0.5% (one of 631 patients). CT was avoided in 333 of the 631 patients (53%) in whom the protocol was followed and in whom the US findings were definitive.A staged US and CT imaging protocol in which US is performed first in children suspected of having acute appendicitis is highly accurate and offers the opportunity to substantially reduce radiation.

    View details for DOI 10.1148/radiol.10100984

    View details for PubMedID 21324843

  • National Survey of Preventive Health Services in US Emergency Departments Scientific Assembly of the American-College-of-Emergency-Physicians Delgado, M. K., Acosta, C. D., Ginde, A. A., Wang, N. E., Strehlow, M. C., Khandwala, Y. S., Camargo, C. A. MOSBY-ELSEVIER. 2011: 104–8

    Abstract

    We describe the availability of preventive health services in US emergency departments (EDs), as well as ED directors' preferred service and perceptions of barriers to offering preventive services.Using the 2007 National Emergency Department Inventory (NEDI)-USA, we randomly sampled 350 (7%) of 4,874 EDs. We surveyed directors of these EDs to determine the availability of (1) screening and referral programs for alcohol, tobacco, geriatric falls, intimate partner violence, HIV, diabetes, and hypertension; (2) vaccination programs for influenza and pneumococcus; and (3) linkage programs to primary care and health insurance. ED directors were asked to select the service they would most like to implement and to rate 5 potential barriers to offering preventive services.Two hundred seventy-seven EDs (80%) responded across 46 states. Availability of services ranged from 66% for intimate partner violence screening to 19% for HIV screening. ED directors wanted to implement primary care linkage most (17%) and HIV screening least (2%). ED directors "agreed/strongly agreed" that the following are barriers to ED preventive care: cost (74%), increased patient length of stay (64%), lack of follow-up (60%), resource shifting leading to worse patient outcomes (53%), and philosophical opposition (27%).Most US EDs offer preventive services, but availability and ED director preference for type of service vary greatly. The majority of EDs do not routinely offer Centers for Disease Control and Prevention-recommended HIV screening. Most ED directors are not philosophically opposed to offering preventive services but are concerned with added costs, effects on ED operations, and potential lack of follow-up.

    View details for DOI 10.1016/j.annemergmed.2010.07.015

    View details for Web of Science ID 000287464900007

    View details for PubMedID 20889237

    View details for PubMedCentralID PMC3538034

  • Characteristics of Pediatric Trauma Transfers to a Level I Trauma Center: Implications for Developing a Regionalized Pediatric Trauma System in California ACADEMIC EMERGENCY MEDICINE Acosta, C. D., Delgado, M. K., Gisondi, M. A., Raghunathan, A., D'Souza, P. A., Gilbert, G., Spain, D. A., Christensen, P., Wang, N. E. 2010; 17 (12): 1364-1373

    Abstract

    since California lacks a statewide trauma system, there are no uniform interfacility pediatric trauma transfer guidelines across local emergency medical services (EMS) agencies in California. This may result in delays in obtaining optimal care for injured children.this study sought to understand patterns of pediatric trauma patient transfers to the study trauma center as a first step in assessing the quality and efficiency of pediatric transfer within the current trauma system model. Outcome measures included clinical and demographic characteristics, distances traveled, and centers bypassed. The hypothesis was that transferred patients would be more severely injured than directly admitted patients, primary catchment transfers would be few, and out-of-catchment transfers would come from hospitals in close geographic proximity to the study center.this was a retrospective observational analysis of trauma patients ≤ 18 years of age in the institutional trauma database (2000-2007). All patients with a trauma International Classification of Diseases, 9th revision (ICD-9) code and trauma mechanism who were identified as a trauma patient by EMS or emergency physicians were recorded in the trauma database, including those patients who were discharged home. Trauma patients brought directly to the emergency department (ED) and patients transferred from other facilities to the center were compared. A geographic information system (GIS) was used to calculate the straight-line distances from the referring hospitals to the study center and to all closer centers potentially capable of accepting interfacility pediatric trauma transfers.of 2,798 total subjects, 16.2% were transferred from other facilities within California; 69.8% of transfers were from the catchment area, with 23.0% transferred from facilities ≤ 10 miles from the center. This transfer pattern was positively associated with private insurance (risk ratio [RR] = 2.05; p < 0.001) and negatively associated with age 15-18 years (RR = 0.23; p = 0.01) and Injury Severity Score (ISS) > 18 (RR = 0.26; p < 0.01). The out-of-catchment transfers accounted for 30.2% of the patients, and 75.9% of these noncatchment transfers were in closer proximity to another facility potentially capable of accepting pediatric interfacility transfers. The overall median straight-line distance from noncatchment referring hospitals to the study center was 61.2 miles (IQR = 19.0-136.4), compared to 33.6 miles (IQR = 13.9-61.5) to the closest center. Transfer patients were more severely injured than directly admitted patients (p < 0.001). Out-of-catchment transfers were older than catchment patients (p < 0.001); ISS > 18 (RR = 2.06; p < 0.001) and age 15-18 (RR = 1.28; p < 0.001) were predictive of out-of-catchment patients bypassing other pediatric-capable centers. Finally, 23.7% of pediatric trauma transfer requests to the study institution were denied due to lack of bed capacity.from the perspective an adult Level I trauma center with a certified pediatric intensive care unit (PICU), delays in definitive pediatric trauma care appear to be present secondary to initial transport to nontrauma community hospitals within close proximity of a trauma hospital, long transfer distances to accepting facilities, and lack of capacity at the study center. Given the absence of uniform trauma triage and transfer guidelines across state EMS systems, there appears to be a role for quality monitoring and improvement of the current interfacility pediatric trauma transfer system, including defined triage, transfer, and data collection protocols.

    View details for DOI 10.1111/j.1553-2712.2010.00926.x

    View details for PubMedID 21122022

  • Defining and Measuring Successful Emergency Care Networks: A Research Agenda ACADEMIC EMERGENCY MEDICINE Glickman, S. W., Delgado, M. K., Hirshon, J. M., Hollander, J. E., Iwashyna, T. J., Jacobs, A. K., Kilaru, A. S., Lorch, S. A., Mutter, R. L., Myers, S. R., Owens, P. L., Phelan, M. P., Pines, J. M., Seymour, C. W., Wang, N. E., Branas, C. C. 2010; 17 (12): 1297-1305

    Abstract

    The demands on emergency services have grown relentlessly, and the Institute of Medicine (IOM) has asserted the need for "regionalized, coordinated, and accountable emergency care systems throughout the country." There are large gaps in the evidence base needed to fix the problem of how emergency care is organized and delivered, and science is urgently needed to define and measure success in the emerging network of emergency care. In 2010, Academic Emergency Medicine convened a consensus conference entitled "Beyond Regionalization: Integrated Networks of Emergency Care." This article is a product of the conference breakout session on "Defining and Measuring Successful Networks"; it explores the concept of integrated emergency care delivery and prioritizes a research agenda for how to best define and measure successful networks of emergency care. The authors discuss five key areas: 1) the fundamental metrics that are needed to measure networks across time-sensitive and non-time-sensitive conditions; 2) how networks can be scalable and nimble and can be creative in terms of best practices; 3) the potential unintended consequences of networks of emergency care; 4) the development of large-scale, yet feasible, network data systems; and 5) the linkage of data systems across the disease course. These knowledge gaps must be filled to improve the quality and efficiency of emergency care and to fulfill the IOM's vision of regionalized, coordinated, and accountable emergency care systems.

    View details for DOI 10.1111/j.1553-2712.2010.00930.x

    View details for Web of Science ID 000284848100007

    View details for PubMedID 21122011

  • National Survey of Preventive Health Services in United States Emergency Departments Delgado, M. K., Wang, N., Acosta, C., Khandwala, Y., West, A. M., Strehlow, M. C., Ginde, A. A., Camargo, J. A. MOSBY-ELSEVIER. 2009: S20
  • A Model for Improving Uninsured Children's Access to Health Insurance via the Emergency Department JOURNAL OF HEALTHCARE MANAGEMENT Acosta, C., Dibble, C., Giammona, M., Wang, N. E., Finley, D. S. 2009; 54 (2): 105-116

    Abstract

    A shift in commercially insured patients to publicly insured or uninsured status has caused an increase in emergency department (ED) visits for routine and nonemergent care. Meanwhile, hospitals struggle to compensate for decreasing reimbursements across all payer groups and increasing underwritten costs of care for the uninsured. Children represent a particularly vulnerable population and a substantial proportion of uninsured patients. In this study we assessed the efficacy and financial benefit of an insurance-referral program that is integrated into the routine pediatric ED admitting protocol of an academic hospital for the period 2004 to 2007. In this model, the ED of Stanford Hospital and Clinics acted as a referral agency to the San Mateo County Children's Health Initiative, a county coalition that carries out screening and enrollment assistance for public insurance. Referral from the ED was available 24 hours a day, and partnership with the county coalition negated the use of a hospital insurance-enrollment worker. Over the four-year study period, the referral program attained a successful linkage rate of 54.5 percent, which represents nearly 800 newly insured children. The vast majority (88.6 percent) of these pediatric patients were linked to Medicaid, which can reimburse retroactively for services rendered. For the academic hospital, this linkage rate resulted in $105,829.25 in insurance reimbursements and $658,559.97 deflected from bad-debt conversion. This pilot program is a sustainable, medically responsible model for linking uninsured children who need medical services with healthcare insurance. In addition, the program has the potential to yield financial return for the hospital. Similar models may be implemented in EDs across the United States. Healthcare managers who are seeking to alleviate the financial impact of care for the uninsured may find this model to be useful.

    View details for Web of Science ID 000264609500006

    View details for PubMedID 19413165

  • Variability in Pediatric Utilization of Trauma Facilities in California: 1999 to 2005 ANNALS OF EMERGENCY MEDICINE Wang, N. E., Saynina, O., Kuntz-Duriseti, K., Mahlow, P., Wise, P. H. 2008; 52 (6): 607-615

    Abstract

    We identify geographic, system, and socioeconomic differences between injured children cared for within and outside of state-designated trauma centers.This was a nonconcurrent observational study of a population-based sample from the California Office of Statewide Health Planning and Development Public Patient Discharge Database 1999 to 2005. Patients were 1 to 14 years of age, with International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes indicative of trauma. Injury Severity Scores were calculated from ICD-9 codes and categorized into severity categories. Outcomes were hospitalization in a trauma or nontrauma center.Children with severe injury who resided 0 to 10, 11 to 25, 26 to 50, and more than 50 miles from a trauma center were hospitalized in these centers at rates of 80.0%, 71.2%, 51.4%, and 28.5%, respectively. Children with severe injury who were living in a county with a trauma center were hospitalized in these centers at rates of 78.8%, whereas children living in a county without a trauma center were hospitalized in trauma centers at rates of 39.0%. Children with severe injury and public, private non-health maintenance organization (HMO), and HMO insurance were hospitalized in trauma centers at rates of 77.7%, 68.0%, and 55.4%, respectively. Age, injury severity, insurance type, residence in a county with a trauma center, and proximity to a trauma center were identified as predictors of trauma center utilization by logistic regression.We demonstrate considerable variation in the utilization pattern of trauma specialty care for children with moderate and severe injuries. Children with HMO and private insurance are cared for less often in trauma centers than those with public insurance, even after adjustment for other variables. Increased distance to a trauma center, as well as lack of trauma center within a county, also decreases trauma center utilization. These results suggest that assessing trauma center utilization patterns in total populations of children may identify opportunities for improved referral policies and practices as part of a larger effort to ensure high-quality trauma care for all children in need.

    View details for DOI 10.1016/j.annemergmed.2008.05.011

    View details for Web of Science ID 000261540200002

    View details for PubMedID 18562043

  • Integrating Collaborative Population Health Projects into a Medical Student Curriculum at Stanford ACADEMIC MEDICINE Chamberlain, L. J., Wang, N. E., Ho, E. T., Banchoff, A. W., Braddock, C. H., Gesundheit, N. 2008; 83 (4): 338-344

    Abstract

    The authors describe the population health curriculum at the Stanford University School of Medicine from 2003 to 2007 that includes a requirement for first-year medical students to engage in community-based population health projects. The new curriculum in population health comprises classroom and experiential teaching methods. Population health projects, a key component of the curriculum, are described and classified by topic and topic area (e.g., health education; health services) and the intended outcome of the intervention (e.g., establishing new policies; advocacy). During the past four years, 344 students have entered the curriculum and have participated in 68 population health projects. The projects were determined both by students' interests and community needs, and they represented diverse topics: 51% of the 68 projects addressed topics in the area of disease prevention and health promotion; 28% addressed health care access; 15% addressed health services; 4% addressed emergency preparedness; and 1% addressed ethical issues in health. Each project had one of three targets for intervention: community capacity building, establishing policies and engaging in advocacy, and bringing about change or improvement in an aspect of the health care system. Projects represented diverse stages in the evolution of a community-campus partnership, from needs assessment to planning, implementation, and evaluation of project outcomes. Experience to date shows that classroom-based sessions and experiential learning in the area of population health can be successfully integrated in a medical school curriculum. When contextualized in a population health curriculum, population health projects can provide future physicians with an experiential counterpart to their classroom learning.

    View details for Web of Science ID 000267654000005

    View details for PubMedID 18367891

  • Hypertensive crisis and NSTEMI after accidental overdose of sustained release pseudoephedrine: A case report CLINICAL TOXICOLOGY Wang, N., Gillis, E., Mudie, D. 2008; 46 (9): 922–23

    View details for DOI 10.1080/15563650701816455

    View details for Web of Science ID 000260796500050

    View details for PubMedID 18608273

  • Tension pneumoperitoneum after intussusception pneumoreduction PEDIATRIC EMERGENCY CARE Sohoni, A., Wang, N. E., Dannenberg, B. 2007; 23 (8): 563-564

    Abstract

    Intussusception is the most common cause of intestinal obstruction in infancy. Presentation, diagnostic workup, and treatment are well understood and noncontroversial. Complications of bowel perforation are also well documented. We discuss a case of tension pneumoperitoneum after intestinal perforation during intussusception pneumoreduction in a 5-month-old child and review initial presentation, diagnosis, and management of this disease. It is important to recognize this rare complication of pneumoreduction and promptly treat the ensuing tension pneumoperitoneum.

    View details for Web of Science ID 000248777100009

    View details for PubMedID 17726417

  • Trauma center utilization for children in California 1998-2004: Trends and areas for further analysis ACADEMIC EMERGENCY MEDICINE Wang, N. E., Chan, J., Mahlow, P., Wise, P. H. 2007; 14 (4): 309-315

    Abstract

    While it is known that trauma systems improve the outcome of injury in children, there is a paucity of information regarding trauma system function amid changes in policies and health care financing that affect emergency medical systems for children.To describe the trends in the proportion of pediatric trauma patients acutely hospitalized in trauma-designated versus non-trauma-designated hospitals.This was a retrospective observational study of a population-based cohort obtained by secondary analysis of a publicly available data set: the California Office of Statewide Health Planning and Development Patient Discharge Database from 1998 to 2004. Patients were included in the analysis if they were 0-19 years old, had International Classification of Disease, Ninth Revision (ICD-9) diagnostic codes and E-codes indicative of trauma, had an unscheduled admission, and were discharged from a general acute care hospital (N = 111,566). Proportions of patients hospitalized in trauma-designated hospitals versus non-trauma-designated hospitals were calculated for Injury Severity Score and death. Injury Severity Scores were calculated from ICD-9 codes. Primary outcomes were hospitalization in a trauma center and death two or more days after hospitalization.Over the study period, the proportion of children aged 0-14 years with acute trauma requiring hospitalization and who were cared for in trauma-designated hospitals increased from 55% (95% confidence interval [CI] = 54% to 56%) in 1998 to 66% (95% CI = 65% to 67%) in 2004 (p < 0.01). For children aged 15-19 years, the proportion increased from 55% (95% CI = 54% to 57%) in 1998 to 74% (95% CI = 72% to 75%) in 2004 (p < 0.0001). When trauma discharges were stratified by injury severity, the proportion of children with severe injury who were hospitalized in trauma-designated hospitals increased from 69% (95% CI = 66% to 72%) in 1998 to 84% (95% CI = 82% to 87%) in 2004, a rate higher than in children with moderate injury (59% [95% CI = 58% to 61%] in 1998 and 75% [95% CI = 74% to 76%] in 2004) and mild injury (51% [95% CI = 50% to 52%] in 1998 and 63% [95% CI = 62% to 64%] in 2004) (p < 0.0001 for each injury severity category and both age groups). Of the hospitalized children who died two or more days after injury (n = 502), 18.1% died in non-trauma-designated hospitals (p < 0.002 for children aged 0-14 years; p = 0.346 for children aged 15-19 years).An increasing majority of children with trauma were cared for in trauma-designated hospitals over the study period. However, 23% of children with severe injuries, and 18.1% of pediatric deaths more than two days after injury, were cared for in non-trauma-designated hospitals. These findings demonstrate an important opportunity for improvement. If we can characterize those children who do not access the trauma system despite severe injury or death, we will be able to design clinical protocols and implement policies that ensure access to appropriate regional trauma care for all children in need.

    View details for DOI 10.1197/j.aem.2006.11.012

    View details for Web of Science ID 000245579300003

    View details for PubMedID 17296799

  • Characteristics of pediatric patients at risk of poor emergency department aftercare ACADEMIC EMERGENCY MEDICINE Wang, N. E., Kiernan, M., Golzari, M., Gisondi, M. A. 2006; 13 (8): 840-847

    Abstract

    To identify and characterize subgroups of a pediatric population at risk of poor emergency department (ED) aftercare compliance.This was a prospective, cohort study conducted at a university hospital ED with a 2003 pediatric census of 11,040 patients. A convenience sample of 461 children was enrolled. The study follow-up rate was 97%. The primary outcomes were guardian compliance with instructions for physician follow-up appointment and with obtaining prescribed medications. Predictors of compliance outcomes were analyzed by using recursive partitioning to describe population subgroups at risk of poor compliance.Only 60.4% of patient guardians followed up with instructions to see a physician. Children with private insurance were more likely to follow up than were children without private insurance (76.8% vs. 46.5%, p < 0.001). Of children with private insurance, those with high-acuity diagnoses were more likely to follow up than were patients with low-acuity diagnoses (80.0% vs. 38.5%, p < 0.001). Of children who were considered underinsured (defined as publicly insured or uninsured), those with English-speaking guardians were more likely to follow up than were those with non-English-speaking guardians (58.0% vs. 40.0%, p < 0.05). Only 63.3% of patient guardians obtained prescribed medications. Privately insured children were more likely to obtain medications than were underinsured children (71.0% vs. 58.0%, p < 0.05). Descriptive profiles of the subgroups revealed that those with lower socioeconomic status were at greatest risk of poor aftercare compliance.Compliance with ED aftercare instructions remains a challenge. Health insurance disparities are associated with poor ED aftercare compliance in our pediatric population. Interventions aimed at improving compliance could be targeted to specific subgroups on the basis of their descriptive profiles.

    View details for DOI 10.1197/j.aem.2006.04.021

    View details for PubMedID 16880500

  • Socioeconomic disparities are negatively associated with pediatric emergency department aftercare compliance ACADEMIC EMERGENCY MEDICINE Wang, N. E., Gisondi, M. A., Golzari, M., van der Vlugt, T. M., Tuuli, M. 2003; 10 (11): 1278-1284

    Abstract

    This study sought to identify demographic, socioeconomic, and clinical predictors of aftercare noncompliance by pediatric emergency department (ED) patients.The authors conducted a prospective, observational study of pediatric patients presenting to a university teaching hospital ED from July 1, 2002, through August 31, 2002. Demographic and clinical information was obtained from guardians during the ED visit. Guardians were contacted after discharge to determine compliance with ED aftercare instructions. Subjects were excluded if they were admitted or if guardians were unavailable or unwilling to consent. Data were analyzed using multivariable logistic regression to identify predictors of noncompliance from a list of predetermined variables.Of the 409 patients enrolled in the study, 111 were prescribed medications and 364 were given specific follow-up instructions. Subtypes of the variable "insurance status" were significantly associated with medication noncompliance in multivariable regression analysis. "Insurance status" and "low-acuity discharge diagnoses" were significantly associated with follow-up noncompliance.Disparity in health insurance has been shown to be a predictor of poor aftercare compliance for pediatric ED patients within the patient population.

    View details for DOI 10.1197/S1069-6563(03)00499-8

    View details for PubMedID 14597505

  • International Emergency Medicine Reference List JOURNAL OF EMERGENCY MEDICINE Shayne, P., Holliman, C. J., Wang, N. E., Parrillo, S. J. 1999; 17 (1): 159–61

    View details for DOI 10.1016/S0736-4679(98)00133-4

    View details for Web of Science ID 000082179300030

    View details for PubMedID 9950407

  • Prediction of poor outcome of intensive care unit patients admitted from the emergency department CRITICAL CARE MEDICINE Rodriguez, R. M., Wang, N. E., Pearl, R. G. 1997; 25 (11): 1801-1806

    Abstract

    To assess whether physicians can identify very low likelihood of survival and very low likelihood of favorable functional outcome in adult nontrauma patients before admission to the intensive care unit (ICU) from the emergency department (ED).Prospective survey.University hospital ED and ICU.Critical care fellows and ED physicians and all adult nontrauma patients admitted to the ICU from the ED over 1 yr.None.The survey compared predictions of poor outcome from three sources: critical care fellows, ED physicians, and the admission Mortality Probability Model (MPM0). All patients were followed until hospital death or hospital discharge. Six-month follow-up data were obtained for patients predicted to have a < 2% chance of surviving with favorable functional outcome. In the ED, critical care fellows and ED physicians predicted likelihood of patient survival and likelihood of favorable functional outcome. MPM0 estimates of mortality were determined. The sensitivities, specificities, and positive predictive values were calculated for the predictions of < 2% survival and the predictions of < 2% chance of favorable functional outcome made by each prediction group. Complete data were obtained on 236 (96%) of 243 eligible patients. With regard to hospital mortality rate, fellows' predictions had a sensitivity of 27%, a specificity of 99%, and a positive predictive value of 88%; ED physicians' predictions had a sensitivity of 24%, a specificity of 98%, and a positive predictive value of 81%; and MPM0 predictions had a sensitivity of 2%, a specificity of 100%, and a positive predictive value of 100%. With regard to mortality rate combined with poor functional outcome, fellows' predictions had a sensitivity of 35%, a specificity of 99%, and a positive predictive value of 96%; ED physicians' predictions had a sensitivity of 37%, a specificity of 99%, and a positive predictive value of 96%.If a cutoff point of < 2% predicted survival is used in the triage of patients away from the ICU, the MPM0 has too low a sensitivity to be used as an effective screen. The low sensitivities and relatively low positive predictive values with wide confidence intervals of physician predictions of < 2% survival also preclude their use in triage. The addition of functional outcome as an end point improves the sensitivity, specificity, and positive predictive value of subjective predictions, making triage of patients away from the ICU at the time of ED evaluation a realistic possibility.

    View details for Web of Science ID A1997YF16400016

    View details for PubMedID 9366761

  • Validating the Use of ICD-9 Code Mapping to Generate Injury Severity Scores. Journal of trauma nursing : the official journal of the Society of Trauma Nurses Fleischman, R. J., Mann, N. C., Dai, M. n., Holmes, J. F., Wang, N. E., Haukoos, J. n., Hsia, R. Y., Rea, T. n., Newgard, C. D. ; 24 (1): 4–14

    Abstract

    The Injury Severity Score (ISS) is a measure of injury severity widely used for research and quality assurance in trauma. Calculation of ISS requires chart abstraction, so it is often unavailable for patients cared for in nontrauma centers. Whether ISS can be accurately calculated from International Classification of Diseases, Ninth Revision (ICD-9) codes remains unclear. Our objective was to compare ISS derived from ICD-9 codes with those coded by trauma registrars. This was a retrospective study of patients entered into 9 U.S. trauma registries from January 2006 through December 2008. Two computer programs, ICDPIC and ICDMAP, were used to derive ISS from the ICD-9 codes in the registries. We compared derived ISS with ISS hand-coded by trained coders. There were 24,804 cases with a mortality rate of 3.9%. The median ISS derived by both ICDPIC (ISS-ICDPIC) and ICDMAP (ISS-ICDMAP) was 8 (interquartile range [IQR] = 4-13). The median ISS in the registry (ISS-registry) was 9 (IQR = 4-14). The median difference between either of the derived scores and ISS-registry was zero. However, the mean ISS derived by ICD-9 code mapping was lower than the hand-coded ISS in the registries (1.7 lower for ICDPIC, 95% CI [1.7, 1.8], Bland-Altman limits of agreement = -10.5 to 13.9; 1.8 lower for ICDMAP, 95% CI [1.7, 1.9], limits of agreement = -9.6 to 13.3). ICD-9-derived ISS slightly underestimated ISS compared with hand-coded scores. The 2 methods showed moderate to substantial agreement. Although hand-coded scores should be used when possible, ICD-9-derived scores may be useful in quality assurance and research when hand-coded scores are unavailable.

    View details for PubMedID 28033134

  • A Practical Guide to Pediatric Emergency Medicine: Caring for Children in the Emergency Department Cambridge University Press, Cambridge, 2010. Amieva-Wang NE, Shandro j, Sohoni A, Fassl B