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Craig D Newgard

Publications and source records attributed to Craig D Newgard.

At least 19 recordsLinked to original sources
PubMed2007

The on-call crisis: a statewide assessment of the costs of providing on-call specialist coverage.

STUDY OBJECTIVE: A recent change in the delivery of emergency care is a growing reluctance of specialists to take call. The objective of this study is to survey Oregon hospitals about the prevalence and magnitude of stipends for taking emergency call and to assess the ways in which hospitals are limiting services. METHODS: This was a cross-sectional, standardized survey of chief executive officers from all hospitals with emergency departments in Oregon (N=56). This e-mail-based survey asked about payments made to specialists to take call and examined changes in hospitals' trauma designation and ability to provide continuous coverage for certain specialties. RESULTS: We received responses from 54 of 56 hospitals, representing a 96% response rate (100% of trauma centers). Twenty-three of 54 (43%) Oregon hospitals pay a stipend to at least 1 specialty, and 17 (31%) hospitals guarantee pay for uninsured patients treated on call. Stipends ranged from $300 per month to more than $3,000 per night, with a median stipend of $1,000 per night to take call. Trauma surgeons, neurosurgeons, and orthopedists were the specialists most likely to receive stipends. Seven of 54 (13%) hospitals have had their trauma designation affected by on-call issues. Twenty-six hospitals (48%) have lost the ability to provide continuous coverage for at least 1 specialty. CONCLUSION: Problems with on-call coverage are prevalent in Oregon and affect hospital financing and delivery of services. A continuation of the current situation could degrade the effectiveness of the trauma system and adversely affect the quality of emergency care.

Cross-Sectional Studies↗
PubMed2006

Variability of trauma transfer practices among non-tertiary care hospital emergency departments.

OBJECTIVES: To assess both the variability of interhospital trauma transfer practices and nonclinical factors associated with the transfer of injured patients from emergency departments (EDs) of non-tertiary care hospitals. METHODS: The authors analyzed a retrospective cohort of trauma patients initially presenting to one of 42 non-tertiary care hospitals (Level 3 or 4 hospitals) and requiring admission or transfer from January 1998 to December 2003. Twenty-one clinical, demographic, and hospital-level variables were included in multivariable logistic regression models (outcome = ED transfer to a tertiary care hospital), with hospital and year included as fixed effects to adjust for clustering. Classification and regression tree analysis was used to determine the importance of different covariates in predicting whether or not a patient was transferred from the ED. RESULTS: Included in the analysis were 10,176 persons, of whom 3,785 (37%) were transferred to a tertiary care hospital from the ED. The hospital of initial presentation was the factor of greatest importance in predicting transfer, and there was substantial variability in transfer practices between hospitals. Several additional nonclinical variables were independently associated with transfer, including type and level of hospital, patient age, increasing distance from the nearest higher-level hospital (a measure of geographic isolation), and the patient's insurance status (particularly among Level 3 hospitals). CONCLUSIONS: The non-tertiary care hospital of initial presentation is the strongest predictor for whether an injured patient is transferred to a tertiary center from the ED. There is substantial variability in transfer practices between hospitals after accounting for important clinical factors, and several nonclinical variables are independently associated with transfer.

Age Factors↗
PubMed2006

The validity of using multiple imputation for missing out-of-hospital data in a state trauma registry.

OBJECTIVES: To assess 1) the agreement of multiply imputed out-of-hospital values previously missing in a state trauma registry compared with known ambulance values and 2) the potential impact of using multiple imputation versus a commonly used method for handling missing data (i.e., complete case analysis) in a typical multivariable injury analysis. METHODS: This was a retrospective cohort analysis. Multiply imputed out-of-hospital data from 1998 to 2003 for four variables (intubation attempt, Glasgow Coma Scale score, systolic blood pressure, and respiratory rate) were compared with known values from probabilistically linked ambulance records using measures of agreement (kappa, weighted kappa, and Bland-Altman plots). Ambulance values were assumed to represent the "true" values for all analyses. A hypothetical multivariable regression model was used to demonstrate the impact (i.e., bias and precision of model results) of handling missing out-of-hospital data with multiple imputation versus complete case analysis. RESULTS: A total of 6,150 matched ambulance and trauma registry records were available for comparison. Multiply imputed values for the four out-of-hospital variables demonstrated fair to good agreement with known ambulance values. When included in typical multivariable analyses, multiple imputation increased precision and reduced bias compared with using complete case analysis for the same data set. CONCLUSIONS: Multiply imputed out-of-hospital values for intubation attempt, Glasgow Coma Scale score, systolic blood pressure, and respiratory rate have fair to good agreement with known ambulance values. Multiple imputation also increased precision and reduced bias compared with complete case analysis in a typical multivariable injury model, and it should be considered for studies using out-of-hospital data from a trauma registry, particularly when substantial portions of data are missing.

Ambulances↗
PubMed2006

Regional differences in outcomes for hospitalized injured patients.

BACKGROUND: Our goal was to use a hospital population-based data set that was a sample of all injured patients admitted to a hospital in the United States to develop universal measures of outcome and processes of care. METHODS: Patients with a primary discharge diagnosis of injury (ICD-9 800 to 959) in the HCUP/Nationwide Inpatient Sample for the years 1995 to 2000 were used to estimate the annual number of hospitalized injured patients. Using census data, we calculated age- and sex- adjusted average annual incidence rates for four census regions in the United States: Northeast, Midwest, South and West. Outcomes measured were annual rates per million populations of hospitalization rate, death rate, and potentially ineffective care (PIC) rate defined as >28 days of hospitalization ending in death. Length of stay (LOS) was calculated as total number of days annually hospitalized for injury for census regions per million populations. RESULTS: Incidence rates per million populations and 95% confidence intervals for rate of hospitalizations for injury were: Northeast, 5596 (5338-5853); Midwest, 5516 (5316-5716); South, 5639 (5410-5869); West, 5307 (5071-5543). Incidence rates per million populations and 95% confidence intervals for rate of in-hospital deaths were: Northeast, 129 (119-139); Midwest, 131 (122-139); South, 141 (129-152); West, 114 (106-123). Incidence rates per million populations and 95% confidence intervals for rate of PIC were: Northeast, 11 (10-13); Midwest, 5 (4-5); South, 6 (5-7); West, 4 (3-4). Incidence rates per million populations and 95% confidence intervals for hospital days were: Northeast, 34 (32-36); Midwest, 30 (28-31); South, 30 (29-32); West, 26 (24-27). CONCLUSION: Regional differences in outcomes and processes of care for hospitalized injured patients exist and may be influenced by hospital characteristics and region of the country. Research to identify the factors that cause these hospital and regional variations is needed. These observations suggest that to develop a uniform standard for quality of care, it will be essential to have valid and robust hospital population-based measures.

Adolescent↗
PubMed2005

Validation of probabilistic linkage to match de-identified ambulance records to a state trauma registry.

OBJECTIVES: To validate the accuracy of using probabilistic linkage for matching de-identified ambulance records to a state trauma registry. METHODS: This was a retrospective cohort analysis. Three thousand nine hundred nineteen true matches between ambulance and state trauma registry data from 1998 to 2003 were identified by deterministic matching on trauma identification number and verified by human review. Two thousand thirty-eight ambulance records from trauma patients not meeting criteria for a true match, and an identical number of trauma registry records randomly selected from the one local county served by a different EMS provider, were included as nonmatches. There were 17 variables considered for linkage, which included the following: age, gender, race, county, hospital, date, rural setting, call and arrival times, mechanism, penetrating injury, vital signs, intubation, and intoxication. Probabilistic linkage was used to link the two data sets, using seven different combinations of common variables (maximum, 17; minimum, 4). The sensitivity and specificity of identifying true matches and nonmatches (95% confidence intervals [95% CI]) were calculated for each combination of variables. RESULTS: Using all 17 available variables, 3,766 of 3,919 true matches were appropriately linked (sensitivity, 96.1%; 95% CI = 95.4% to 96.7%), with eight mismatches (specificity, 99.6%; 95% CI = 99.2% to 99.8%). Sensitivity fell below 95% with < 15 variables; however, sensitivity was very dependent on the inclusion of variables with high discriminatory power. Specificity remained >98% regardless of the number of variables included. CONCLUSIONS: Probabilistic linkage is a valid method for matching ambulance records to a trauma registry without the use of patient identifiers; however, the sensitivity of identifying true matches is critically dependent on the number and type of common variables included in the analysis.

Ambulances↗
PubMed2005

Pretest probability assessment derived from attribute matching.

BACKGROUND: Pretest probability (PTP) assessment plays a central role in diagnosis. This report compares a novel attribute-matching method to generate a PTP for acute coronary syndrome (ACS). We compare the new method with a validated logistic regression equation (LRE). METHODS: Eight clinical variables (attributes) were chosen by classification and regression tree analysis of a prospectively collected reference database of 14,796 emergency department (ED) patients evaluated for possible ACS. For attribute matching, a computer program identifies patients within the database who have the exact profile defined by clinician input of the eight attributes. The novel method was compared with the LRE for ability to produce PTP estimation <2% in a validation set of 8,120 patients evaluated for possible ACS and did not have ST segment elevation on ECG. 1,061 patients were excluded prior to validation analysis because of ST-segment elevation (713), missing data (77) or being lost to follow-up (271). RESULTS: In the validation set, attribute matching produced 267 unique PTP estimates [median PTP value 6%, 1st-3rd quartile 1-10%] compared with the LRE, which produced 96 unique PTP estimates [median 24%, 1st-3rd quartile 10-30%]. The areas under the receiver operating characteristic curves were 0.74 (95% CI 0.65 to 0.82) for the attribute matching curve and 0.68 (95% CI 0.62 to 0.77) for LRE. The attribute matching system categorized 1,670 (24%, 95% CI = 23-25%) patients as having a PTP < 2.0%; 28 developed ACS (1.7% 95% CI = 1.1-2.4%). The LRE categorized 244 (4%, 95% CI = 3-4%) with PTP < 2.0%; four developed ACS (1.6%, 95% CI = 0.4-4.1%). CONCLUSION: Attribute matching estimated a very low PTP for ACS in a significantly larger proportion of ED patients compared with a validated LRE.

Acute Disease↗
PubMed2005

Seat position and the risk of serious thoracoabdominal injury in lateral motor vehicle crashes.

CONTEXT: Previous studies have suggested that motor vehicle occupants seated on the near-side of a lateral impact have a higher proportion of thoracoabdominal injuries. However, due to limitations in previous studies, the true association between seat position, side of lateral impact, and thoracoabdominal injury is unclear. OBJECTIVE: To assess the relationship between seat position (i.e., near-side, middle-seat, and far-side, regardless of row), side of lateral motor vehicle crash (MVC), and serious thoracoabdominal injury after adjusting for important crash factors. DESIGN: National population-based cohort of adult subjects involved in MVCs and included in the National Automotive Sampling System Crashworthiness Data System database (NASS CDS) from 1995 to 2003. PATIENTS: Occupants aged > or =16 years involved in MVCs where the highest external deformation of the vehicle was located on the right or left side (i.e., lateral). MAIN OUTCOME MEASURE: Serious thoracic or abdominal injury, defined as an Abbreviated Injury Scale (AIS) > or =3 in the thoracic or abdominal body region. RESULTS: Fifteen thousand, one hundred and sixty persons involved in primary lateral MVCs were represented in the NASS CDS database during the 9-year period. There were 1867 (2%) persons with serious thoracic injuries and 507 persons (0.5%) with serious abdominal injuries. In multivariable logistic regression models that adjusted for important crash factors and the NASS CDS sampling design, seat position was a strong effect modifier of the association between side of lateral impact and serious thoracic (p<0.0001) and abdominal (p=0.0009) injury, with the risk of serious thoracic and abdominal injury highest for occupants seated on the near-side of the crash. The mean probability of injury was higher for near-side and middle-seat occupants compared to far-side occupants, and the probability of thoracic injury was approximately four times higher than that of abdominal injury for all seat positions. CONCLUSIONS: There is a strong, synergistic relationship between seat position and side of lateral MVC in assessing risk of serious thoracic and abdominal injury among adult occupants. The probability of serious thoracoabdominal injury increases with increasing proximity of seat position to side of the crash and the risk of thoracic injury is higher than abdominal injury for all seat positions.

Abdominal Injuries↗
PubMed2005

Steering wheel deformity and serious thoracic or abdominal injury among drivers and passengers involved in motor vehicle crashes.

STUDY OBJECTIVE: We assess the relationship between steering wheel deformity and serious thoracic or abdominal injury among drivers and front seat passengers involved in motor vehicle crashes, while adjusting for important crash factors. METHODS: This was a national population-based cohort of adults involved in motor vehicle crashes from 1995 to 2002 and included in the National Automotive Sampling System Crashworthiness Data System database. Participants were front seat occupants aged 16 years or older involved in motor vehicle crashes with collision. Outcome measure was serious thoracic or abdominal injury, defined as an Abbreviated Injury Scale score greater than or equal to 3 in these body regions. RESULTS: There were 42,860 persons involved in motor vehicle crashes and seated in the driver or front passenger seat whose data were available for analysis. Five hundred fifty-four (1.3%) persons had serious thoracic injuries, and 169 (0.4%) persons had serious abdominal injuries. In multivariable logistic regression models that adjusted for important crash factors and the National Automotive Sampling System Crashworthiness Data System sampling design, increasing steering wheel deformity was associated with serious thoracic injury in drivers (odds ratio [OR] for each 5-cm increase in steering wheel deformity 1.28, 95% confidence interval [CI] 1.04 to 1.59) and front seat passengers (OR 1.77, 95% CI 1.26 to 2.49). Increasing steering wheel deformity was associated with serious abdominal injury in front seat passengers (OR 1.45, 95% CI 1.11 to 1.89) but not in drivers (OR 0.95, 95% CI 0.79 to 1.15). CONCLUSION: Steering wheel deformity is an independent predictor of serious thoracic injury in drivers and front seat passengers and is associated with serious abdominal injury among front seat passengers. For these occupants, the risk of these injuries increases incrementally with increasing steering wheel deformity.

Abbreviated Injury Scale↗
PubMed2005

Mortality benefit of transfer to level I versus level II trauma centers for head-injured patients.

OBJECTIVE: To determine whether head-injured patients transferred to level I trauma centers have reduced mortality relative to transfers to level II trauma centers. DATA SOURCE/STUDY SETTING: Retrospective cohort study of 542 patients with head injury who initially presented to 1 of 31 rural trauma centers in Oregon and Washington, and were transferred from the emergency department to 1 of 15 level I or level II trauma centers, between 1991 and 1994. STUDY DESIGN: A bivariate probit, instrumental variables model was used to estimate the effect of transfer to level I versus level II trauma centers on 30-day postdischarge mortality. Independent variables included age, gender, Injury Severity Scale (ISS), other indicators of injury severity, and a dichotomous variable indicating transfer to a level I trauma center. The differential distance between the nearest level I and level II trauma centers was used as an instrument. PRINCIPAL FINDINGS: Patients transferred to level I trauma centers differ in unmeasured ways from patients transferred to level II trauma centers, biasing estimates based on standard statistical methods. Transfer to a level I trauma center reduced absolute mortality risk by 10.1% (95% confidence interval 0.3%, 22.2%) compared with transfer to level II trauma centers. CONCLUSIONS: Patients with severe head injuries transferred from rural trauma centers to level I centers are likely to have improved survival relative to transfer to level II centers.

Catchment Area, Health↗
PubMed2005

Institutional variability in a minimal risk, population-based study: recognizing policy barriers to health services research.

OBJECTIVE: To describe (1) the institutional variability in study approval and willingness to obtain federal assurance documents for a federally supported, minimal risk health services research project conducted during the implementation of the Privacy Rule and federalwide assurances, and (2) the potential impact of such policy on selection of research subjects and generalizability of study results. DATA SOURCES: Primary data collection from 2001 to 2004. STUDY DESIGN: We provide a descriptive analysis of a prospective, observational, out-of-hospital study. STUDY SETTING: Twenty-seven pediatric receiving hospitals were approached for participation in a study validating a decision rule to identify seriously injured children involved in motor vehicle crashes in Los Angeles County. Two federal research policies, the Privacy Rule and the requirement for federalwide assurances, were implemented during the project. DATA COLLECTION: All 27 hospitals were sent an identical research protocol requesting approval to review charts of children transported to their facility. The research protocol included strict confidentiality protections, was noninterventional, did not alter the standard of care at the scene or at the hospital, and met requirements for waivers of both informed consent and the Health Insurance Portability and Accountability Act. Because the project was federally supported, all participating hospitals were required to have a federalwide assurance. The hospitals receiving the research protocol were the unit of analysis and outcomes included: approval of the research protocol, total number of days to study approval, and successfully obtaining a federalwide assurance. PRINCIPLE FINDINGS: Overall, 6 of 27 (22 percent) hospitals refused to participate in the study, all of which were community hospitals. The median time from submitting an application to study approval was 118 days (interquartile range 34-254, range 12-960 days) and time to study approval differed when hospitals were categorized by type and the presence of an institutional review board (p=.053). No institutional review resulted in a change in the basic study protocol, although one hospital required paramedic consent. Following intensive efforts to secure federalwide assurances, 12 of 27 hospitals (44 percent) possessed the necessary assurance to conduct the study. If all patients transported to hospitals that failed to obtain such an assurance were omitted, the sample size would have been reduced by 62 percent and would have excluded all children transported to community hospitals. CONCLUSIONS: There is substantial institutional variability in approval of a minimal risk observational study and in willingness to obtain a federalwide assurance, particularly among community hospitals. Federal research policy involving patient privacy and institutional assurances may be contributing to this variability, which can adversely affect selection of research subjects, disrupt population-based study design, and threaten the generalizability of study results.

Academic Medical Centers↗
PubMed2005

The incidence and burden of ladder, structure, and scaffolding falls.

OBJECTIVES: The national morbidity and mortality associated with falls from a height is incompletely described. The authors estimated the rates of injury, hospitalization, and mortality due to these falls for subgroups of the U.S. population. METHODS: Administrative databases (1995-2000) provided national samples of patients treated for injuries following a fall from a height (ICD-9-CM E-codes E881.0, E881.1, or E882). Inpatient data are from the Nationwide Inpatient Sample, and emergency department data are from the National Hospital Ambulatory Medical Care Survey. RESULTS: A total of 347,484 (95% confidence interval = 308,417 to 386,551) emergency department presentations occur annually for injuries following a fall. Hospitalized patients older than 75 years of age had a 3.3% case fatality, and 42% were discharged to a skilled nursing facility. For patients older than 55 years of age, 86% of falls were not work related. CONCLUSIONS: Ladder and structure falls by elders are a substantial emergency department problem warranting thorough clinical evaluation and injury prevention efforts.

Accidental Falls↗
PubMed2005

Prospective validation of an out-of-hospital decision rule to identify seriously injured children involved in motor vehicle crashes.

OBJECTIVES: To prospectively validate a previously published out-of-hospital clinical decision rule to identify seriously injured children involved in motor vehicle crashes (MVCs). METHODS: The authors selected 20 Los Angeles County Fire Department fire stations, based on pediatric MVC call volume and geographic diversity, and 21 associated hospitals for participation in the study. Immediately following an MVC call involving a pediatric patient aged 0-14 years, each engine/paramedic squad completed a data form (15 variables, including vital signs, Glasgow Coma Scale score, and vehicular and crash characteristics). This study was conducted over a 24-month period. Outcomes included: 1) "serious injury" as defined by an Injury Severity Score (ISS) > or = 16 (primary outcome), and 2) need for specialized trauma care (emergent intubation, major nonorthopedic operative intervention or death in the first 24 hours, or pediatric intensive care unit stay longer than 48 hours), as assessed by retrospective chart review. Accuracy measures and binominal confidence intervals (CIs) were calculated for the decision rule validation. RESULTS: One hundred seventy-five children were prospectively enrolled in the study; 36 children were excluded due to lack of hospital participation or missing hospital charts. There were four children with ISS > or = 16 (3%) and six children requiring specialized trauma care (4%). The sensitivities and specificities of the rule were: 100% (95% CI = 40% to 100%) and 73% (95% CI = 65% to 81%) for serious injury, and 83% (95% CI = 36% to 100%) and 74% (95% CI = 65% to 81%) for specialized trauma care, respectively. CONCLUSIONS: Although definitive conclusions are limited by the sample size, the decision rule identified all seriously injured children involved in MVCs and had moderate specificity. The decision rule was less sensitive for identifying children requiring specialized trauma care. Larger validation studies are needed to adequately assess the utility of this rule before implementation.

Accidents, Traffic↗
PubMed2005

Effects of child age and body size on serious injury from passenger air-bag presence in motor vehicle crashes.

BACKGROUND: Current recommendations regarding children traveling in passenger vehicles equipped with passenger air bags are based, in part, on evidence that the air-bag-related risk of injury and death is higher for children < or =12 years of age. However, the age or body size required to allow a child to be seated safely in front of a passenger air bag is unknown. OBJECTIVE: To evaluate specific cutoff points for age, height, and weight as effect modifiers of the association between the presence of a passenger air bag and serious injury among children involved in motor vehicle crashes (MVCs), while controlling for important crash factors. DESIGN: A national population-based cohort of children involved in MVCs and included in the National Automotive Sampling System (NASS) Crashworthiness Data System (CDS) database from 1995 to 2002 was studied. NASS CDS clusters, strata, and weights were included in all analyses. SUBJECTS: Children 0 to 18 years of age involved in MVCs and seated in the right front passenger seat. MAIN OUTCOME MEASURE: Serious injury, defined as an Abbreviated Injury Scale score of > or =3 for any body region. RESULTS: A total of 3790 patients (1 month to 18 years of age) were represented in the NASS CDS database during the 8-year period. Sixty children (1.6%) were seriously injured (Abbreviated Injury Scale score of > or =3). Among age, height, and weight, age of 0 to 14 years (versus 15-18 years) was the only consistent effect modifier of the association between air-bag presence (or air-bag deployment) and serious injury, particularly for crashes with a moderate probability of injury. In analyses stratified according to age and adjusted for important crash factors, children 0 to 14 years of age involved in frontal collisions seemed to be at increased risk of serious injury from air-bag presence (odds ratio [OR]: 2.66; 95% confidence interval [CI]: 0.23-30.9) and deployment (OR: 6.13; 95% CI: 0.30-126), although these values did not reach statistical significance. Among children 15 to 18 years of age involved in frontal collisions, there was a protective effect on injury from both air-bag presence (OR: 0.19; 95% CI: 0.05-0.75) and deployment (OR: 0.31; 95% CI: 0.09-0.99). These findings persisted in analyses involving all collision types. We did not identify similar cutoff points for height or weight. CONCLUSIONS: Children up to 14 years of age may be at risk for serious preventable injury when seated in front of a passenger air bag, and children 15 to 18 years of age seem to experience protective effects of air-bag presence and deployment. Age may be a better marker than height or weight for risk assessment regarding children and air bags.

Accidents, Traffic↗
PubMed2004

Advanced statistics: the propensity score--a method for estimating treatment effect in observational research.

Observational studies assessing the effect of a particular treatment or exposure may be subject to bias, which can be difficult to eliminate using standard analytic techniques. Multivariable models are commonly used in observational research to assess the relationship between a certain exposure or treatment and an outcome, while adjusting for important variables necessary to ensure comparability between the groups. Large differences in the observed covariates between two study groups may exist in observational studies in which the investigator has no control over who was allocated to each treatment group, and these differences may lead to biased estimates of treatment effect. When there are large differences in important prognostic characteristics between the treatment groups, adjusting for these differences with conventional multivariable techniques may not adequately balance the groups, and the remaining bias may limit valid causal inference. Use of a propensity score, described as a conditional probability that a subject will be "treated" based on an observed group of covariates, may better adjust covariates between the groups and reduce bias. The purpose of this article is to describe the use of propensity scores to adjust for bias when estimating treatment effects in observational research and to compare use of this technique with conventional multivariable regression. The authors present three methods for integrating propensity scores into observational analyses using a database collected on head-injured trauma patients. The article details the methods for creating a propensity score, analyzing data with the score, and explores differences between propensity score methods and conventional multivariable methods, including potential benefits and limitations. Graphical representations of the analyses are provided as well.

Adolescent↗
PubMed2003

Use of pulse oximetry to predict in-hospital complications in normotensive patients with pulmonary embolism.

PURPOSE: A simple method is needed to risk stratify normotensive patients with pulmonary embolism. We studied whether bedside clinical data can predict in-hospital complications from pulmonary embolism. METHODS: We performed a multicenter derivation phase, followed by validation in a single center. All patients were normotensive; the diagnosis of pulmonary embolism was established by objective imaging. Classification and regression analysis was performed to derive a decision tree from 27 parameters recorded from 207 patients. The validation study was conducted on a separate group of 96 patients to determine the derived criterion's diagnostic accuracy for in-hospital complications (cardiogenic shock, respiratory failure, or death). RESULTS: Mortality in the derivation phase was 4% (n = 8) at 24 hours and 10% (n = 21) at 30 days. A room-air pulse oximetry reading <95% was the most important predictor of death; mortality was 2% (95% confidence interval [CI]: 0% to 6%) in patients with pulse oximetry >or=95% versus 20% (95% CI: 12% to 29%) with pulse oximetry <95%. In the validation phase, the room-air pulse oximetry was <95% at the time of diagnosis in 9 of 10 patients who developed an in-hospital complication (sensitivity, 90%) and >or=95% in 55 of 86 patients without complications (specificity, 64%). CONCLUSION: Mortality from pulmonary embolism in normotensive patients is high. A room-air pulse oximetry reading >or=95% at diagnosis is associated with a significantly lower probability of in-hospital complications from pulmonary embolism.

Blood Pressure↗
PubMed2003

Emergency medicine leadership in industry-sponsored clinical trials.

OBJECTIVE: To identify and characterize emergency medicine (EM) researchers who, since 1990, have served on a steering committee (SC) or as overall principal investigator (PI) of an industry-sponsored, multicenter clinical trial involving a pharmaceutical or device. METHODS: North American EM research directors (RDs) and other prominent EM investigators (for those hospitals without a RD) were identified from eight sources, including the Society for Academic Emergency Medicine RD Interest Group and the Multicenter Airway Research Collaboration (MARC) database. The identified investigators were sent a screening survey requesting information regarding industry-sponsored clinical research at their site. The individual EM investigators identified by this screening survey were then interviewed by telephone (validation survey) to further explore their leadership experience in industry-sponsored clinical trials. RESULTS: Of 153 identified RDs and prominent EM researchers, 138 responded to the screening survey (90% response rate). Eighty-five EM investigators reportedly had served on a SC or as overall PI for an industry-sponsored clinical trial. Of these 85 North American EM investigators, 77 were available for a structured telephone interview (91% response rate). Although 41 (53%) of the investigators confirmed their leadership role, 36 (47%) had not served in either role. Among the 41 confirmed investigators, 19 (25%) had served as a SC member, 10 (13%) had served as overall PI, and 12 (16%) had experience in both roles. Individual responses provided suggestions for pursuing such leadership positions. CONCLUSIONS: These data suggest the opportunity to expand EM leadership in industry-sponsored clinical trials and demonstrate the need for validation of reports obtained by a departmental research contact. The suggestions from EM researchers who have attained these leadership roles may provide strategies for investigators interested in pursuing these positions.

Adult↗
PubMed2002

Use of out-of-hospital variables to predict severity of injury in pediatric patients involved in motor vehicle crashes.

STUDY OBJECTIVE: We sought to create a clinical decision rule, on the basis of variables available to out-of-hospital personnel, that could be used to accurately predict severe injury in pediatric patients involved in motor vehicle crashes as occupants. METHODS: We analyzed the National Automotive Sampling System database, a national probability sample, using pediatric patients up to 15 years old (occupants only) involved in motor vehicle crashes from January 1993 to December 1999. The National Automotive Sampling System database includes patients from regions throughout the country, weighted to represent a nationwide sample. Twelve out-of-hospital variables were used in classification and regression tree analysis to create a decision rule separating children with severe injuries (Injury Severity Score [ISS] > or =16) from those with minor injuries (ISS < 16). Misclassification costs and complexity parameters were selected to yield a decision tree with appropriate sensitivity and specificity for the identification of severely injured patients, while also being simple and practical for out-of-hospital use. Probability weights were used throughout the analysis to account for the sampling design and sampling weights. RESULTS: Using a sample size of 8,392 children, we constructed a decision rule using 3 out-of-hospital variables (Glasgow Coma Scale score, passenger space intrusion > or =6 in [> or =15 cm], and restraint use) to predict those patients with an ISS of 16 or more. Internal cross-validation was used to determine the sensitivity and specificity, yielding values of 92% and 73%, respectively, for the prediction of patients with an ISS of 16 or more. CONCLUSION: Out-of-hospital variables available to field personnel could be used to effectively triage pediatric motor vehicle crash patients using the decision rule developed here. Prospective trials would be needed to test this decision rule in actual use.

Accidents, Traffic↗