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Educational programs for clinicians managing patients with burn injuries represent a critical aspect of burn disaster preparedness. Managing a disaster, which includes a surge of burn-injured patients, remains one of the more challenging aspects of disaster medicine. During a 6-year period that included the development of a burn surge disaster program for one state, a critical gap was recognized as public presentations were conducted across the state. This gap revealed an acute and greater than anticipated need to include burn care education as an integral part of comprehensive burn surge disaster preparedness. Many hospital and prehospital providers expressed concern with managing even a single, burn-injured patient. While multiple programs were considered, Advanced Burn Life Support (ABLS), a national standardized educational program was selected to help address this need. The curriculum includes initial care for the burn-injured patient as well as an overview of the burn centers role in the disaster preparedness community. After 4 years and 56 classes conducted across the state, a survey was developed including a section that measured the perceptions of those who completed the ABLS educational program. The study specifically examines questions including whether clinicians perceived changes in their burn care knowledge, skills and abilities, and burn disaster preparedness following completion of the program? including whether clinicians.

Objectives: Guidelines advise that a prehospital electrocardiogram (ECG) should be obtained in any patients with chest pain, yet up to 20% of patients with ST-elevation myocardial infarction (STEMI) do not present with chest pain. The objective was to determine the association of atypical presentations in the prehospital setting on the likelihood of receiving a prehospital ECG and subsequent time to reperfusion therapy., Methods: This study used a data set that linked prehospital medical information from a statewide EMS data system with a clinical registry of treatment and outcomes data for patients with STEMI. Among 2,639 STEMI patients from 2008 to 2010, the association between non-chest pain presentations, prehospital ECG use, and reperfusion times among patients undergoing primary percutaneous coronary intervention (PCI) were examined. Inverse probability weights were used to account for observed baseline confounders., Results: Overall, 318 of 2,639 patients (12.1%) presented without chest pain. A prehospital ECG was obtained in 2,021 of 2,321 (87.1%) patients with chest pain compared with only 230 of 318 (72.3%) without chest pain (odds ratio [OR] = 2.24, 95% confidence interval [CI] = 1.69 to 2.98). Among patients without chest pain, those who received a prehospital ECG had significantly shorter first medical contact (FMC) to device times (30.9% < 90 minutes vs. 11.4% > 90 minutes, adjusted OR = 2.81, 95% CI = 1.29 to 6.11, p < 0.01)., Conclusions: Over one-quarter of STEMI patients presenting without chest pain did not receive prehospital ECGs and had significantly longer FMC to device times. Future efforts are needed to promote the use of prehospital ECGs to achieve more rapid identification of STEMI patients with atypical presentations in the prehospital setting., (© 2014 by the Society for Academic Emergency Medicine.)

This article will review the use of temporary hospitals to augment the healthcare system as one solution for dealing with a surge of patients related to war, pandemic disease outbreaks, or natural disaster. The experiences highlighted in this article are those of North Carolina (NC) over the past 150 years, with a special focus on the need following the September 11, 2001 (9/11) attacks. It will also discuss the development of a temporary hospital system from concept to deployment, highlight recent developments, emphasize the need to learn from past experiences, and offer potential solutions for assuring program sustainability. Historically, when a particular situation called for a temporary hospital, one was created, but it was usually specific for the event and then dismantled. As with the case with many historical events, the details of the 9/11 attacks will fade into memory, and there is a concern that the impetus which created the current temporary hospital program may fade, as well. By developing a broader and more comprehensive approach to disaster responses through all-hazards preparedness, it is reasonable to learn from these past experiences, improve the understanding of current threats, and develop a long-term strategy to sustain these resources for future disaster medical needs.

On the morning of June 9, 2009, an explosion occurred at a manufacturing plant in Garner, North Carolina. By the end of the day, 68 injured patients had been evaluated at the 3 Level I trauma centers and 3 community hospitals in the Raleigh/Durham metro area (3 people who were buried in the structural collapse died at the scene). Approximately 300 employees were present at the time of the explosion, when natural gas being vented during the repair of a hot water heater ignited. The concussion from the explosion led to structural failure in multiple locations and breached additional natural gas, electrical, and ammonia lines that ran overhead in the 1-story concrete industrial plant. Intent is the major difference between this type of accident and a terrorist using an incendiary device to terrorize a targeted population. But while this disaster lacked intent, the response, rescue, and outcomes were improved as a result of bioterrorism preparedness. This article discusses how bioterrorism hospital preparedness planning, with an all-hazards approach, became the basis for coordinated burn surge disaster preparedness. This real-world disaster challenged a variety of systems, hospitals, and healthcare providers to work efficiently and effectively to manage multiple survivors. Burn-injured patients served as a focus for this work. We describe the response, rescue, and resuscitation provided by first responders and first receivers as well as efforts made to develop burn care capabilities and surge capacity.

Study Objective: Although regionalized care for ST-segment elevation myocardial infarction (STEMI) has improved the use of timely reperfusion therapy, its effect on patient outcomes has been difficult to assess. Our objective is to explore temporal trends in STEMI mortality with the implementation of a statewide STEMI regionalization program (Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments [RACE])., Methods: We compared trends in inpatient mortality among STEMI patients treated at North Carolina (NC) hospitals participating in the RACE program, relative to those not participating, using state inpatient claims data. Using Medicare claims data, we compared trends in 30-day mortality among Medicare beneficiaries in NC with those nationally. Logistic models with random effects were used to evaluate the association of the program with mortality., Results: From 2005 to 2007, inpatient mortality for 6,565 STEMI patients treated at NC hospitals participating in RACE decreased from 11.6% to 10.1% (risk difference -1.5%; 95% confidence interval [CI] -3.0% to 0.04%), whereas inpatient mortality among 5,850 STEMI patients treated at NC nonparticipating hospitals decreased from 10.2% to 8.6% (risk difference -1.6%; 95% CI -3.1% to 0.10%); (adjusted odds ratio 1.28; 95% CI 0.88 to 1.85 for temporal differences between groups). During the same period, 30-day STEMI mortality among Medicare beneficiaries decreased from 22.7% to 21.4% in NC (risk difference -1.28%; 95% CI -3.60% to 1.03%) and from 22.3% to 21.6% nationally (risk difference -0.71%, 95% CI -1.13% to -0.29%; adjusted odds ratio 0.99, 95% CI 0.85 to 1.15 for temporal differences between regions)., Conclusion: The initiation of a statewide STEMI collaborative care model was associated with a reduction in mortality rates according to claims data, yet these changes were similar to those seen nationally. Further study is needed to evaluate regionalized systems of STEMI care and to determine the role of claims data to evaluate population-based STEMI outcomes., (Copyright © 2011 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Background: The ability to rapidly identify patients with ST-segment elevation-myocardial infarction (STEMI) at hospitals without percutaneous coronary intervention (PCI) and transfer them to hospitals with PCI capability is critical to STEMI regionalization efforts. Our objective was to assess the association of prehospital, emergency department (ED), and hospital processes of care implemented as part of a statewide STEMI regionalization program with door-in-door-out times at non-PCI hospitals., Methods and Results: Door-in-door-out times for 436 STEMI patients at 55 non-PCI hospitals were determined before (July 2005 to September 2005) and after (January 2007 to March 2007) a year-long implementation of standardized protocols as part of a statewide regionalization program (Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments, RACE). The association of 8 system care processes (encompassing emergency medical services [EMS], ED, and hospital settings) with door-in-door-out times was determined using multivariable linear regression. Median door-in-door-out times improved significantly with the intervention (before: 97.0 minutes, interquartile range, 56.0 to 160.0 minutes; after: 58.0 minutes, interquartile range, 35.0 to 90.0 minutes; P<0.0001). Hospital, ED, and EMS care processes were each independently associated with shorter door-in-door-out times (-17.7 [95% confidence interval, -27.5 to -7.9]; -10.1 [95% confidence interval, -19.0 to -1.1], and -7.3 [95% confidence interval, -13.0 to -1.5] minutes for each additional hospital, ED, and EMS process, respectively). Combined, adoption of EMS processes was associated with the shortest median treatment times (44 versus 138 minutes for hospitals that adopted all EMS processes versus none)., Conclusions: Prehospital, ED, and hospital processes of care were independently associated with shorter door-in-door-out times for STEMI patients requiring transfer. Adoption of several EMS processes was associated with the largest reduction in treatment times. These findings highlight the need for an integrated, system-based approach to improving STEMI care.

The University of North Carolina at Chapel Hill and the Special Warfare Training Group, Airborne (SWTG)(A) at Fort Bragg, NC began a bilateral partnership in 2009 to enhance medical training, care and innovation in austere environments. As a result of this partnership, instructors from the Joint Special Operations Training Center have been completing month-long rotations in the North Carolina Jaycee Burn Center and University of North Carolina Hospitals. This rotation has been successful and prompted us to assess the interest of Special Operation Forces (SOF) medics is in pursuing careers in healthcare, especially medical school. We surveyed the Special Forces Medical Sergeant (SFMS) listserve on Army Knowledge Online (AKO) to collect these data. This article will review SFMS survey responses and offer information on how to negotiate medical school admissions., (2011.)

Background: Prior studies have demonstrated differences in time to reperfusion for ST-segment-elevation myocardial infarction (STEMI) in women, minorities, and the elderly, relative to their counterparts. Regionalization has been shown to improve overall STEMI treatment times, but its impact on care differences among these important patient subgroups is unknown. The objective of this analysis was to assess the impact of a statewide system of STEMI care (The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments) on treatment times according to patient sex, race, and age., Methods and Results: STEMI treatment times were determined before (July 2005 to September 2005) and after (January 2007 to March 2007) a year-long implementation of coordinated regional treatment protocols. Times in the pre- and postintervention periods were compared by mixed-effects models. A total of 2063 STEMI patients were analyzed: 1140 at percutaneous coronary intervention hospitals and 923 at non-percutaneous coronary intervention hospitals. The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments was associated with significant improvements in treatment times in women and the elderly, including door-to-ECG, door-to-device, door-in-door-out, and door-to-needle times (all P<0.05). Temporal improvements in treatment times at percutaneous coronary intervention hospitals were not significantly different in blacks than in whites. There was a reduction in baseline treatment disparities in door-to-ECG times in women versus men (4.4-minute reduction in difference; 95% CI, -8.1 to -0.4; P=0.03). After Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments, an age-treatment time gap persisted in the elderly, relative to younger patients., Conclusions: A statewide STEMI regionalization program was associated with comparable improvement in treatment times for female, black, and elderly patients compared with middle-aged, white male patients. Nevertheless, there remain opportunities to further narrow treatment differences, particularly among the elderly.

Objectives: Methods to accurately identify elderly patients with a high likelihood of hospital admission or subsequent return to the emergency department (ED) might facilitate the development of interventions to expedite the admission process, improve patient care, and reduce overcrowding. This study sought to identify variables found among elderly ED patients that could predict either hospital admission or return to the ED., Methods: All visits by patients 75 years of age or older during 2007 at an academic ED serving a large community of elderly were reviewed. Clinical and demographic data were used to construct regression models to predict admission or ED return. These models were then validated in a second group of patients 75 and older who presented during two 1-month periods in 2008., Results: Of 4,873 visits, 3,188 resulted in admission (65.4%). Regression modeling identified five variables statistically related to the probability of admission: age, triage score, heart rate, diastolic blood pressure, and chief complaint. Upon validation, the c-statistic of the receiver operating characteristic (ROC) curve was 0.73, moderately predictive of admission. We were unable to produce models that predicted ED return for these elderly patients., Conclusions: A derived and validated triage-based model is presented that provides a moderately accurate probability of hospital admission of elderly patients. If validated experimentally, this model might expedite the admission process for elderly ED patients. Our models failed, as have others, to accurately predict ED return among elderly patients, underscoring the challenge of identifying those individuals at risk for early ED returns., (Copyright (c) 2010 by the Society for Academic Emergency Medicine.)

Background: The EMS Agenda for the Future describes emergency medical services (EMS) as the intersection between public health, public safety, and health care. The most comprehensive method to describe, evaluate, and optimize these systems of care is using a state EMS data system. A centralized EMS data system can be a valuable tool to identify, evaluate, target, and improve EMS service delivery and patient care. Significant barriers, however, still exist to the standardization of EMS data systems and infrastructure nationally. Indeed, there is no comprehensive measurement of EMS service delivery or patient volume at the national level., Objective: In this article, we describe the successful development of a fully integrated, statewide EMS data system for quality improvement of EMS service delivery and patient care in North Carolina. The article also provides a platform for linking EMS with emergency physicians, other health care providers, and public health agencies responsible for planning, disease surveillance, and disaster preparedness., Results and Conclusion: The North Carolina EMS Data System represents the successful development of a large, fully integrated, comprehensive statewide EMS database and quality improvement effort. The North Carolina EMS Data System applications include the Prehospital Medical Information System (PreMIS), the Credentialing Information System (CIS), the State Medical Asset Resource Tracking Tool (SMARTT), and the EMS Performance Improvement Toolkits. The system provides a quality and performance improvement program consistent with the idealized EMS design described in the EMS Agenda for the Future. The program has already achieved significant improvements in the quality of EMS service delivery, patient care, and integrated systems of care. Consistent with the goals of the 2007 Institute of Medicine's recommendations for EMS, the linkage of the North Carolina EMS Data System with other health care registries has created an environment that can evaluate larger systems of care and ultimate patient outcomes.