ObjectiveThe mass casualty triage system known as START (Simple Triage and Rapid Treatment) has been widely utilized in the United States since the 1980s. However, no outcomes assessment has been conducted after a disaster to determine whether assigned triage levels match patients' actual clinical status. Researchers hypothesized that START achieves at least 90% sensitivity and specificity for each triage level, and ensures that the most critical patients are transported first to area hospitals. MethodsThe performance of START was evaluated at a train crash disaster in 2003. Patient field triage categories and scene times were obtained from county reports. Patient medical records were then reviewed at all receiving hospitals. Victim arrival times were obtained and correct triage categories determined a priori using a combination of the modified Baxt criteria and hospital admission. Field and outcomes-based triage categories were compared, defining the appropriateness of each triage assignment. ResultsInvestigators reviewed 148 records at 14 receiving hospitals. Field triage designations comprised 22 red (immediate), 68 yellow (delayed), and 58 green (minor) patients. Outcomes-based designations found 2 red, 26 yellow, and 120 green patients. Seventynine patients were over-triaged, three were under-triaged, and 66 patients' outcomes matched their triage level. No triage level met both the 90% sensitivity and 90% specificity requirement set forth in the hypothesis, although red was 100% sensitive (95% CI 15.8-100) and green was 89.3% specific (95% CI 71.8-97.7). The Obuchowski statistic was 0.81, meaning that victims from a higher acuity outcome group had an 81% chance of assignment to a higher acuity triage category. Red patients arrived at hospitals 0.92 hours (95% CI 0.71-1.1) faster than other patients. ConclusionsThis analysis demonstrates poor agreement between triage levels assigned by START at a train crash and a priori outcomes criteria for each level. START ensured acceptable levels of under-triage (100% red sensitivity and 89% green specificity) but incorporated a significant amount of over-triage. START proved useful in prioritizing transport of the most critical patients to area hospitals first.

The antidote expert recommendations provide a tool to be used in creating practices for appropriate and adequate antidote stocking in hospitals that provide emergency care.

Escherichia coli is a routinely used microbiological indicator of water quality. To determine whether holding time and storage conditions had an effect on E. coli densities in surface water, studies were conducted in three phases, encompassing 24 sites across the United States and four commonly used monitoring methods. During all three phases of the study, E. coli samples were analyzed at time 0 and at 8, 24, 30, and 48 h after sample collection. During phase 1, when 4°C samples were evaluated by Colilert or by placing a membrane onto mFC medium followed by transfer to nutrient agar containing 4-methylumbelliferyl-␤-D-glucuronide (mFC/NA-MUG), three of four sites showed no significant differences throughout the 48-h study. During phase 2, five of seven sites showed no significant difference between time 0 and 24 h by membrane filtration (mFC/NA-MUG). When evaluated by the Colilert method, five of seven sites showed no significant difference in E. coli density between time 0 and 48 h. During phase 3, 8 of 13 sites showed no significant differences in E. coli densities between time 0 and the 48-h holding time, regardless of method. Based on the results of these studies, it appears that if samples are held below 10°C and are not allowed to freeze, most surface water E. coli samples analyzed by commonly used methods beyond 8 h after sample collection can generate E. coli data comparable to those generated within 8 h of sample collection. Notwithstanding this conclusion, E. coli samples collected from surface waters should always be analyzed as soon as possible.Escherichia coli testing is an important tool used by public health experts for the prevention of waterborne disease. The detection of E. coli in a water sample from an environmental source provides direct evidence of fecal contamination. Regulatory agencies are increasingly requiring more emphasis on E. coli testing as part of programs aimed at curtailing waterborne disease. Holding time and temperature can have a significant impact on the density of microbiological indicators at the time of sample analysis (4, 5, 7). Recommendations for E. coli holding times range from 8 h (2, 3, 9) to 24 h (8), and holding temperatures below 10°C are generally considered acceptable (2,3,8,9). It is also recommended that when transport conditions result in delays longer than 6 h, the use of field laboratory facilities located at the site of collection or delayed incubation procedures be considered (2). The Surface Water Treatment Rule requirements of the U.S. Environmental Protection Agency (USEPA) for total coliform and fecal coliform monitoring of surface water used as drinking water sources (3) specify that the time from sample collection to initiation of analysis is not to exceed 8 h; the regulations also encourage (but do not require) drinking water system personnel to hold samples at below 10°C during transit.Unfortunately, data from evaluations of microbiological indicator density that support current holding time recommendations are limited, particularly for E. coli....

No abstract

BACKGROUND AND PURPOSE Organized systems of care have the potential to improve acute stroke care delivery. The current report describes the experience of implementing a countywide system of spoke-and-hub Stroke Neurology Receiving Centers (SNRC) that incorporated several comprehensive stroke center recommendations. METHODS Observational study of patients with suspected stroke <5 hours duration transported by Emergency Medical System personnel to an SNRC during the first year of this system. RESULTS A total of 1,360 patients with suspected stroke were evaluated at 9 hub SNRCs, of which 553 (40.7%) had a discharge diagnosis of ischemic stroke. Of these 553, intravenous (IV) tPA was given to 110 patients (19.9% of ischemic strokes). Care at the 6 neurointerventional-ready SNRC was a major focus, where 25.1% (99/395) of the patients with ischemic stroke received acute IV or intraarterial reperfusion therapy, and where provision of such therapies was less common with milder stroke, higher age, and Hispanic origin. The door-to-needle time for IV tPA met the <60 minute target in only 25% of patients and was 37% longer (p=0.0001) when SNRCs were neurointerventional-ready. CONCLUSIONS A stroke system that incorporates features of comprehensive stroke centers can be effectively implemented, and with substantial rates of acute reperfusion therapy administration. Experiences potentially useful to broader implementation of comprehensive stroke centers are considered.