Academic Appointments

Administrative Appointments

  • Associate Professor Surgery, Division of Emergency Medicine, Department of Surgery Stanford Medical School (2010 - Present)
  • Associate Director Pediatric Emergency Medicine, Division of Emergency Medicine, Department of Surgery, Stanford University Hospital (2002 - Present)
  • Associate Professor of Pediatrics, Lucille Packard Children's Hospital (2010 - Present)
  • Course director - International Health, Stanford University (2000 - 2003)
  • Course director - Sophomore seminar, Stanford University (2001 - 2003)

Honors & Awards

  • Career Development Award (K23), National Institute of Child Health and Human Development (2007-2012)
  • Emergency Medicine Foundation (EMF) Career Development Award, Emergency Medicine Foundation (2006-2007)
  • Clinical Teaching Award, Stanford Kaiser Emergency Medicine Residency Program (2005)
  • Pediatric Health Disparity Research and Advocacy Fellowship, Lucille Packard Children's Hospital (2004-2006)
  • Kellogg National Leadership Fellow, Kellogg Foundation (1997-2000)
  • Harry S. Truman Scholar, Harry S. Truman Foundation (1983-1990)
  • Physician Scholar in International health, Johnson and Johnson (2003, 2011, 2013)
  • Teaching Fellowship Scholarship, Robert J Doherty Foundation (1999-2000)
  • Foreign Language Area Studies Scholarship (FLAS), US Department of Education (1990)
  • RRI Emergency Medicine Fellow - international emergency medicine projects, George Washington University (1995)

Professional Education

  • Fellowship, Oakland Children's Hospital, Pediatric Emergency Medicine (1999)
  • Residency, Stanford Emergency Medicine, Emergency Medicine (1997)
  • MD, Stanford Medical School, Medicine (1993)
  • BA, Harvard University, East Asian Studies (1986)

Community and International Work

  • Children's Safety Center, Stanford/LPCH Emergency Department


    Stanford Health Advocates and Research Program (SHARP)

    Ongoing Project


    Opportunities for Student Involvement


  • Child Family Health International

    Ongoing Project


    Opportunities for Student Involvement


  • Disparities in pediatric trauma care, Stanford Hospital


    Evaluation of the disparities regarding pediatric access to and care at trauma centers

    Partnering Organization(s)

    Emergency department; Pediatrics department

    Populations Served




    Ongoing Project


    Opportunities for Student Involvement


  • Family Resource Desk, Stanford Hospital


    To address the basic social needs of patients and their families in the Emergency Department

    Partnering Organization(s)

    Stanford Emergency Department

    Populations Served



    Bay Area

    Ongoing Project


    Opportunities for Student Involvement


Research & Scholarship

Current Research and Scholarly Interests

Dr. Nancy Ewen Wang has strong interest and dedication to, community health, education, and researching disparities in pediatric emergency care, both internationally and in California. Currently Dr. Wang serves as Associate Director of Pediatric Emergency Medicine and Associate Professor of Surgery and Pediatrics at the Stanford University School of Medicine. Among her teaching endeavors, she has served as course director of the population health curriculum at the Stanford School of Medicine, which emphasizes population health and community collaboration. In conjunction with Child Health International, she has initiated an advanced pediatric life support curriculum in Puerto Escondido, Oaxaca. Outside the scope of the medical school, Dr. Wang is active in undergraduate education. She has served as course director of the Human Biology undergraduate course “International Public Health”, as well a the sophomore seminar which focuses on teaching students about the social and economic aspects of international health. She is presently working with the undergraduate student group, Stanford Health Advocates and Research Program (SHARP) . In addition, Dr. Wang has worked extensively with medical and non-medical students as academic advisor. Dr. Wang is also founding member of the nonprofit organization, International Medical Options, that serves to increase educational opportunities and resources for health professionals working internationally. She presently serves on the board of the Sustainable Sciences Institute. Internationally, Dr. Wang has worked extensively in Latin America in countries such as Mexico, Guatemala and Bolivia as a practicing physician as well as medical educator for Latin American medical students, residents and physicians. Most recently, she has also worked at the ASRI clinic in rural Borneo as a volunteer physician. Dr. Wang has a strong interest in decreasing health outcome disparities in the pediatric emergency medicine population. Her current research includes investigating disparities in trauma access in the California pediatric population.


2014-15 Courses


All Publications

  • 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


    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

  • 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
  • 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


    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 Web of Science ID 000319316600024

    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


    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 Web of Science ID 000315634500001

    View details for PubMedID 23452003

  • 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


    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/

    View details for Web of Science ID 000308841700010

    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


    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

  • 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


    "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 Web of Science ID 000304195100026

    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


    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 Web of Science ID 000302858200014

    View details for PubMedID 22506952

  • 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


    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 Web of Science ID 000298003700005

    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


    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 Web of Science ID 000288848800028

    View details for PubMedID 21324843

  • National Survey of Preventive Health Services in US Emergency Departments Delgado, M. K., Acosta, C. D., Ginde, A. A., Wang, N. E., Strehlow, M. C., Khandwala, Y. S., Camargo, C. A. MOSBY-ELSEVIER. 2011: 104-108


    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

  • 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


    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 Web of Science ID 000284848100018

    View details for PubMedID 21122022

  • 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


    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


    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


    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

  • 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


    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


    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 Web of Science ID 000242967300005

    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


    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 Web of Science ID 000186426300019

    View details for PubMedID 14597505

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