data from Ontario, Canada. Patients who were discharged home from an ED in Ontario with a primary diagnosis of chest pain from April 1, 2004 to March 31, 2010 were included. High-risk patients were defined as the presence of diabetes or pre-existing cardiovascular disease, while low-risk patients were defined as the absence of these conditions. ED volume was categorized as low, medium, or high, based on tertiles of annual chest pain patient volume. The primary outcome of this study was all-cause mortality one year after the index ED visit. Mantel-Haenszel Chi-Square was used to compare crude outcome rates. Results: There were 56,767 high-risk patients. The average age was 66 years and 53% were male. All-cause mortality rates were 6.8%, 6.3%, and 6.0% (p = 0.028), and rates of hospitalization for acute coronary syndrome were 5.8%, 4.6%, and 4.0% (p < 0.001) among low, medium, and high volume EDs respectively. There were 216,527 low-risk patients. The average age was 64 years and 42% were male. All-cause mortality rates were 2.0%, 1.9%, and 1.6% (p < 0.001), and rates of hospitalization for acute coronary syndrome were 1.5%, 1.4%, and 1.0% (p < 0.001) among low, medium, and high volume EDs respectively. Conclusion: Higher volume EDs were associated with decreased rates of all-cause mortality and admission for acute coronary syndrome among chest pain patients who were discharged home. Future research should study the reasons for this finding and attempt to improve outcomes in lower volume EDs.

Introduction: Minimizing haemorrhage using direct pressure is intuitive and widely taught. In contrast, this study examines the use of indirect-pressure, such as external aortic compression which has been identified as an immediately applicable maneuver to address the leading cause of battlefield mortality: junctional hemorrhage. However, it is currently unclear how to optimize this technique. Methods: This prospective, block-randomized, cross-over simulation study of compression optimization was performed on a model of central vessel compression that recorded weight (lbs) and pressure (mmHg). Forty participants simulated external aortic compression on the ground as well as a stretcher with and without a backboard. Participants were blinded to compression weight and pressure, as well as the purpose of the study, to minimize preparation bias. Manoeuvres were performed in alternating order to control for skill acquisition and fatigue. Scripted instructions were followed to compress with 1 then 2 hands, and to apply “sustainable effort” and then “maximal effort”. Results: The greater the compressor's bodyweight the greater their mean compression (Pearson’s correlation 0.9342). Using one-hand, a mean of 28% participant bodyweight (95%CI, 26% - 30%) could be transmitted at sustainable effort, waist-height, and on a stretcher. A second compressing hand increased rescuer bodyweight transmission by 10-22% regardless of other factors (i.e. presence/absence or a backboard; rescuer position) (p<0.001). Adding a backboard increased transmission of rescuer bodyweight 7%-15% (p<0.001). Lowering the patient from waist-height backboard to the floor increased transmission of rescuer bodyweight 4%-9% (p < 0.001). Kneeling on the model was the most efficient method and transmitted 11% more weight compared to two-handed maximal compression (p <0.001). Conclusion: Efficacy is maximized with larger-mass, two hands, and compression on hard surfaces/backboards. Knee compression is most effective and least fatiguing, thus assisting rescuers of lower weight and lesser strength, where no hard surfaces exist (i.e. no available backboard or trauma on soft ground), or when lengthy compression is required (i.e. remote locations). This study demonstrates the feasibility of indirect pressure as a potential temporizing measure for life-threatening haemorrhage not amenable to direct compression.