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Biomedical subjects

D W Spaite

Publications and source records attributed to D W Spaite.

At least 37 records · Page 2Linked to original sources
PubMed1996

Analysis of federally imposed penalties for violations of the Consolidated Omnibus Reconciliation Act.

STUDY OBJECTIVE: To identify the incidence of federally imposed penalties for violations of the Consolidated Omnibus Reconciliation Act (COBRA). METHODS: Under the Freedom of Information Act, we retrieved a copy of any document related to fines imposed on, settlements made by, or litigation against physicians or hospitals as a result of COBRA violations from the Office of the Inspector General. Under a separate inquiry, also under the Freedom of Information Act, we requested and received from the central office of the Health Care Financing Administration the National Composite Log showing the status of all complaint investigations pursuant to COBRA since the inception of the law. RESULTS: One thousand seven hundred fifty-seven complaint investigations were authorized. Of the 1,729 investigations completed, 412 (24%) were found to be out of compliance with federal regulations. Of these, 27 cases resulted in fines imposed on hospitals. These fines ranged from $1,500 to $150,000 with a mean of $33,917, a median of $25,000, and standard deviation of $35,899. The six fines that were imposed against physicians ranged in value from $2,500 to $20,000 with a mean of $8,500, a median of $7,500, and an SD of $8,612. Seven hospitals but no physicians were terminated from the Medicare program for COBRA violations. CONCLUSION: The incidence of federally imposed penalties for COBRA violations is low given the multitude of patient transfers that have occurred since the enactment of COBRA. The growing concern regarding this issue may be related to current litigation efforts to broaden the scope and applications of these laws.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1995

Emergency medical service systems research: problems of the past, challenges of the future.

Out-of-hospital emergency care was designed around the concept of a system of interrelated events that combine to offer a patient the best care possible outside the hospital. However, in contrast to the actual operations of emergency medical service (EMS) systems, research has not typically used systems-based models as the method for evaluation. In this discussion we outline the weaknesses of component-based research models in EMS evaluation and attempt to provide a "systems-analysis" framework that can be used for future research. Incorporation of this multidiscipline approach into EMS research is essential if there is to be any hope of finding answers to many of the important questions that remain in the arena of out-of-hospital health care.

Emergency Medical Services↗
PubMed1995

Comparison of clinically significant infection rates among prehospital-versus in-hospital-initiated i.v. lines.

STUDY OBJECTIVE: To compare the risk of infection for i.v. lines placed in the prehospital versus in the in-hospital setting in a midsized emergency medical service system. DESIGN: A retrospective analysis was made of all i.v. line site infections among patients admitted to ward beds from a university hospital emergency department in 1992. METHODS: The hospital's infection control team conducted daily ward rounds and a surveillance of all wound and blood cultures. Patients with signs and/or symptoms consistent with Centers for Disease Control and Prevention guidelines for skin and soft tissue infection were reported to the responsible medical team. Infections were documented based on consensus opinion between the infection control team and the physicians responsible for the care of the patient. IV lines placed in the prehospital phase of care were identified by electronic retrieval from the prehospital database. RESULTS: Three thousand one hundred eighty-five patients who had a prehospital or an in-hospital i.v. line placed were admitted from the ED. Eight hundred fifty-nine i.v. lines were prehospital placed (27%), and 2,326 were in-hospital placed (73%). There was one infection in the prehospital group and four in the in-hospital group (infection rate: .0012 for prehospital patients and .0017 for in-hospital patients; P = .591 by Fisher's exact test). CONCLUSION: Both cohorts had exceptionally low infection rates. No clinically or statistically significant increase in the risk of infection among prehospital- or in-hospital-initiated i.v. lines was identified.

Arizona↗
PubMed1995

A prospective investigation of the impact of alcohol consumption on helmet use, injury severity, medical resource utilization, and health care costs in bicycle-related trauma.

STUDY OBJECTIVE: To examine if a relationship exists between bicycle-related injuries, consumption of alcohol, helmet use, and medical resource utilization. DESIGN: A prospective cohort study with data from emergency department, operating room, and inpatient records. SETTING: University-based trauma center in a medium-sized metropolitan area. TYPE OF PARTICIPANTS: Adult victims (age > or = 18 years) of bicycle-related injury presenting to the emergency department. A total of 350 patients made up the study population. RESULTS: Group 1 consisted of 29 patients (8.3%) with detectable blood alcohol levels at the time of the incident. Group 2 (321 patients) had a measured blood alcohol level of 0 or no clinical indication of alcohol consumption. Group 1 mean Injury Severity Score was 10.3, with six (20.7%) sustaining at least one severe anatomic injury. Group 2 had an Injury Severity Score of 3.3 (p < 0.0001), with only 4.4% (p = 0.0013) sustaining severe anatomic injury. Mean length of hospitalization for group 1 was 3.5 days, including a mean of 1.4 intensive care unit days. Mean hospitalization (0.5 days, p < 0.0001) and intensive care unit (0.1 days, p < 0.0001) were significantly lower in group 2. Mean combined hospital and physician charges were more than six times greater for group 1 ($7,206) than group 2 patients ($1170, p < 0.0001). CONCLUSION: In patients presenting with bicycle-related injuries, prior consumption of alcohol is highly associated with greater injury severity, longer hospitalization, and higher health care costs. This information is useful in the development of injury prevention strategies to decrease incidence and severity of adult bicycle injuries.

Accidents, Traffic↗
PubMed1994

A prospective in-field comparison of intravenous line placement by urban and nonurban emergency medical services personnel.

STUDY HYPOTHESIS: Emergency medical services personnel are highly proficient at rapid i.v. line placement in the prehospital setting, with little difference between urban and nonurban areas in a geographically diverse state. DESIGN: Prospective evaluation by an in-field observer of timing, sequence, success rates, and patient characteristics for IV line placement by prehospital personnel for 1 year. SETTING: Twenty advanced life support agencies from all four emergency medical service regions of Arizona. PARTICIPANTS: Fifty-eight patients encountered by participating emergency medical service agencies who had at least one i.v. line placement attempt in the prehospital setting. RESULTS: Urban agencies encountered 24 patients (41.4%), and nonurban agencies encountered 34 (58.6%). Fifty-seven of 58 patients (98.3%) had at least one successful i.v. line started before arrival at a hospital. All 24 urban patients and 33 of 34 nonurban patients (97.1%) had a successful i.v. line attempt (P = .586, power = .09). In the urban setting, 24 of 31 attempts (77.4%) were successful, and in the nonurban setting 35 of 52 attempts (67.3%) were successful (P = .464, power = .28). Mean i.v. line procedure intervals were 1.6 minutes in urban and 1.4 minutes in nonurban settings (P = .408, power = .7). Thirty of 31 i.v. line attempts (96.7%) were completed in less than 4 minutes in urban systems, and 49 of 52 IV line attempts (94.2%) were completed in less than 4 minutes in nonurban systems (P = .520, power = .13). Mean i.v. line procedure intervals were 1.3 minutes for successful attempts and 2.1 minutes for unsuccessful ones (P = .015). Mean i.v. line procedure intervals for on-scene attempts were 1.3 minutes compared with 2.0 minutes for attempts during transport (P = .005). On average, i.v. line attempts in trauma patients took only 1.0 minutes compared with 1.7 in medical patients (P = .017). CONCLUSION: Personnel in the 20 advanced life support agencies studied were extremely adept (rate of 98.3%) at obtaining i.v. line access in the prehospital setting. The time required to complete i.v. line placement was very short, and little difference was noted between urban and nonurban providers. I.v. procedure intervals were shorter for successful attempts, on-scene attempts, and attempts in trauma patients compared with their counterparts.

Adolescent↗
PubMed1993

Emergency vehicle intervals versus collapse-to-CPR and collapse-to-defibrillation intervals: monitoring emergency medical services system performance in sudden cardiac arrest.

STUDY OBJECTIVE: To compare emergency vehicle response intervals with collapse-to-intervention intervals to determine which of these system data better correlated with survival after prehospital sudden cardiac arrest. STUDY DESIGN: A 22-month case series, collected prospectively, of out-of-hospital cardiac arrests. Times of collapse, dispatch, scene arrival, CPR, and initial defibrillation were determined from dispatch records, recordings of arrest events, interviews with bystanders, and hospital records. SETTING: Southwestern city (population, 400,000; area, 390 km2) with a two-tiered basic life support-advanced life support emergency medical services system. Emergency medical technician-firefighters without electrical defibrillation capability comprised the first response tier; firefighter-paramedics were the second tier. PATIENTS: One hundred eighteen cases of witnessed, out-of-hospital cardiac arrest in adults with initial ventricular fibrillation. MAIN OUTCOME MEASURES: Survival was defined as a patient who was discharged alive from the hospital. RESULTS: Eighteen of 118 patients (15%) survived. Survivors did not differ significantly from nonsurvivors in age, sex, or basic life support or advanced life support response intervals. Survivors had significantly (P < .05) shorter intervals from collapse to CPR (1.7 versus 5.2 minutes) and to defibrillation (7.4 versus 9.5 minutes). CONCLUSION: Collapse-to-intervention intervals, not emergency vehicle response intervals, should be used to characterize emergency medical services system performance in the treatment of sudden cardiac death.

Aged↗
PubMed1993

Prospective validation of a new model for evaluating emergency medical services systems by in-field observation of specific time intervals in prehospital care.

STUDY OBJECTIVE: To develop and validate a new time interval model for evaluating operational and patient care issues in emergency medical service (EMS) systems. DESIGN/SETTING/TYPE OF PARTICIPANT: Prospective analysis of 300 EMS responses among 20 advanced life support agencies throughout an entire state by direct, in-field observation. RESULTS: Mean times (minutes) were response, 6.8; patient access, 1.0; initial assessment, 3.3; scene treatment, 4.4; patient removal, 5.5; transport, 11.7; delivery, 3.5; and recovery, 22.9. The largest component of the on-scene interval was patient removal. Scene treatment accounted for only 31.0% of the on-scene interval, whereas accessing and removing patients took nearly half of the on-scene interval (45.8%). Operational problems (eg, communications, equipment, uncooperative patient) increased patient removal (6.4 versus 4.5; P = .004), recovery (25.4 versus 20.2; P = .03), and out-of-service (43.0 versus 30.1; P = .007) intervals. Rural agencies had longer response (9.9 versus 6.4; P = .014), transport (21.9 versus 10.3; P < .0005), and recovery (29.8 versus 22.1; P = .049) interval than nonrural. The total on-scene interval was longer if an IV line was attempted at the scene (17.2 versus 12.2; P < .0001). This reflected an increase in scene treatment (9.2 versus 2.8; P < .0001), while patient access and patient removal remained unchanged. However, the time spent attempting IV lines at the scene accounted for only a small part of scene treatment (1.3 minutes; 14.1%) and an even smaller portion of the overall on-scene interval (7.6%). Most of the increase in scene treatment was accounted for by other activities than the IV line attempts. CONCLUSION: A new model reported and studied prospectively is useful as an evaluative research tool for EMS systems and is broadly applicable to many settings in a demographically diverse state. This model can provide accurate information to system researchers, medical directors, and administrators for altering and improving EMS systems.

Arizona↗
PubMed1992

Case and survival definitions in out-of-hospital cardiac arrest. Effect on survival rate calculation.

OBJECTIVE: To determine the effect of different case and survival definitions of out-of-hospital cardiac arrest on survival rate calculations. DESIGN: A 22-month case series of nontraumatic, out-of-hospital cardiac arrests. SETTING: Southwestern city (population, 400,000; area, 390 km2) with a two-tiered emergency response system consisting of emergency medical technicians and paramedics. PATIENTS: A consecutive sample of 372 patients found without palpable pulse of spontaneous respiration. MAIN OUTCOME MEASURES: Survival rate after cardiac arrest was calculated using three case definitions of arrest and two definitions of survival. RESULTS: Twenty percent of all patients survived to hospital admission and 6% survived to hospital discharge. Twenty-six percent of adults whose collapse was witnessed survived to hospital admission, and 10% survived to hospital discharge. Patients whose collapse was witnessed and who experienced initial ventricular fibrillation survived to hospital admission in 38% and to hospital discharge in 15% of cases. CONCLUSIONS: The survival rate after out-of-hospital cardiac arrest varies widely depending on the case and survival definitions selected. To facilitate intersystem comparison and assessment of interventions designed to improve outcome, the Utstein Consensus Conference recommended that case and survival definitions should be adopted by all prehospital emergency systems.

Aged↗
PubMed1992

Meeting the goals of academia: characteristics of emergency medicine faculty academic work styles.

STUDY OBJECTIVES: Emergency medicine faculty have 24-hour clinical responsibilities in addition to the academic requirements of research and administration/teaching. This study was undertaken to determine the existing and ideal work style of such faculty by professional rank, administrative title, and/or tenure versus clinical track. DESIGN: Data analysis from department or residency directors of Accreditation Council for Graduate Medical Education-approved emergency medicine residency programs. SETTING: ACGME-approved emergency medicine residency programs. TYPE OF PARTICIPANTS: Emergency medicine faculty. RESULTS: Ninety-three percent of programs submitted appropriate data. Programs averaged 11 full- and four part-time faculty. Mean time ranged from 15 to 30 hours per week with an average mean of 23 hours (48% of total work week) for clinical responsibilities, from ten to 32 hours per week with an average mean of 19 hours per week (38%) for administrative/teaching efforts, and from three to 14 hours per week with an average mean of seven hours per week (15%) for research. Total time averaged between 44 and 51 hours per week. Ideal work style emphasized less clinical time and a shorter work week. Responsibilities varied by rank, administrative position, and clinical versus tenure track. CONCLUSION: Emergency medicine faculty accomplish the clinical, research, and teaching/administrative demands of academia by increasing the number of faculty, varying the faculty responsibilities by rank and title, and shortening the total work week. Research time is extremely limited.

Clinical Medicine↗
PubMed1991

The impact of injury severity and prehospital procedures on scene time in victims of major trauma.

STUDY OBJECTIVE: To evaluate the relationship among injury severity, prehospital procedures, and time spent at the scene by paramedics for victims of major trauma. DESIGN: Retrospective study of 98 consecutive patients with an Injury Severity Score of more than 15 who were brought to a trauma center by fire department paramedics. SETTING: A medium-sized metropolitan emergency medical services (EMS) system and a Level I trauma center. RESULTS: There were 66 male and 32 female patients with a mean age of 34 years. Thirty-two patients (32.6%) died. Blunt and penetrating trauma accounted for 68.4% and 31.6% of cases, respectively. Thirty-three patients (33.7%) had successful advanced airway procedures, and 81 (82.7%) had at least one IV line started in the field. Analysis of scene time, prehospital procedures, and injury severity parameters revealed that more procedures were performed in the field on the more severely injured cases; that despite this, there was a trend toward shorter scene time for more severely injured patients; and that there was a mean scene time of 8.1 minutes. This is the shortest scene time reported to date for prehospital trauma care in an EMS system. CONCLUSION: Extremely short scene times can be attained without foregoing potentially life-saving advanced life support interventions in an urban EMS system with strong medical control. In such a system, the most severely injured victims may spend less time at the scene although more procedures are performed on them.

Adolescent↗
PubMed1991

A prospective analysis of injury severity among helmeted and nonhelmeted bicyclists involved in collisions with motor vehicles.

To evaluate the impact of helmet use on injury severity, patient information was prospectively obtained for all bicyclists involved in collisions with motor vehicles seen at a level-I trauma center from January 1986 to January 1989. Two hundred ninety-eight patients were evaluated; in 284 (95.3%, study group) cases there was documentation of helmet use or nonuse. One hundred sixteen patients (40.9%) wore helmets and 168 (59.1%) did not. One hundred ninety-nine patients (70.1%) had an ISS less than 15, while 85 (29.9%) were severely injured (ISS greater than 15). Only 5.2% of helmet users (6/116) had an ISS greater than 15 compared with 47.0% (79/168) of nonusers (p less than 0.0001). The mean ISS for helmet users was 3.8 compared with 18.0 for nonusers (p less than 0.0001). Mortality was higher for nonusers (10/168, 6.0%) than for helmet users (1/116, 0.9%; p less than 0.025). A striking finding was noted when the group of patients without major head injuries (246) was analyzed separately. Helmet users in this group still had a much lower mean ISS (3.6 vs. 12.9, p less than 0.001) and were much less likely to have an ISS greater than 15 (4.4% vs. 32.1%, p less than 0.0001) than were nonusers. In this group, 42 of 47 patients with an ISS greater than 15 (89.4%) were not wearing helmets. We conclude that helmet nonuse is strongly associated with severe injuries in this study population. This is true even when the patients without major head injuries are analyzed as a group; a finding to our knowledge not previously described.(ABSTRACT TRUNCATED AT 250 WORDS)

Accidents, Traffic↗
PubMed1990

Prehospital cricothyrotomy: an investigation of indications, technique, complications, and patient outcome.

The records of all patients who presented to a Level 1 trauma center during a two-year period for whom a prehospital cricothyrotomy was attempted or ordered were reviewed. Twenty patients met the study criteria. The average age was 37 years (range, 11 to 65 years). Indications for prehospital cricothyrotomy were massive facial trauma (eight), failed oral intubation (seven), and suspected cervical-spine injury (one). Cricothyrotomy was attempted in 16 patients (80%), with the remaining four having the procedure ordered but not attempted. A successful airway was achieved in 14 patients (88%). Horizontal incisions were used in all cases and were anatomically correct in 15 of 16 attempts (94%). The overall immediate complication rate was 31%. Two patients (12%) sustained major complications (failure to obtain an airway). No hemorrhagic complications occurred, but 16 of the 20 were in cardiac arrest in the field. Long-term complications were not evaluated. All patients sustained major injuries (mean Injury Severity Score, 53.7), except one patient who suffered airway obstruction from food. Three patients (15%) survived; two of the three suffered permanent, severe brain dysfunction. These preliminary findings demonstrate that prehospital cricothyrotomy is being used chiefly in massively injured patients who are already beyond recovery. It is thus difficult to assess whether the procedure is either safe or effective. There is a need for further investigation to determine whether prehospital cricothyrotomy has any beneficial effect on outcome and, if so, in what setting.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1990

Prehospital cardiac arrest: the impact of witnessed collapse and bystander CPR in a metropolitan EMS system with short response times.

OBJECTIVE: Numerous studies have shown initiation of bystander CPR to significantly improve survival from prehospital cardiac arrest. However, in emergency medical services (EMS) systems with very short response times, bystander CPR has not been shown to impact outcome. The purpose of this study was to determine the effect of bystander CPR on survival from out-of-hospital cardiac arrest in such a system. DESIGN: Prehospital, hospital, and death certificate data from a medium-sized metropolitan area were retrospectively analyzed for adult, nontraumatic cardiac arrest during a 16-month period. RESULTS: A total of 298 patients met study criteria. One hundred ninety-five arrests (65.4%) were witnessed, and 103 (34.6%) were unwitnessed. Twenty-five witnessed victims (12.8%) were discharged alive, whereas no unwitnessed victims survived (P less than .001). Patients suffering a witnessed episode of ventricular fibrillation/tachycardia (VF/VT) were more likely to survive (21.9%) than were other patients (2.0%, P less than .0001). Among witnessed patients, initiation of bystander CPR was associated with a significant improvement in survival (20.0%) compared with the no-bystander CPR group (9.2%, P less than .05). Bystander CPR was also associated with improved outcome when witnessed patients with successful prehospital resuscitation were evaluated as a group; 18 had bystander CPR, of whom 13 (72.2%) survived compared with only 12 of 38 patients with no bystander CPR (31.6%, P less than .01). CONCLUSION: Our data revealed improved survival rates when bystander CPR was initiated on victims of witnessed cardiac arrest in an EMS system with short response times.

Adult↗