Ultrasonographic guidance for internal jugular vein cannulation: an educational imperative, a desirable practice alternative.
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Catheterization, Central Venous↗
Biomedical subjects
Jerris R Hedges
Publications and source records attributed to Jerris R Hedges.
Variability of trauma transfer practices among non-tertiary care hospital emergency departments.
OBJECTIVES: To assess both the variability of interhospital trauma transfer practices and nonclinical factors associated with the transfer of injured patients from emergency departments (EDs) of non-tertiary care hospitals. METHODS: The authors analyzed a retrospective cohort of trauma patients initially presenting to one of 42 non-tertiary care hospitals (Level 3 or 4 hospitals) and requiring admission or transfer from January 1998 to December 2003. Twenty-one clinical, demographic, and hospital-level variables were included in multivariable logistic regression models (outcome = ED transfer to a tertiary care hospital), with hospital and year included as fixed effects to adjust for clustering. Classification and regression tree analysis was used to determine the importance of different covariates in predicting whether or not a patient was transferred from the ED. RESULTS: Included in the analysis were 10,176 persons, of whom 3,785 (37%) were transferred to a tertiary care hospital from the ED. The hospital of initial presentation was the factor of greatest importance in predicting transfer, and there was substantial variability in transfer practices between hospitals. Several additional nonclinical variables were independently associated with transfer, including type and level of hospital, patient age, increasing distance from the nearest higher-level hospital (a measure of geographic isolation), and the patient's insurance status (particularly among Level 3 hospitals). CONCLUSIONS: The non-tertiary care hospital of initial presentation is the strongest predictor for whether an injured patient is transferred to a tertiary center from the ED. There is substantial variability in transfer practices between hospitals after accounting for important clinical factors, and several nonclinical variables are independently associated with transfer.
Age Factors↗
Automated external defibrillator program does not impair cardiopulmonary resuscitation initiation in the public access defibrillation trial.
OBJECTIVES: To evaluate whether automated external defibrillator (AED) training and AED availability affected the response of volunteer rescuers and performance of cardiopulmonary resuscitation (CPR) in presumed out-of-hospital cardiac arrest (OOH-CA) during the multicenter Public Access Defibrillation Trial. METHODS: The Public Access Defibrillation Trial recruited 1,260 facilities in 24 North American regional sites to participate in a trial addressing survival from OOH-CA when AED training and availability were added to a volunteer-based emergency response team. Volunteers at each facility were trained to perform either CPR alone (CPR) or CPR in conjunction with AED use (CPR+AED) according to randomized assignments. This study reports the frequency of response and initiation of CPR actions (chest compressions and/or ventilations) by volunteers in the CPR and CPR+AED study groups. RESULTS: A total of 314 presumed OOH-CA episodes occurred in CPR facilities, and 308 occurred in CPR+AED facilities. The volunteers were matched well for age, gender, and other features. Overall, ventilations (23.1% vs. 13.1%), chest compressions (24.4% vs. 12.1%), and both actions (19.8% vs. 10.5%; all p < 0.05) were more commonly performed in OOH-CA cases in the CPR+AED group. However, when only OOH-CA cases with volunteers responding were analyzed, the rates of CPR actions were similar. In the subgroup of CPR+AED cases with a responding volunteer, the AED was turned on for only 47% of cases. Volunteers initiated a CPR action more commonly when the AED was turned on (60.7% vs. 39.3%; p = 0.003). CONCLUSIONS: In the Public Access Defibrillation Trial, rates of CPR actions for presumed OOH-CA victims were low but similar for CPR and CPR+AED responding volunteer rescuers. Factors associated with volunteer response, CPR action initiation, and AED activation warrant further investigation.
Adult↗
Regional differences in outcomes for hospitalized injured patients.
BACKGROUND: Our goal was to use a hospital population-based data set that was a sample of all injured patients admitted to a hospital in the United States to develop universal measures of outcome and processes of care. METHODS: Patients with a primary discharge diagnosis of injury (ICD-9 800 to 959) in the HCUP/Nationwide Inpatient Sample for the years 1995 to 2000 were used to estimate the annual number of hospitalized injured patients. Using census data, we calculated age- and sex- adjusted average annual incidence rates for four census regions in the United States: Northeast, Midwest, South and West. Outcomes measured were annual rates per million populations of hospitalization rate, death rate, and potentially ineffective care (PIC) rate defined as >28 days of hospitalization ending in death. Length of stay (LOS) was calculated as total number of days annually hospitalized for injury for census regions per million populations. RESULTS: Incidence rates per million populations and 95% confidence intervals for rate of hospitalizations for injury were: Northeast, 5596 (5338-5853); Midwest, 5516 (5316-5716); South, 5639 (5410-5869); West, 5307 (5071-5543). Incidence rates per million populations and 95% confidence intervals for rate of in-hospital deaths were: Northeast, 129 (119-139); Midwest, 131 (122-139); South, 141 (129-152); West, 114 (106-123). Incidence rates per million populations and 95% confidence intervals for rate of PIC were: Northeast, 11 (10-13); Midwest, 5 (4-5); South, 6 (5-7); West, 4 (3-4). Incidence rates per million populations and 95% confidence intervals for hospital days were: Northeast, 34 (32-36); Midwest, 30 (28-31); South, 30 (29-32); West, 26 (24-27). CONCLUSION: Regional differences in outcomes and processes of care for hospitalized injured patients exist and may be influenced by hospital characteristics and region of the country. Research to identify the factors that cause these hospital and regional variations is needed. These observations suggest that to develop a uniform standard for quality of care, it will be essential to have valid and robust hospital population-based measures.
Adolescent↗
Introduction--What critical care practitioners should know about terrorism agents.
Terrorist attack by chemical, biologic, or radiologic agents is a prime concern of emergency planners, and would likely lead to casualties that require critical care. This article reviews the past military and terrorist uses of these agents and reviews the most likely agents to be used by terrorists against civilian populations.
Biological Warfare↗
Modeling instructor preferences for CPR and AED competence estimation.
INTRODUCTION: Cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) skills competency can be tested using a checklist of component skills, individually graded "pass" or "fail." Scores are typically calculated as the percentage of skills passed, but may differ from an instructor's overall subjective assessment of simulated CPR or AED adequacy. OBJECTIVE: To identify and evaluate composite measures (methods for scoring checklists) that reflect instructors' subjective assessments of CPR or AED skills performance best. METHODS: Associations between instructor assessment and lay-volunteer skill performance were made using 6380 CPR and 3313 AED skill retention tests collected in the Public Access Defibrillation Trial. Checklists included CPR skills (e.g., calling 911, administering compressions) and AED skills (e.g., positioning electrodes, shocking within 90 s of AED arrival). The instructor's subjective overall assessment (adequate/inadequate) of CPR performance (perfusion) or AED competence (effective shock) was compared to composite measures. We evaluated the traditional composite measure (assigning equal weights to individual skills) and several nontraditional composite measures (assigning variable weights). Skills performed out of sequence were further weighted from 0% (no credit) to 100% (full credit). RESULTS: Composite measures providing full credit for skills performed out of sequence and down-weighting process skills (e.g., calling 911, clearing oneself from the AED) had the strongest association with the instructor's subjective assessment; the traditional CPR composite measure had the weakest association. CONCLUSION: Our findings suggest that instructors in public CPR and AED classes may tend to down-weight process skills and to excuse step sequencing errors when evaluating CPR and AED skills subjectively for overall proficiency. Testing methods that relate classroom performance to actual performance in the field and to clinical outcomes require further research.
Cardiopulmonary Resuscitation↗
Mortality benefit of transfer to level I versus level II trauma centers for head-injured patients.
OBJECTIVE: To determine whether head-injured patients transferred to level I trauma centers have reduced mortality relative to transfers to level II trauma centers. DATA SOURCE/STUDY SETTING: Retrospective cohort study of 542 patients with head injury who initially presented to 1 of 31 rural trauma centers in Oregon and Washington, and were transferred from the emergency department to 1 of 15 level I or level II trauma centers, between 1991 and 1994. STUDY DESIGN: A bivariate probit, instrumental variables model was used to estimate the effect of transfer to level I versus level II trauma centers on 30-day postdischarge mortality. Independent variables included age, gender, Injury Severity Scale (ISS), other indicators of injury severity, and a dichotomous variable indicating transfer to a level I trauma center. The differential distance between the nearest level I and level II trauma centers was used as an instrument. PRINCIPAL FINDINGS: Patients transferred to level I trauma centers differ in unmeasured ways from patients transferred to level II trauma centers, biasing estimates based on standard statistical methods. Transfer to a level I trauma center reduced absolute mortality risk by 10.1% (95% confidence interval 0.3%, 22.2%) compared with transfer to level II trauma centers. CONCLUSIONS: Patients with severe head injuries transferred from rural trauma centers to level I centers are likely to have improved survival relative to transfer to level II centers.
Catchment Area, Health↗
The incidence and burden of ladder, structure, and scaffolding falls.
OBJECTIVES: The national morbidity and mortality associated with falls from a height is incompletely described. The authors estimated the rates of injury, hospitalization, and mortality due to these falls for subgroups of the U.S. population. METHODS: Administrative databases (1995-2000) provided national samples of patients treated for injuries following a fall from a height (ICD-9-CM E-codes E881.0, E881.1, or E882). Inpatient data are from the Nationwide Inpatient Sample, and emergency department data are from the National Hospital Ambulatory Medical Care Survey. RESULTS: A total of 347,484 (95% confidence interval = 308,417 to 386,551) emergency department presentations occur annually for injuries following a fall. Hospitalized patients older than 75 years of age had a 3.3% case fatality, and 42% were discharged to a skilled nursing facility. For patients older than 55 years of age, 86% of falls were not work related. CONCLUSIONS: Ladder and structure falls by elders are a substantial emergency department problem warranting thorough clinical evaluation and injury prevention efforts.
Accidental Falls↗
Impact of a transfer center on interhospital referrals and transfers to a tertiary care center.
BACKGROUND: The partnership of faculty physicians and senior clinical hospital administrators in the decision to accept interhospital transfers has not been fully studied. Transfers to academic medical centers on the basis of economics have been of particular concern. OBJECTIVES: To evaluate the impact of joint decision making on transfer acceptance, and to evaluate the basis for decisions to transfer patients to an academic medical center. METHODS: This was a database study of requested adult interhospital transfers, excluding psychiatric transfers, occurring between January 1, 2003, and December 31, 2003, by using data from a computerized patient-tracking system. Where possible, comparisons with the prior calendar year (i.e., prior to implementation of the administrative review process) were made. Incidence of refusal to accept requested transfers and payer mix of transfer patients were the main outcomes of interest. RESULTS: More than 90% of the adult patients were transferred for conditions that required tertiary care or met Emergency Medical Treatment and Labor Act (EMTALA) requirements. The patient conditions that did not meet tertiary care needs included obstetric patients who did not have prenatal care, patients who had hand and facial trauma, and patients who weighed more than 300 pounds. The payer mix of transfer patients remained stable when using the administrator and physician team to determine acceptance of transfers. During the evaluation period, approximately 91,500 patients statewide lost some level of Medicaid coverage. CONCLUSIONS: The value of an administrator and physician team as partners in the interhospital transfer process was demonstrated. Active management of interhospital transfers supports transfer of patients who require tertiary care or who meet EMTALA criteria, thus conserving limited bed capacity and ensuring financial equity, while caring for the uninsured and underinsured patients throughout the state.
Adult↗
A survey of Oregon emergency physicians to assess mandatory reporting knowledge and reporting patterns regarding intoxicated drivers in the state of Oregon.
OBJECTIVES: To assess emergency physician reporting patterns in Oregon before and after the passage of a mandatory intoxicated driving reporting law. METHODS: A one-page survey was mailed to 504 emergency physicians in Oregon in April 2004. Data on reporting frequency were collected using a four-point ordinal scale regarding motor vehicle crash-involved drivers (MIDs) and intoxicated persons attempting to drive away from the emergency department (DAEDs). Paired observations were assessed for a stated increase in reporting activity following passage of the law using the Wilcoxon signed-rank test. Associations of postlaw reporting and demographic and knowledge factors were sought using Spearman rank correlation analysis. RESULTS: Of the 504 surveys mailed, 298 (59%) were adequate for analysis. Many respondents (57%) were already aware of the law. Most (92%) agreed that physicians should be mandated to report some crimes. MIDs were always reported by 18% of physicians before the law and by 47% afterward, whereas DAEDs were always reported by 56% of physicians before the law and by 69% afterward. Emergency medicine-trained physicians, higher emergency department census, and increased years of experience were associated with a significantly higher increase in reporting pattern after passage of the law for both MIDs and DAEDs. CONCLUSIONS: Although 44% of responding emergency physicians in Oregon were unaware of a mandated reporting law for intoxicated drivers presenting to the ED, most physicians stated an increase in their reporting practice.
Alcoholic Intoxication↗
Hospital factors associated with splenectomy for splenic injury: a national perspective.
BACKGROUND: The management of patients with splenic injury has shifted from routine splenectomy to attempts at splenic salvage. Using the Healthcare Cost and Utilization Project's National Inpatient Sample (HCUP-NIS), we assessed the patterns of care for splenic trauma. We hypothesized that the processes of care in urban and rural hospitals would differ. METHODS: Generalized estimating equations were used to identify predictor variables associated with laparotomy and splenectomy from a national, population-based sample of inpatients (HCUP-NIS). Fourteen thousand nine hundred one patients with an International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis code of 865 were selected from the 1998 to 2000 HCUP-NIS data. Exclusion criteria included age greater than 80 years. Analyses were compared using all patients and excluding patients who died during the first 2 hospital days. RESULTS: Eight thousand five hundred fifty-three patients were treated in urban teaching hospitals. Forty percent underwent a laparotomy and 28% underwent a splenectomy at that time. Another 4,461 patients were cared for in urban nonteaching hospitals. Of these, 46% had a laparotomy and 35% underwent a splenectomy. The remaining 1,887 patients were seen in rural hospitals. Forty-six percent had a laparotomy and 36% had a splenectomy. Patients in urban teaching hospitals had lower risk-adjusted odds of splenectomy in multivariate models controlling for confounders including overall injury severity. Overall splenic salvage increased from 1998 to 2000, primarily because of increased salvage rates among urban teaching hospitals. CONCLUSION: The management of patients with splenic injury differs among urban teaching, urban nonteaching, and rural hospitals. Surgeons at urban teaching hospitals appear more willing to attempt splenic salvage by means of nonoperative management.
Abdominal Injuries↗
Advanced statistics: the propensity score--a method for estimating treatment effect in observational research.
Observational studies assessing the effect of a particular treatment or exposure may be subject to bias, which can be difficult to eliminate using standard analytic techniques. Multivariable models are commonly used in observational research to assess the relationship between a certain exposure or treatment and an outcome, while adjusting for important variables necessary to ensure comparability between the groups. Large differences in the observed covariates between two study groups may exist in observational studies in which the investigator has no control over who was allocated to each treatment group, and these differences may lead to biased estimates of treatment effect. When there are large differences in important prognostic characteristics between the treatment groups, adjusting for these differences with conventional multivariable techniques may not adequately balance the groups, and the remaining bias may limit valid causal inference. Use of a propensity score, described as a conditional probability that a subject will be "treated" based on an observed group of covariates, may better adjust covariates between the groups and reduce bias. The purpose of this article is to describe the use of propensity scores to adjust for bias when estimating treatment effects in observational research and to compare use of this technique with conventional multivariable regression. The authors present three methods for integrating propensity scores into observational analyses using a database collected on head-injured trauma patients. The article details the methods for creating a propensity score, analyzing data with the score, and explores differences between propensity score methods and conventional multivariable methods, including potential benefits and limitations. Graphical representations of the analyses are provided as well.
Adolescent↗
Emergency nursing: historical, current, and future roles.
Building upon a historical context, the current and future roles of the clinical emergency nurse are reviewed. For several reasons, emergency nurse availability is expected to be insufficient to meet staffing demands in the near future. Emergency physicians can partner with emergency nurses and hospital administrators to pursue the following strategies for addressing the nursing shortage: (1) improve the workplace environment by improving nurse-to-patient ratios and avoiding the boarding of admitted patients in the emergency department (ED); (2) refocus the emergency nurse job description to patients and their families; (3) promote mutually supportive relationships and comradeship between emergency nurses and physicians; (4) create an environment that allows unique solutions to staff scheduling and accommodates shiftwork; (5) increase nursing wages, and recognize special contributions of emergency nurses with financial reward; (6) identify and promote the personnel of the hospital ED as members of an elite unit; (7) develop preceptorships and internships for nurses new to emergency nursing and invest in clinical specialists or nurse-mentors to assist in "on-the-job" instruction of nurses with previous experience; and (8) invest in nursing education. Taking these steps today will strengthen the ED health care safety net for decades to come.
Clinical Competence↗
Emergency nursing: historical, current, and future roles.
Building upon a historical context, the current and future roles of the clinical emergency nurse are reviewed. For several reasons, emergency nurse availability is expected to be insufficient to meet staffing demands in the near future. Emergency physicians can partner with emergency nurses and hospital administrators to pursue the following strategies for addressing the nursing shortage: 1) improve the workplace environment by improving nurse-to-patient ratios and avoiding the boarding of admitted patients in the emergency department (ED); 2) refocus the emergency nurse job description to patients and their families; 3) promote mutually supportive relationships and comradeship between emergency nurses and physicians; 4) create an environment that allows unique solutions to staff scheduling and accommodates shiftwork; 5) increase nursing wages, and recognize special contributions of emergency nurses with financial reward; 6) identify and promote the personnel of the hospital ED as members of an elite unit; 7) develop preceptorships and internships for nurses new to emergency nursing and invest in clinical specialists or nurse-mentors to assist in "on-the-job" instruction of nurses with previous experience; and 8) invest in nursing education. Taking these steps today will strengthen the ED health care safety net for decades to come.
Career Choice↗
Survival of seriously injured patients first treated in rural hospitals.
BACKGROUND: Patients injured in rural counties are hypothesized to have improved survival if local hospitals are categorized as Level III, Level IV, and Level V trauma centers. METHODS: Data were abstracted on patients with brain, liver, or spleen injuries who were first treated in 16 rural hospitals in Oregon (with categorized trauma centers) and 16 hospitals in Washington (without categorized trauma centers). Logistic regression models evaluated survival up to 30 days after hospital discharge. RESULTS: Among Oregon's 642 study patients, 63% were transferred to another hospital. Among Washington's 624 patients, a higher proportion, 70%, were transferred. Risk-adjusted odds of death for Washington patients (reference odds, 1) were the same as for Oregon patients (odds ratio, 0.82; 95% confidence interval, 0.53-1.28). Most patients died after transfer to another hospital. CONCLUSION: In states with a prevailing practice of promptly transferring brain-injured patients, survival of these patients may not be enhanced by categorization of hospitals as rural trauma centers. To further improve the outcome of these patients, policy makers should adjust statewide trauma system guidelines to enhance integration and to perfect coordination among sequential decision makers.
Adult↗
Satisfied Patients Exiting the Emergency Department (SPEED) Study.
BACKGROUND/OBJECTIVE: Patient satisfaction has been associated with patient perceptions of emergency department (ED) wait intervals, but not necessarily actual wait intervals. The objective was to address the associations of actual versus perceived wait intervals in ED patients and the association of overall satisfaction with perceived and actual wait intervals. METHODS: The authors performed a prospective, cross-sectional study using a volume-stratified sample of adult ED patients presenting to an urban, university teaching hospital. Patient wait intervals were monitored using a computerized tracking system. Patients were confidentially surveyed regarding their overall satisfaction with care and perceptions of wait intervals after a disposition decision was made by the treating physician. The Spearman's rho (two-tailed, alpha = 0.05) was used to evaluate the association between patient satisfaction and perceived wait intervals, estimated wait intervals, and measured wait intervals. Associations between these measures of wait intervals were similarly assessed. RESULTS: One hundred twenty-six eligible patients (including 15 admissions) completed the survey. The median wait interval (interquartile range [IQR] was 14 (7 to 22) minutes to a room. Overall satisfaction was more strongly associated with the perception that the wait interval to a room was shorter than expected (r = 0.44; p = 0.00001) than with the estimated wait interval (r = 0.03; p = 0.97) or the measured wait interval (r = -0.06; p = 0.49). Patients had a median wait interval of 13 (3 to 26) minutes in a room until seen by a physician. Overall satisfaction was more strongly associated with the perception of the physician wait interval's being shorter than expected (r = 0.37; p = 0.00001) than with the estimated wait interval (r = -0.09; p = 0.32) or the measured wait interval (r = 0.05; p = 0.58). Similar findings were found for the total time in the ED. For both the wait for a room interval and the wait for a physician interval, the measured wait intervals were more strongly associated with the estimated wait intervals (r = 0.63 and r = 0.34, respectively) than with the perception that the wait intervals were shorter than expected (r = -0.20 and r = -0.17, respectively). CONCLUSIONS: Efforts to improve ED patient satisfaction should focus on improving patients' perceptions that wait intervals are appropriate rather than simply shortening wait intervals per se.
Adult↗
The effect of computer-assisted prescription writing on emergency department prescription errors.
OBJECTIVE: To determine whether computer-assisted prescription writing reduces the frequency of prescription errors in the emergency department (ED). METHODS: A pre-post retrospective analysis was used to compare errors between handwritten (HW) and computer-assisted (CA) ED prescriptions. Prescriptions were reviewed for pharmacist clarifications. A clarification was defined as an error if missing information, incorrect information, incorrect dose, non-formulary medication, or illegibility was the reason for clarification. The HW and CA error rates were compared using odds ratios (ORs) with 95% confidence intervals (95% CIs). RESULTS: During the pre-intervention period, there were 7,036 patient visits with 2,326 HW ED prescriptions filled for 1,459 patients. There were 91 clarifications, with a rate of 3.9%. There were 54 HW errors, for an error rate of 2.3%. During the post-intervention period, there were 7,845 patient visits with 1,594 CA prescriptions filled for 1,056 patients. There were 13 clarifications, with a clarification rate of 0.8%, and 11 errors, for a CA error rate of 0.7%. The CA prescriptions were substantially less likely to contain an error [OR 0.31 (95% CI = 0.10 to 0.36)] or to require pharmacist clarification [OR 0.19 (95% CI = 0.10 to 0.36)] than were the HW prescriptions. CONCLUSIONS: Computer-assisted prescriptions were more than three times less likely to contain errors and five times less likely to require pharmacist clarification than handwritten prescriptions.
Clinical Pharmacy Information Systems↗
Injury mortality following the loss of air medical support for rural interhospital transport.
OBJECTIVES: This study evaluated variation in mortality among interfacility transfers three years before and after discontinuation of a rotor-wing transport service. METHODS: A retrospective cohort assessment was conducted among severely injured patients transferred from four rural hospitals to a single tertiary center in regions with continued versus discontinued rotor-wing service. Thirty-day mortality following discharge from the receiving tertiary facility served as the primary outcome measure. RESULTS: Discontinuation of rotor-wing transport decreased interfacility transfers and increased transfer time. Transferred patients were four times more likely to die after (compared with before) rotor-wing service was discontinued (p = 0.05). No difference was noted in the region with continued rotor-wing service [odds ratio (OR) = 0.53, p = 0.47]. CONCLUSIONS: Injury mortality increased with loss of air transport for interfacility transfer in a rural area.
Adolescent↗