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Biomedical subjects

K W Neely

Publications and source records attributed to K W Neely.

17 recordsLinked to original sources
PubMed2000

Do emergency medical services dispatch nature and severity codes agree with paramedic field findings?

UNLABELLED: Emergency medical services (EMS) systems increasingly seek to triage patients to alternative EMS resources. Emergency medical services dispatchers may be asked to perform this triage. New protocols may be necessary. Alternatively, existing protocols may be sufficient for this task. For an existing dispatch protocol to be sufficient, it at least must accurately categorize patient condition and severity based on an external standard. OBJECTIVE: To examine the extent to which nature codes (NCs), or patient condition codes, and severity codes (SCs) currently assigned in one urban 911 center agree with paramedic field findings. The null hypothesis was that there is no routine agreement (75%) between dispatcher-assigned NC or SC and paramedic-assigned NC or SC for the same patient using the same protocol. METHODS: Emergency medical services dispatch nature and severity code data and matching out-of-hospital data were prospectively gathered over six months. Dispatch data included the NC: caller-identified problem, and the SC: dispatcher-assessed severity. Each NC is modified by one of three SCs (1, 3, or 9): 1 is emergent, 3 is urgent, and 9 is neither. Paramedics verified and/or corrected dispatcher-assigned NCs and SCs using the same dispatch protocol. RESULTS: One thousand forty usable cases fell into 33 unique NC/SC combinations. The designation of SC 1 was assigned 275 times, SC 3 was assigned 736 times, and SC 9 was assigned 24 times. The SC was missing five times. The overall NC agreement was 0.70 (95% CI = 0.697 to 0.703). The overall SC agreement was 0.65 (95% CI = 0.645 to 0.655). The NC agreement exceeded 75% for ten (59%) NC/SC combinations. The SC agreement exceeded 75% for five (29%) NC/SC combinations. There was both NC and SC agreement for four (24%) combinations: urgent breathing problems, urgent diabetic problems, urgent falls, and urgent overdoses. The greatest NC/SC disagreement occurred within emergent and urgent traffic crashes. Paramedics adjusted SC toward lower severity 29% of the time and toward higher severity 5.4% of the time. There was no upward SC adjustment for eight (47%) combinations. CONCLUSIONS: Certain dispatcher-assigned NC and SC codes and NC/SC combinations achieved the study threshold. Overall agreement failed to achieve the threshold. The lowest SC level was rarely assigned, preventing a meaningful analysis of all severity levels.

Allied Health Personnel↗
PubMed1999

Survey of health maintenance organization instructions to members concerning emergency department and 911 use.

STUDY OBJECTIVE: Anecdotal concerns suggest that health management organization (HMO) membership instructions may deter members from calling 911 or going to an emergency department for a perceived emergency. This study examines such instructions, specifically in regard to their definition of an emergency condition and associated instructions. METHODS: Member instructions were requested from 28 HMOs in 3 large West Coast cities with HMO penetration exceeding 30%. Fifteen (54%) provided membership materials. Features examined included the definition of an emergency, instructions for calling 911, specific instructions regarding chest pain and stroke, and mention of costs associated with emergency care. RESULTS: Instructions and definitions varied widely. Six HMOs (40%) included chest pain in their definition of an emergency; 2 (13%) included symptoms of stroke. Ten (67%) made mention of calling 911 or going to the ED somewhere within their instructions; 4 (27%) provided no options for calling 911 or seeking ED care. Three (20%) cited higher costs associated with ED care. Eleven (73%) indicated that claims would be denied for visits determined on retrospective review to be nonemergencies. CONCLUSION: Instructions varied considerably. Most did not include chest pain or symptoms of stroke in their definition of an emergency. Most did include directions to call 911 or go to an ED. Other instructions may lead members to call the HMO first during an emergency.

California↗
PubMed1997

Multiple options and unique pathways: a new direction for EMS?

The same forces transforming the health care delivery system also are reshaping EMS. The changing economic and organizational structures of the health services delivery system may predict how EMS systems will redesign themselves. We discuss one template for future EMS systems.

Decision Support Techniques↗
PubMed1986

Evaluation of injury mechanism as a criterion in trauma triage.

Triage of potentially injured patients to the appropriate trauma hospital was carried out using mechanism of injury as a triage criterion rather than physiologic changes (trauma score). Injury mechanism includes field evidence of high energy transfer, such as falls of more than 15 feet, automobile accidents with structural intrusion, extrication difficulties, passenger ejection, or death at the scene. Evaluation of triage decisions for a 3 month period in 631 patients showed an overtriage rate of 14 to 43 percent. Using the trauma score alone would have missed significant injuries in at least 8 to 36 percent of these patients using the injury severity score or clinical criteria. Methods of evaluation of overtriage and undertriage are presented, but accepted standards for these must be addressed in each trauma system. Injury mechanism as a primary trauma triage criterion is an acceptable means of identification of potential injury for transport to a trauma facility.

Allied Health Personnel↗
PubMedDate not supplied

Analysis of base station morphine orders: assessment of supervising physician consistency.

Paramedic contact with a base station should gemerate consistent recommendations reflecting a consensus of base station physician care. In our urban EMS system, paramedics must contact a single base station to provide morphine sulfate (MS) for a patient with chest pain. We performed a retrospective cohort analysis of all prehospital MS requests for chest pain to determine the consistency of the circumstances for which the paramedic team was refused MS. These MS requests represented 123 of the 1,715 (7%) on-line physician consultations during the 6-month study. Only 15 of the 123 (12%) MS requests were refused. Neither the mean patient age, sex distribution, or presenting vital signs correlated with MS refusal. A maximum estimate of transport time to the hospital of less than or equal to 5 minutes was noted for 7 of 15 (47%) medication refusals compared to only 11 of 96 (11%) approvals with documented estimated transport times (P less than or equal to 0.005). A simultaneous request for nitroglycerin (NTG) was noted for 6 of the 15 (40%) medication refusals and 15 of the 108 (14%) approvals (P less than 0.05). We found refusal of MS administration to be uncommon. Supervising physicians tended to refuse MS when the transport time was short and when NTG was requested for concomitant administration. We also noted physician inconsistencies in refusal scenarios. These findings can guide physician consensus development to avoid sending mixed messages to paramedics.

Aged↗
PubMedDate not supplied

Analysis of hospital ability to provide trauma services: a comparison between teaching and community hospitals.

HYPOTHESIS: Teaching hospitals (TH) can maintain the American College of Surgeons Committee on Trauma (ACSCOT) criteria for Level II trauma care more consistently than can community hospitals (CH). METHODS: A retrospective analysis of 2,091 trauma system patients was done to determine if TH in an urban area are better able to meet the criteria for Level II trauma care than are CH. During the study period, a voluntary trauma plan existed among five hospitals; two TH and three CH. A hospital could accept patients that met trauma system entry criteria as long as, at that moment, it could provide the resources specified by ACSCOT. Hospitals were required to report their current resources accurately. A centralized communications center maintained a computerized, inter-hospital link which continuously monitored the availability of all participating hospitals. Trauma system protocols required paramedics to transport system patients to the closest available trauma hospital that had all the required resources available. Nine of the required ACSCOT Level II trauma center criteria were monitored for each institution emergency department (ED); trauma surgeon (TS); operating room (OR); angiography (ANG); anesthesiologist (ANE); intensive care unit (ICU); on-call surgeon (OCS); neurosurgeon (NS); and CT scanner (CT) available at the time of each trauma system entry. RESULTS: With the exception of OR, TH generally maintained the required staff and services more successfully than did CH. Further, less day to night variation in the available resources occurred at the TH. Specifically, ANE, ICU, TS, NS, and CT were available more often both day and night, at TH than CH. However, OR was less available at TH than CH during both day and night (p less than .01). CONCLUSIONS: In this community, TH provided a greater availability of trauma services than did CH. This study supports the designation of TH as trauma centers. A similar availability can be performed in other communities to help guide trauma center designation.

Emergency Medical Services↗
PubMedDate not supplied

Computerized hospital on-line resources allocation link (CHORAL): a mechanism to monitor and establish policy for hospital ambulance diversions.

Ongoing monitoring of the availability of hospital critical care resources is necessary to assure patients in the emergency medical services (EMS) system reach appropriate care. In this densely populated area Multnomah County, Oregon, ambulances have been diverted by radio from several hospitals before finding one that would accept the patient. Dispatch centers and base-stations had no reliable method to monitor the availability of hospital resources. Data were not available for use in establishing policy. In response, this community developed an on-line, computerized system known as Computerized Hospital On-Line Resources Allocation Link (CHORAL) that visually displays the resource status of all hospitals to the 911 center, base station, and participating hospitals. A change of status requires simple keystrokes for entry into the computer which in turn transmitted automatically to all other CHORAL computers. Six patient care resources are monitored: Adult Ward (AW); Computerized Axial Tomography Scan (CT); Critical Care (CC); Labor and Delivery (LD); Pediatric (PEDS); and Psychiatric Secure Beds (PSB). Paramedics use protocol to determine if a particular patient fits one of these categories. Availability is relayed to paramedics by the 911 center and the base-station. During the first three months of system operation, there were 337 diversions representing 4,527 hours among 10 of the 12 participating hospitals. The most common resource resulting in diversion was PSB, which was unavailable for 2,195 hours (48.5%). Unavailability of CT resulted in the lowest number of diversions (1.3%, 60.3 hours).(ABSTRACT TRUNCATED AT 250 WORDS)

Ambulances↗
PubMedDate not supplied

The effect of hospital resource unavailability and ambulance diversions on the EMS system.

HYPOTHESES: 1) There is no increase in transport or scene time of diverted patients and no increase in distances traveled; 2) hospital resource shortages bear no relationship to the number of patients diverted; and 3) paramedics are able to match their patient correctly with the resources available at a given hospital. METHODS: This was a five-month, prospective, observational study in an urban area with a population of 600,000 comparing all 9-1-1 ambulance diversions against a randomly selected sample of 5% of all other 9-1-1 originated patients. All patient diversions that originated from the 9-1-1 center are included in the study. RESULTS: Hospitals identify their diversion status on a community-wide computer system monitored at the 9-1-1 center and base station. Accepted categories include: 1) diversion of all patients through the 9-1-1 center from the emergency department (ED); 2) trauma system patients (T); 3) psychiatric secure beds (PSB); 4) general acute ward beds (AW); 5) critical care (CC); 6) computed tomography scan (CT); 7) labor and delivery (LD); and 8) pediatric beds (PEDS). Data were abstracted from 481 patients' records. A total of 111 were diverted from their intended destination. Transport times were longer and diverted patients traveled further (p < .002). Hospitals showing ED and LD diversion categories were more likely to have patients diverted away (r2 = .895, multilinear regression, p < .001). Of the 111 patients, 21 (19%) were diverted because of CC unavailability. Six of these (28%) were inappropriate because they did not fit the CC definition. CONCLUSIONS: In this system, hospital diversions increase transport times and distances traveled. Diversion of patients correlated strongly to unavailability of specific categories. Paramedics make errors in determining appropriate CC diversions. Systems reviewing their diversion problems need to assess the impact of longer out-of-hospital times and of certain diversion categories, and to clarify definitions.

Ambulances↗
PubMedDate not supplied

The strength of specific EMS dispatcher questions for identifying patients with important clinical field findings.

INTRODUCTION: There is growing interest in more efficiently matching emergency medical services (EMS) resources to patient need. Emergency medical services dispatchers may be asked to distinguish between callers with an immediate need for EMS and those who may safely use alternative services. New dispatcher protocols are required or existing protocols must be shown to be reliable for this new task. OBJECTIVE: To examine whether answers to currently asked dispatcher questions in one urban center can identify callers with important clinical field findings (ICFFs). METHODS: Audio recordings of EMS dispatcher-caller conversations within three nature codes (falls, sick, trauma) were retrospectively reviewed. Specifically scripted "cardinal" questions, asked of all callers, identify what happened, whether the patient is breathing okay, and whether the patient is conscious. "Key" questions are specific to each nature code and further specify patient circumstances. Compliance with protocol and caller answers were documented. Researchers developed a list of ICFFs that, if present on the corresponding EMS record, were judged to justify an immediate EMS response. Logistic regression was used to analyze the relationship between caller answers and the presence of ICFFs. A p-value of 0.10 was used. RESULTS: Of 430 recordings, 383 (89%) were usable. Falls: 103 (26%); trauma: 136 (37%); sick: 144 (37%). The caller was the patient 41 (11%) times. There were 198 (52%) females in the sample. There was no matching EMS record for 96 (25%) cases. An ICFF was determined to be present in 191 (67%) of the 287 recordings with matching EMS data. Compliance across the cardinal and key questions ranged from 62% to 88%. Age alone was suggestive of a patient who may be identified at dispatch as having an ICFF [adjusted OR 1.01 (90% CI: 0.999-1.025), p < 0.10]. No other key or cardinal questions were related to ICFFs. CONCLUSION: Cardinal questions are most often asked. Implied or volunteered information is often relied upon to answer key questions. Key questions for certain nature codes are not answered about one third of the time. Increasing age may suggest a stronger likelihood for an ICFF to be identified at dispatch. Otherwise, in this sample, caller answers to currently asked questions do not appear useful if the goal is to identify at dispatch those without an ICFF.

Clinical Protocols↗
PubMedDate not supplied

Can current EMS dispatch protocols identify layperson-reported sentinel conditions?

INTRODUCTION: Managed care organizations are seeking opportunities to capitate for emergency medical services (EMS). These and others pressures are motivating EMS planners to find innovative ways to redeploy existing EMS resources. A successful redeployment of resources implies a mechanism for more carefully matching EMS resources to need than currently exists. OBJECTIVE: To determine whether the methods dispatchers currently use to assign nature codes (NCs) and severity codes (SCs) also can distinguish between patients with important sentinel conditions and those without. METHODS: This was a six-month prospective study (June to November 1997). Portland Fire Bureau (PFB) paramedic units documented dispatcher-assigned NCs and SCs and the presence or absence of study-established sentinel findings. The PFB paramedics also verified or corrected dispatcher-assigned NCs and SCs using dispatch algorithms identical to those in use at this urban dispatch center. Cross-tabulation tables (SPSS version 6.1) with chi-square statistics were established to illustrate the relationship between SC strata within specific NCs and the presence or absence of sentinel findings. RESULTS: One thousand two hundred eighty-five usable cases fell into 25 unique NCs. The designation SC 1 (emergent) was assigned by the dispatcher 307 (24%) times, SC 3 (urgent) was assigned 907 (71%) times, and SC 9 (neither emergent nor urgent) was assigned 26 (2%) times. The SC was missing 45 (3%) times. The PFB records were matched to 1,040 (82%) dispatch records. Sentinel conditions were identified in 411 (40%) of these cases. Eight (32%) of 25 NCs were stratified into two or more levels of dispatcher-determined SCs. One cross-tabulation table for each of these eight NCs was developed to display the relationship between SC strata and the presence or absence of a sentinel condition. Five tables produced statistically significant chi-square tables (p < 0.05). None achieved the study-specified level of 95% sensitivity. CONCLUSION: Current dispatcher-assigned NCs and SCs do not appear adequate to detect callers with study-developed sentinel criteria.

Aged↗
PubMedDate not supplied

EMS dispatch.

Explore the source record for details and available documents.

Efficiency, Organizational↗
PubMedDate not supplied

State insurance commissioner actions against health maintenance organizations for denial of emergency care.

OBJECTIVE: Concerns have emerged from two west coast communities that health maintenance organizations (HMOs) may deter their members from calling 911. One means of influence is retrospective denial of emergency department (ED) or emergency medical services (EMS) claims. The study objective was to systematically assess legal action taken to contest HMO denial of claims. METHODS: Telephone survey of all state insurance commissioners (SICs). The specific question asked was: "What actions, if any, have been taken by the Office of Insurance Commissioner since 1990 against HMOs for denying claims for emergency department care or care provided by paramedics after a person has called 911?" Each office was contacted at least three times. RESULTS: Representatives from 49 states were interviewed. Three states (6%, Oregon, Texas, and Virginia) have taken formal action since 1990. Oregon fined two HMOs a total of $25,000 for inappropriate systematic claim denial of ED care. Texas fined one HMO $1,000,000 for similar practices. Virginia, with no authority to fine, has issued citations. No action had been taken for denying EMS claims. Thirty-eight states (78%) reported no formal actions. Eight (16%) state SICs could not easily retrieve these data and did not report. Fourteen (29%) representatives reported receiving these complaints. Most of these complaints were resolved without formal SIC action. CONCLUSIONS: Three health plans in two states received financial penalties for systematic denial of ED claims. A fourth was cited. This may underrepresent the true incidence of appealed ED and EMS claim denials. While complaints occurred in 29% of states, recent actions by SICs are relatively rare (6% of states). These results speak more to the extent systematic claim denials are discovered by SICs than to the true incidence of this practice.

Emergency Medical Services↗
PubMedDate not supplied

A model for a statewide critical incident stress (CIS) debriefing program for emergency services personnel.

PURPOSE: Emergency services personnel are highly vulnerable to acute and cumulative critical incident stress (CIS) that can manifest as anger, guilt, depression, and impaired decision-making, and, in certain instances, job loss. Interventions designed to identify such distress and restore psychological functioning becomes imperative. METHODS: A statewide debriefing team was formed in 1988 through a collaborative effort between an academic department of emergency medicine and a social work department of a teaching hospital, and a metropolitan area fire department and ambulance service. Using an existing CIS debriefing model, 84 prescreened, mental health professionals and emergency services personnel were provided with 16 hours of training and were grouped into regional teams. Debriefing requests are received through a central number answered by a communicator in a 24-hour communications center located within the emergency department. Debriefings are conducted 48-72 hours after the event for specific types of incidents. Follow-up telephone calls are made by the debriefing team leader two to three weeks following a debriefing. The teams rely on donations to pay for travel and meals. RESULTS: One hundred sixty-eight debriefings were conducted during the first four years. Rural agencies accounted for 116 (69%) requests. During this period, 1,514 individuals were debriefed: 744 (49%) firefighters, 460 (30%) EMTs, and 310 (21%) police officers, dispatchers, and other responders. Deaths of children, extraordinary events, and incidents involving victims known to the responders (35%, 14%, and 14% respectively) were the most common reasons for requesting debriefings. Feedback was received from 48 (28%) of the agencies that requested the debriefing. All of those who responded felt that the debriefing had a beneficial effect on its personnel. Specific individuals identified by agency representatives as having the greatest difficulty were observed to be returned to their pre-incident state. CONCLUSIONS: CIS debriefings are judged as beneficial. A statewide response team is an effective way to provide these services at no cost to agencies.

Adaptation, Psychological↗