Peer review of on-scene air medical triage in Connecticut.
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Air Ambulances↗
Biomedical subjects
L M Jacobs
Publications and source records attributed to L M Jacobs.
The response of scene call volume to prehospital education.
INTRODUCTION: Transport of injured patients directly from a scene to a trauma center improves survival of patients and shortens their length of stay in the hospital. This paper studies the relationship between education presentations to prehospital personnel and scene call volume. The education sessions emphasize safety issues and how, when, and why to call for air medical transport. METHODS: The town and date of scene flights were compared to the town and date of flight nurse presentations and aircraft demonstrations. The length of time from a presentation to a scene call for each town was determined, and a cumulative frequency graph was drawn. Epidemiologic curves of presentations and calls were drawn for each town. Based on these graphs, observations of a relationship were obtained. RESULTS: There were 65 scene calls to 27 towns that had no education programs. There were 880 scene calls to 90 towns that had 235 education programs. There were 21 towns that received a total of 41 presentations and never initiated a scene call. The results show that scene call requests are more likely to occur within three months of a presentation. Individual town analysis shows variability of response to education programs. CONCLUSION: Prehospital provider education programs increase scene call volume, but this effect seems to last for three months. On a town-by-town basis there are many other determinants of scene call volume.
Air Ambulances↗
Continuous quality improvement applied to a scientific assembly: the history of the Eastern Association for the Surgery of Trauma.
INTRODUCTION: The purpose of this study was to measure the quality of the research presented at the Eastern Association for the Surgery of Trauma (EAST) for the first 5 years. METHODS: Abstracts from the scientific assemblies of EAST, 1988-1992, were reviewed. Five elements were identified for each abstract, the research question, the research design, the sampling method, the validity of the conclusions, and if the research question was answered. These were identified because of their significant impact on the quality of the research presented in the abstract format. RESULTS: Two hundred two abstracts were reviewed. There was a significant improvement in research design, in the sampling method, in the validity of the conclusions, and in the proportion of research questions answered. There was an initial improvement in the presence of a research question, but it was not sustained. CONCLUSION: The results clearly demonstrate an improvement in the quality of the abstracts chosen for presentation at the scientific assembly of the Eastern Association for the Surgery of Trauma. Further improvements can be made by adding the category of 'research question' or 'purpose' and requiring a structured abstract.
Abstracting and Indexing↗
Delayed hemorrhagic pericardial effusion: case reports of a complication from severe blunt chest trauma.
The rare occurrence of delayed hemorrhagic pericardial effusion requiring treatment is reported following significant blunt chest trauma (AIS greater than or equal to 3) in three patients from 12 to 15 days after injury. Cardiomegaly was suspected on serial chest roentgenograms, and the pericardial effusion was confirmed by echocardiography. Two of three patients required systemic anticoagulation early after their admission to the hospital. It is currently unknown whether the number of delayed hemorrhagic pericardial effusions is increasing with the use of certain anticoagulation treatment regimens.
Adult↗
The effect of the new trauma DRGs on reimbursement.
Reimbursement for trauma care based on prospective payment has not been satisfactory. The Health Care Financing Administration introduced four new Multiple Significant Trauma (MST) DRGs in 1991 with the intention of covering patients who have had at least two body sites injured. To determine the effect if any on reimbursement, a sample of patients who were assigned the new DRGs over a 5-month period were analyzed. The analysis compared the calculated reimbursement for these 49 patients based on their total accumulated charges, DRG weights, and the average Medicare dollar blend along with the additional weight factor specific for the study facility. This analysis was compared with an additional analysis determining the reimbursement performed on the same patient sample but with DRG weights determined from DRGs derived from the 1989 DRG GROUPER/FINDER. During the 5-month study period, 5.5% of the patients discharged from the hospital has sustained at least one injury covered by ICD-9-CM codes. Of these, 49 (3.9%) were classified into one of the four new MST DRGs. The majority of patients were male (75.5%), the mean age was 31.8 years, and the total charges accumulated were $1,809,192.23. The calculated DRG-based reimbursement was $1,183,495.40, or 65.5% of the total charges. In the second part of the study, using the DRGs available in 1989 for the same sample of patients, the DRG-based reimbursement was $691,437.72, or only 38.2% of the accumulated charges.(ABSTRACT TRUNCATED AT 250 WORDS)
Diagnosis-Related Groups↗
Factors associated with outcome in blunt aortic injury: a population-based study.
A population-based study was conducted for two contiguous states representing a population of 9.1 million to determine whether age, injury severity score, major complications, and preexisting conditions contribute to the outcome of patients diagnosed with blunt traumatic aortic injury. A secondary analysis reviewed patients with blunt aortic injury admitted over a six-year period to a trauma center located in one of the states to examine other more detailed factors related to mortality. Age was the only variable that correlated statistically with mortality in both populations analyzed. (Region P = .004; trauma center P = .0012) The severity of injury showed a tendency for decreased survival with increasing injury severity score. The elderly (age > or = 55) in both data sets sustained higher mortality from blunt aortic injury. In the trauma center population, the elderly had more delay in diagnosis than the younger patient population.
Adult↗
The changing perspectives of trauma care. The Sinkler Memorial Lecture.
Trauma and the management of injuries have changed considerably over the past century. A sound understanding of the factors that generate injuries and sophisticated systems that can be accessed immediately are now in place in most of the United States. The concept of a team approach to the management of multiple system injuries using specialists from all disciplines has resulted in the reduction of morbidity and mortality. Although many of the challenges of managing the trauma patient have been overcome, there are still a number of exciting areas that lend themselves to ongoing research. These changing perspectives allow for many exciting challenges for the trauma team.
Emergency Medicine↗
Evaluating the compliance of universal precautions by aeromedical personnel before and after an educational seminar on infectious diseases.
STUDY OBJECTIVE: To measure the compliance of an aeromedical crew with universal precautions and demonstrate what effect education has on utilization. DESIGN: Blinded time-series design. SETTING: Helicopter emergency medical service. TYPE OF PARTICIPANTS: Aeromedical crew consisting of flight nurses, respiratory therapists, and doctors. INTERVENTIONS: A mandatory educational seminar on universal precautions as required by the Centers for Disease Control. MEASUREMENTS AND MAIN RESULTS: Before the educational seminar the flight crew utilized gloves in 42% of patient contacts and goggles 0% of the time. At that time, masks and gowns were not available. The nurses used gloves in 28/72 (39%) of patients, respiratory therapists in 27/71 (38%) of patients, and doctors in 12/19 (63%) of patients. The overall compliance after the education seminar was 61% for gloves and 0% for goggles. The nurses used gloves in 20/36 (56%) of patients, the respiratory therapist in 23/34 (68%) of patients, and the doctors in 11/16 (69%) of patients. CONCLUSIONS: The use of gloves and goggles as preventive measures to protect the aeromedical crew from the potential hazards of body fluid contact and transmission of disease during their treatment of patients is low. Compliance increased after an educational seminar on universal precautions but still remained low. Other modalities, such as quality assurance measures, continuing education, policies, and peer pressure, in addition to education, are necessary.
Aerospace Medicine↗
Intraperitoneal femoral venous catheter insertion with free blood return in presence of tense hemoperitoneum.
The authors report a case of intraperitoneal insertion of a femoral venous catheter, with blood return, in a patient with hemoperitoneum. In such patients, skin puncture at or below the inguinal ligament is important. Aspiration of unusually dark blood and medial catheter location should raise the possibility of intraperitoneal catheter placement.
Abdominal Muscles↗
Evaluation of liver function tests in screening for intra-abdominal injuries.
STUDY OBJECTIVES: To determine the utility of serum glutamic oxaloacetic transaminase (SGOT) and serum glutamic pyruvic transaminase (SGPT) in predicting intra-abdominal injury in blunt trauma patients. DESIGN: Descriptive review of 309 blunt trauma admissions during study period. SETTING: A 1,000-bed Level I trauma center in a major metropolitan area. TYPE OF PARTICIPANTS: Consecutive adult blunt trauma admissions to the trauma service. INTERVENTIONS: Serum levels of study enzymes were measured at initial evaluation and subsequent hospitalization. Results of all intra-abdominal evaluations were recorded. MAIN RESULTS: Significantly greater numbers of patients with SGOT and/or SGPT elevated to more than 130 IU/L had associated intra-abdominal injuries as compared with patients with enzyme elevations of less than 130 IU/L (52% versus 8%). All 18 patients with liver injuries had one or both enzymes elevated to more than 130 IU/L. Higher enzyme levels were more frequently associated with liver injury. CONCLUSIONS: Elevation of serum levels of the study enzymes is a marker for intra-abdominal injury. Levels in excess of 130 IU/L are relative indicators of abdominal computed tomography scan. Levels of less than 130 IU/L are unlikely to be associated with liver injury.
Abdominal Injuries↗
Quality assurance in the Connecticut Helicopter Emergency Medical Service.
Quality Assurance (QA) is a vital aspect of the Connecticut Helicopter Emergency Medical Service (HEMS). The program has three components: 1. scene flight audit, 2. random chart audit, and 3. biweekly patient care QA conferences. The scene flight audit identifies patients who, in retrospect, may not have required helicopter transportation. These patients are identified by the following criteria: trauma score greater than 12 and injury severity score less than 16, emergency department deaths, discharged within 24 hours, medical patients. Patient care QA involves review of all flights. A random chart audit is a method of peer review of the written flight record for completeness. The scene flight audit was from 6/85 to 12/87, with 17/107 (16%) in group one, 0/137 (0%) in group two, 5/29 (17%) in group three, and 8/54 (15%) in group four not justified. There were four audit review periods, each with a feedback mechanism to share results with providers. Each audit resulted in a decrease in the number of non-justified flights. There were 57 patient care QA conferences with 231 cases presented. Technical errors and policy issues decreased over time. Random review of five charts/month were reported quarterly. Omitted elements of standard documentation decreased over time. QA can be accomplished in HEMS. Monitored areas should include appropriateness of flights, proper documentation, and patient care review. A QA program improves appropriateness of flights, medical record keeping, and care given.
Aircraft↗
Roles of a helicopter emergency medical service in mass casualty incidents.
The Connecticut helicopter emergency medical service (HEMS) has responded to 12 mass casualty incidents (MCI) in two years. Eight were drills and four were actual events. An MCI response plan was instituted prior to the onset of the HEMS program. All MCIs were reviewed to determine actual victims, knowledge of MCI prior to lift-off, and roles of the HEMS. The actual roles were compared with the pre-established roles. The four actual MCIs (building explosion, hotel fire, bus rollover and plane crash) were reviewed. Sixty-seven victims were involved. Prenotification occurred in one MCI. The roles of the HEMS in each MCI were: triage (n = 4), medical treatment (n = 4), transport (n = 3), augmented response (n = 1), and air surveillance (n = 0). The roles of HEMS response to MCI should be well-defined prior to an event. Air medical benefits include response within a large geographic area, highest level of prehospital medical care, identification of trauma receiving hospitals, and facilitation of transport.
Aircraft↗
Eastern Association for the Surgery of Trauma 1991: presidential address.
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Aircraft↗
A prospective analysis of a two-year experience using computed tomography as an adjunct for cervical spine clearance.
The role of CT scanning as an adjunct to plain roentgenograms of the cervical spine was reviewed in acutely injured blunt trauma patients. Following institution of a protocol to evaluate the cervical spine in all blunt trauma patients, 179 patients underwent CT scanning of their cervical spine. This was performed for patients whose x-ray findings were positive, for patients with plain x-ray films suggestive of a pathologic condition, for patients with plain x-ray films that did not reveal all of the cervical vertebrae, and for patients who had persistent pain or neurologic deficits despite normal plain x-ray films. Of 123 patients not able to have their cervical spine cleared by normal roentgenograms, 93% were cleared within 24 hours of admission based on CT scans. There were no missed injuries in this setting. A false-positive rate of 28% and a false-negative rate of 1.5% were found for plain roentgenograms. Computed tomographic scans detected 98% of the injuries in our study and when combined with a three-view plain x-ray series of the cervical spine, 100% of cervical spine injuries were detected. Computed tomographic scanning as an adjunct to plain x-ray films of the cervical spine is a highly accurate and expedient modality to clear the cervical spine of blunt trauma patients.
Adolescent↗
An objective method to measure and manage occult pneumothorax.
Of 457 patients with multisystem injuries undergoing abdominal computed tomographic (CT) scan, 26 patients were found to have 31 pneumothoraces. None of these were apparent on prior roentgenograms of the chest. Each pneumothorax was quantified by measuring its maximal width in millimeters and the number of 10 millimeter CT sections on which it appeared. Serial roentgenograms of the chest and patient charts were reviewed. The major factor determining the clinical course and management of these pneumothoraces was size. Seventeen per cent of pneumothoraces measuring less than 5 X 80 millimeters (group 1) and 85 per cent of those measuring greater than or equal to 5 X 80 millimeters (group 2) had tube thoracostomy performed. The percentage of pneumothoraces in each group with positive pressure ventilation was 55 and 77 per cent, respectively. Our results suggest that such occult pneumothoraces may be managed with close observation if they measure less than 5 X 80 millimeters, whether or not the patient is to receive positive pressure ventilation. Larger pneumothoraces and those associated with more than two rib fractures may require early treatment.
Adolescent↗
Interhospital transport audit criteria for helicopter emergency medical services.
A quality assurance audit of all interhospital patient transports from 17 June 1985 through 31 December 1989 by Connecticut's critical care helicopter system was performed to determine the number of medically appropriate and justified flights. There were 1,839 transports reviewed using nationally established criteria. Flights not fulfilling any of these criteria (n = 401) were reviewed in detail by a panel consisting of medical and nursing representatives. During this case by case review, additional acceptable criteria for transport were developed. The audit determined that 1,792 (97%) of interhospital transfers were justified for helicopter emergency medical transport. The use of these national criteria along with the proposed additional criteria is recommended to health care personnel in the decision to transport a patient to a tertiary care hospital by air. In addition, these criteria should be prospectively utilized by aeromedical flight programs for quality assurance review of appropriateness of helicopter interhospital requests.
Aircraft↗
Evaluation of an alcohol education package for non-specialist health care and social workers.
A quasi-experimental non-equivalent control group design was used to assess the influence of a two-day experiential alcohol education package for non-specialist health care and social workers. Four pairs of teams took part in the study: general practice; accident and emergency; medicine for the elderly; and social work. The dual foci of the evaluation were agents' knowledge and attitudes, and these were assessed using a modified version of the Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ). For both variables, the one-month follow-up scores of the education teams were significantly higher than those of the comparisons, although the effect was stronger in the case of therapeutic attitudes than knowledge. There were also significant differences in improvement in attitude scores, with significant effects being observed in the general practice, medicine for the elderly and social work teams but not the accident and emergency. At 6 months, the level of fall-off in improvement varied and this, along with the pattern of change evident in the five components which comprise the AAPPQ attitude scale, was examined and discussed in relation to previous research in this field of inquiry.
Adult↗
A comparison of ground paramedics and aeromedical treatment of severe blunt trauma patients.
This study compared a hospital-based aeromedical program to a ground paramedic service in order to determine whether the element of prehospital time or prehospital care is the major contributor towards improved survival. One hundred twenty-six severe blunt trauma patients were studied. There were 93(73.81%) transported by air and 33(26.19%) transported by ground. Utilizing the TRISS methodology, the air patients had a probability of survival of 2.23 SD better than the national norm, and the ground patients had a -2.69 SD below the national norm. The air patients had a higher percentage of intubated patients (42% vs 3%) and use of PASG(56% vs 30%). There was no significant difference in the prehospital times of either the air or ground services once they had arrived at the scene. Since the scene time of both services is similar, the improved survival of the air patients may be due to the technical intervention procedures performed.
Aircraft↗