Biomedical subjects

R L Norton

Publications and source records attributed to R L Norton.

24 records · Page 2Linked to original sources

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

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

Urinary excretion of chromium by humans following ingestion of chromium picolinate. Implications for biomonitoring.

This study investigated the variability in urinary chromium (Cr) excretion following the ingestion of Cr picolinate by human volunteers. A pharmacokinetic model was used to estimate the bioavailability of Cr from ingested Cr picolinate using known distribution patterns and elimination rates of Cr by humans. The possible advantages of using sequential, individual spot, or 24-hr urine sample collection for biomonitoring of Cr exposure were examined. Background concentrations of urinary Cr determined from the spot samples in this study compared well with values reported by others. The variability in urinary excretion of Cr in untreated volunteers indicated that it is virtually impossible to distinguish exposures to most occupational and virtually all environmental exposures to Cr. Sequential urine sampling was found superior to both 24-hr and spot urine collection for indicating exposure to Cr picolinate. The extent of absorption of Cr from the picolinate matrix in the gastrointestinal tract was 2.80 +/- 1.14% (SD). It was estimated that 10 mg of soil containing between 7,400 and 52,000 mg Cr(III)/kg would have to be ingested by an adult to result in urinary excretion of Cr clearly above the upper bound of Cr in urine from background populations (1.8 microgram Cr/liter), depending on certain assumptions regarding bioavailability. This study supports the results of other recent work that demonstrated urinary excretion of Cr resulting from low-level environmental exposure is unlikely to be distinguished from that resulting from dietary uptake.

Administration, Oral↗