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Biomedical subjects

Russell D MacDonald

Publications and source records attributed to Russell D MacDonald.

17 recordsLinked to original sources
PubMed2006

Validation of the Provincial Transfer Authorization Centre database: a comprehensive database containing records of all inter-facility patient transfers in the province of Ontario.

BACKGROUND: The Provincial Transfer Authorization Centre (PTAC) was established as a part of the emergency response in Ontario, Canada to the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003. Prior to 2003, data relating to inter-facility patient transfers were not collected in a systematic manner. Then, in an emergency setting, a comprehensive database with a complex data collection process was established. For the first time in Ontario, population-based data for patient movement between healthcare facilities for a population of twelve million are available. The PTAC database stores all patient transfer data in a large database. There are few population-based patient transfer databases and the PTAC database is believed to be the largest example to house this novel dataset. A patient transfer database has also never been validated. This paper presents the validation of the PTAC database. METHODS: A random sample of 100 patient inter-facility transfer records was compared to the corresponding institutional patient records from the sending healthcare facilities. Measures of agreement, including sensitivity, were calculated for the 12 common data variables. RESULTS: Of the 100 randomly selected patient transfer records, 95 (95%) of the corresponding institutional patient records were located. Data variables in the categories patient demographics, facility identification and timing of transfer and reason and urgency of transfer had strong agreement levels. The 10 most commonly used data variables had accuracy rates that ranged from 85.3% to 100% and error rates ranging from 0 to 12.6%. These same variables had sensitivity values ranging from 0.87 to 1.0. CONCLUSION: The very high level of agreement between institutional patient records and the PTAC data for fields compared in this study supports the validity of the PTAC database. For the first time, a population-based patient transfer database has been established. Although it was created during an emergency situation and data collection is dependent on front-line medical workers, the PTAC data has achieved a high level of validity, perhaps even higher than many purpose built databases created during non-emergency settings.

Database Management Systems↗
PubMed2006

Prehospital transcutaneous cardiac pacing for symptomatic bradycardia or bradyasystolic cardiac arrest: a systematic review.

BACKGROUND: Advanced cardiac life support (ACLS) guidelines suggest transcutaneous cardiac pacing (TCP) for the treatment of symptomatic bradycardia (SB) and bradyasystolic cardiac arrest (BACA). Many EMS systems are extrapolating these guidelines and employing TCP in the prehospital setting. Our objective was to conduct a systematic review to determine the efficacy of prehospital TCP in the management of these two conditions. METHODS: MEDLINE (1966-2004), EMBase and Science Citation Index (1980-2004) were searched using: prehospital/emergency medical services; external/transcutaneous; pacing. Two reviewer teams blinded to the source and author conducted a hierarchical selection (title, abstract, article) and quality assessment using a validated scale. Kappa agreement at each level of review was measured. Data abstraction was done by consensus. RESULTS: Thirty-four articles were identified and seven selected (Kappa agreement; title: 0.85, abstract: 0.78, full article: 0.82). Article quality was poor in all trials. There were three case series (BACA, n=215), three unblinded randomised controlled trials (one BACA, two BACA+SB), and one subgroup (SB) analysis. In the case series of paced BACA patients, 0/215 survived to hospital discharge. In the BACA trials 16/509 (paced) versus14/497 (control) survived to discharge. In a subgroup of one SB trial 5/6 (paced) versus 1/7 (control) survived to discharge (p=0.01). When a SB trial subgroup was combined with a case series 4/27 (paced) versus 0/24 (control) survived to discharge (p=0.07). CONCLUSIONS: In the prehospital setting, there is no evidence to support the use of TCP in bradyasystolic cardiac arrest. There is inadequate evidence to determine the efficacy of prehospital TCP in the treatment of symptomatic bradycardia.

Bradycardia↗
PubMed2006

Outcomes of interfacility critical care adult patient transport: a systematic review.

INTRODUCTION: We aimed to determine the adverse events and important prognostic factors associated with interfacility transport of intubated and mechanically ventilated adult patients. METHODS: We performed a systematic review of MEDLINE, CENTRAL, EMBASE, CINAHL, HEALTHSTAR, and Web of Science (from inception until 10 January 2005) for all clinical studies describing the incidence and predictors of adverse events in intubated and mechanically ventilated adult patients undergoing interfacility transport. The bibliographies of selected articles were also examined. RESULTS: Five studies (245 patients) met the inclusion criteria. All were case-series and two were prospective in design. Due to the paucity of studies and significant heterogeneity in study population, outcome events, and results, we synthesized data in a qualitative manner. Pre-transport severity of illness was reported in only one study. The most common indication for transport was a need for investigations and/or specialist care (three studies, 220 patients). Transport modalities included air (fixed or rotor wing; 66% of patients) and ground (31%) ambulance, and commercial aircraft (3%). Transport teams included a physician in three studies (220 patients). Death during transfer was rare (n = 1). No other adverse events or significant therapeutic interventions during transport were reported. One study reported a 19% (28/145) incidence of respiratory alkalosis on arrival and another study documented a 30% overall intensive care unit mortality, while no adverse events or outcomes were reported after arrival in the three other studies. CONCLUSION: Insufficient data exist to draw firm conclusions regarding the mortality, morbidity, or risk factors associated with the interfacility transport of intubated and mechanically ventilated adult patients. Further study is required to define the risks and benefits of interfacility transfer in this patient population. Such information is important for the planning and allocation of resources related to transporting critically ill adults.

Adult↗
PubMed2005

West Nile virus. Primer for family physicians.

OBJECTIVE: To provide primary care physicians with an understanding of West Nile virus in North America. This article focuses on epidemiology, clinical features, diagnosis, and prevention of infection. QUALITY OF EVIDENCE: MEDLINE and EMBASE searches revealed epidemiologic, surveillance, cohort, and outcome studies providing level II evidence. There were no randomized controlled trials of treatment. Recommended prevention and treatment strategies are based on level II and III evidence. MAIN MESSAGE: The mosquito-borne virus that first appeared on this continent in 1999 is now prevalent throughout North America. Most infections are asymptomatic. Fewer than 1% of those infected develop severe illness; 3% to 15% of those with severe illness die. While methods for controlling the mosquito population are available, we lack evidence that they reduce infection in the general human population. Family physicians have an important role in advising their patients on ways to prevent infection and in identifying patients who might be infected with West Nile virus. CONCLUSION: The general population is at low risk of West Nile virus infection. Prevention of infection rests on controlling the mosquito population and educating people on how to protect themselves against mosquito bites.

Family Practice↗
PubMed2004

Impact of CT scan in patients with first episode of suspected nephrolithiasis.

This prospective observational outcome study assessed the impact of helical computed tomography (CT) scan in patients with a first episode of suspected nephrolithiasis. Before CT scanning, Emergency Physicians completed a questionnaire, including diagnostic certainty of nephrolithiasis and anticipated patient disposition. Primary outcome measure was the comparison of physician diagnostic certainty and CT scan results. Secondary outcome measures included alternate diagnoses and changes in patient disposition after CT scan. Four categories grouped the pre-CT diagnostic certainty: 0-49%, 50-74%, 75-90%, and 90-100%. The CT scan found urinary calculi in 28.6%, 45.7%, 74.2%, and 80.5% of patients in each category, respectively. CT scanning revealed alternate diagnoses in 40 cases (33.1%). Of these, 19 (47.5%) included other significant pathology. Before CT scanning, physicians planned to discharge 115 patients and admit six patients. After CT scanning, six of the former group were admitted, and five of the latter group were discharged. Patients presenting with a first episode of clinically suspected nephrolithiasis should undergo CT scanning because it enhances diagnostic certainty by identifying alternate diagnoses not suspected on clinical grounds alone.

Adult↗
PubMedDate not supplied

An emergency medical services transfer authorization center in response to the Toronto severe acute respiratory syndrome outbreak.

OBJECTIVE: To describe the rapid development and implementation of an innovative emergency medical services (EMS) command, control, and tracking system to mitigate the risk of iatrogenic spread of severe acute respiratory syndrome (SARS) among health care facilities, health care workers, and patients in Ontario, Canada, as a result of interfacility patient transfers. METHODS: A working group of stakeholders in health care and transport medicine developed and implemented a medically based command, control, and tracking center for all interfacility (including acute and long-term care) patient transfers in Ontario, Canada. Development and implementation took place in three distinct but overlapping phases: needs assessment, design and implementation, and expansion and ongoing operations. RESULTS: The needs assessment, design, and implementation were completed in less than 48 hours using existing EMS infrastructure and personnel. The center was successfully handling more than 500 requests for interfacility patient transfer per day within 36 hours of operation and more than 1,100 requests per day within two weeks. Expansion into a new physical space enables 40 staff to process up to 1,500 requests per day. There was no reported spread of SARS resulting from interfacility patient transfers since the center began operation on April 1, 2003, and anecdotal evidence demonstrates it identified up to 13 new SARS cases. The center continues to operate as a part of Ontario's commitment as a result of diligence in transport medicine and infection control, even though no new cases of SARS were reported since June 12, 2003. Further study is needed to determine its overall efficacy at risk mitigation. CONCLUSIONS: Rapid establishment of an EMS-based command, control, and tracking center is possible in the setting of a public health emergency. In addition to risk mitigation, this type of center could provide syndromic surveillance in real time and provide the earliest indication of a potential threat to public health in acute and long-term care facilities.

Communicable Disease Control↗
PubMedDate not supplied

Half-a-million strong: the emergency medical services response to a single-day, mass-gathering event.

INTRODUCTION: Emergency medical services (EMS) responses to mass gatherings have been described frequently, but there are few reports describing the response to a single-day gathering of large magnitude. OBJECTIVE: This report describes the EMS response to the largest single-day, ticketed concert held in North America: the 2003 "Toronto Rocks!" Rolling Stones Concert. METHODS: Medical care was provided by paramedics, physicians, and nurses. Care sites included ambulances, medically equipped, all-terrain vehicles, bicycle paramedic units, first-aid tents, and a 124-bed medical facility that included a field hospital and a rehydration unit. Records from the first-aid tents, ambulances, paramedic teams, and rehydration unit were obtained. Data abstracted included patient demographics, chief complaint, time of incident, treatment, and disposition. RESULTS: More than 450,000 people attended the concert and 1,870 sought medical care (42/10,000 attendees). No record was kept for the 665 attendees simply requesting water, sunscreen, or bandages. Of the remaining 1,205 patients, the average of the ages was 28 +/- 11 years, and 61% were female. Seven-hundred, ninety-five patients (66%) were cared for at one of the first-aid tents. Physicians at the tents assisted in patient management and disposition when crowds restricted ambulance movement. Common complaints included headache (321 patients; 27%), heat-related complaints (148; 12%), nausea or vomiting (91; 7.6%), musculoskeletal complaints (83; 6.9%), and breathing problems (79; 6.6%). Peak activity occurred between 14:00 and 19:00 hours, when 102 patients per hour sought medical attention. Twenty-four patients (0.5/10,000) were transferred to off-site hospitals. CONCLUSIONS: This report on the EMS response, outcomes, and role of the physicians at a large single-day mass gathering may assist EMS planners at future events.

Adolescent↗
PubMedDate not supplied

Impact of prompt defibrillation on cardiac arrest at a major international airport.

OBJECTIVE: To describe the impact of a rapidly deployable, automated external defibrillator (AED)-equipped first-responder service at Boston's Logan International Airport on the rate of survival to hospital discharge after cardiac arrest. METHODS: A prospective observational outcome study was undertaken for cardiac arrests taking place on the airport grounds from January 1, 1995, to December 31, 1999. Patients were included if they were unresponsive, they had no palpable pulse and no spontaneous respirations, an AED was turned on, and the cardiac arrest took place on airport grounds. Airport fire rescue and emergency medical services (EMS) personnel submitted resuscitation records and AED memory modules for each cardiac arrest. Each author independently reviewed all cardiac arrest reports and code summaries to ensure accuracy and data integrity. Relevant dispatch and response times were determined from airport fire rescue and EMS dispatch records. Patient outcome was determined from hospital patient records. Descriptive statistics were calculated. RESULTS: The airport fire rescue crew responded to 53 cardiac arrests. Of those, 38 met inclusion criteria. In 36 of 38 cases (94.7%), the airport fire rescue crew was first to apply the defibrillator, and the first to deliver a shock in 28 of 32 cases (87.5%) where a shock was delivered. The median response time for the airport fire rescue crew was 2 minutes, with a mode of 1 minute. The EMS response times were 5:29 (95% CI 4:37-6:19) for basic life support crews and 8:07 (95% CI 7:17-8:57) for advanced life support crews. All patients who survived to hospital admission (n = 15) and hospital discharge (n = 8) received their first shock by the airport fire rescue crew. Eight patients (21.1%) survived to hospital discharge. In five of the eight survivors to hospital discharge, defibrillation by the airport crew alone achieved a return of spontaneous circulation. CONCLUSIONS: A rapidly deployable first-responder service permits early defibrillation minutes before arrival of EMS personnel. This rapid response positively impacts the return of spontaneous circulation and survival to hospital discharge after cardiac arrest.

Aged↗
PubMedDate not supplied

Paramedic performance in calculating drug dosages following stressful scenarios in a human patient simulator.

BACKGROUND: Paramedics face many stressors in their work environment. Studies have shown that stress can have a negative effect on the psychological well-being of health professionals. However, there is little published research regarding the effects of stress on the cognitive skills necessary for optimal patient care. OBJECTIVES: The primary purpose of this study was to investigate the effects of acute stress on the emotional response and performance of paramedics. Furthermore, the authors explored whether a paramedic's level of training or years of experience would mediate the effects of stress on performance. METHODS: Paramedic performances in calculating drug dosages were compared in two stress conditions. In the low-stress condition, 30 paramedics calculated the drug dosages in a quiet classroom free of any stressor. In the high-stress condition, the same paramedics calculated comparable drug dosages immediately after working through a challenging scenario with a human patient simulator. RESULTS: The paramedics obtained lower accuracy scores in the high-stress condition than in the low-stress condition [43% (95% confidence interval [CI]: 36.9-49.2) vs. 58% (95% CI: 48.6-67.1), p < 0.01 based on univariate analysis]. Neither work experience nor level of training predicted the individual differences in the stress-induced performance decrements. CONCLUSION: These results suggest that the types of stressors encountered in clinical situations can increase medical errors, even in highly experienced individuals. These findings underline the need for more research to determine the mechanisms by which stress influences clinical performance, with the ultimate goal of targeting education or technologic interventions to those tasks, situations, and individuals most likely to benefit from such interventions.

Adaptation, Psychological↗
PubMedDate not supplied

Transfer of intra-aortic balloon pump-dependent patients by paramedics.

This prospective case series describes the experience of a specially trained critical care paramedic transfer program that transports intra-aortic balloon pump (IABP)-dependent patients to definitive cardiac surgical care without additional medical escorts. Paramedics complete a standard ambulance patient care report and a quality management report for each IABP-dependent patient transported. All patient care reports were routinely screened for calls involving IABP-dependent patients to ensure all calls were captured. Demographic, patient care, adverse event, and transfer-related data were collected prospectively. The program manager and medical director independently examined all reports for quality of care and occurrence of adverse events. Missing data were obtained from paramedic crews and referring facilities. The IABP program transported 29 patients during its first 24 months. The mean patient age was 63.4 +/- 10.4 years, and the majority were male (25 of 29; 86.2%). The most common indications for IABP insertion were bridge to definitive surgical care (17; 58.6%) and cardiogenic shock (13; 44.8%). The mean out-of-hospital time was 39.9 +/- 26.1 minutes. There were 22 complications in 11 patients. Paramedics successfully managed all complications. There was no persistent life-threatening patient-related complication or IABP-related malfunction, and no patient died during transport. This case series demonstrates that specially trained critical care paramedics can safely IABP-dependent patients to definitive cardiac surgical care without additional medical escorts.

Aged↗
PubMedDate not supplied

Performance of resuscitation skills by paramedic personnel in chemical protective suits.

OBJECTIVES: Determine whether wearing a chemical protective suit increases time to successful completion of four resuscitation skills. METHODS: This prospective experimental study examined the ability of civilian paramedic personnel to complete four resuscitative skills (electrical defibrillation, administration of epinephrine subcutaneously, intravenous cannulation, and tracheal intubation) carried out using standard methods on mannequins under two test conditions (wearing the protective suit and not wearing the suit). Primary outcome was time to successful completion of each skill. RESULTS: Sixteen paramedics were enrolled and completed each skill under two test conditions. Paramedics took longer to complete administration of epinephrine (87 vs. 60 seconds; p < 0.01) and intravenous cannulation (220 vs. 158 seconds; p < 0.01) tasks when wearing a protective suit. Wearing the suit did not impair electrical defibrillation (57 vs. 46 seconds) or tracheal intubation (79 vs 69 seconds). CONCLUSIONS: Chemical protective suit use increased time to successful completion of resuscitation skills where fine motor skills are required, namely administration of epinephrine subcutaneously and intravenous cannulation, but did not increase time to successful completion of resuscitation skills requiring gross motor skills, namely electrical defibrillation and tracheal intubation.

Emergency Medical Technicians↗
PubMedDate not supplied

Performance analysis of a medical decision algorithm to mitigate spread of SARS due to interfacility patient transfers.

OBJECTIVE: To determine performance of a medical decision algorithm to mitigate spread of severe acute respiratory syndrome (SARS) from interfacility patient transfers during the Toronto SARS outbreak. METHODS: Records from the Provincial Transfer Authorization Centre and Toronto Public Health from April 1 to July 31, 2003, were linked using probabilistic methods. Authorization decision (transfer authorized or denied) and SARS status (probable case, suspect case, or patient under investigation for SARS; or non-SARS case) were obtained for linked records. Primary outcome was the number of patients where correct authorization decisions were made based on SARS status at the time of request. Secondary outcome was the number for whom, in retrospect, authorization decision was correct knowing final SARS status. Algorithm sensitivity, specificity, and predictive values were determined. RESULTS: There were 14,571 requests for transfer and 2,132 patients investigated for SARS during the study period. The algorithm authorized 14,551 and did not authorize 20 requests. Sensitivity and specificity to make appropriate authorization decisions at the time of request were 100% (95% confidence interval [CI], 77.2%-100%) and 99.95% (95% CI, 99.9-100%), respectively. Positive and negative predictive values were 65% (95% CI, 44.1%-85.9%) and 100% (95% CI, 98.4%-100%), respectively. Sensitivity and specificity, in retrospect, within ten days of the transfer request were 100% (95% CI, 80.6%-100%) and 99.97% (95% CI, 99.9%-100%), respectively. Positive and negative predictive values were 80% (95% CI, 62.5%-97.5%) and 100% (95% CI, 98.4%-100%), respectively. Seven of the 20 patients with nonauthorized requests were not known to have SARS at the time of request. Within ten days, three of seven were under investigation for, a suspect case of, or a probable case of SARS. CONCLUSIONS: The medical decision algorithm was highly sensitive and specific in correctly authorizing transfers. Despite its highly sensitive and specific algorithm, it did incorrectly deny authorization to a very small number of patients without SARS.

Algorithms↗
PubMedDate not supplied

Interfacility transport of patients with decompression illness: literature review and consensus statement.

OBJECTIVE: Decompression illness (DCI) is a potentially lethal complication of diving and may occur far from hyperbaric facilities. The need for prompt transport to a hyperbaric facility often involves air medical transport, but this may exacerbate DCI. The authors reviewed available literature to establish evidence-based transport strategies utilizing safe altitudes for patients, with DCI. METHODS: MEDLINE, EMBASE, and materials from organizations with expertise in diving medicine were searched for the following terms: decompression sickness, caisson disease, hyperbaric oxygenation, depth intoxication, or diving. Two reviewers independently selected relevant citations involving patients with DCI and air medical transport for review and consensus statement development by an expert working group. RESULTS: A total of 341 citations were identified, and 53 unique citations were reviewed. Nine relevant citations were selected for consensus statement development. There were no clinical trials or prospective cohort studies. Only two retrospective case series, including nine patients, specifically examined the effect of altitude on patients with DCI during transport. No symptom recurrence occurred when the cabin altitude remained within 500 feet of ground level. Seven citations were either letters or statements of expert opinion, recommending a maximum cabin altitude of 500-1000 feet (152-305 meters). CONCLUSIONS: The working group identified the paucity of clinical studies and evidence-based recommendations for air medical transport of patients with DCI. Transport selection should be based on minimizing total transport time and, when transporting by air, ensuring that a cabin altitude of the transporting vehicle does not exceed 500 feet (152 meters) above the departure point.

Air Ambulances↗