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PubMed2003

Emergence and re-emergence of Vibrio cholerae 0139: an epidemiological study during 1993-2002 at Nagpur, Central India.

The pattern of Vibrio cholerae 01 and 0139 isolates at Indira Gandhi Medical College and Mayo General Hospital, Nagpur from 1993 to 2002 is presented. Emergence of the novel serotype 0139 in 1993 was followed by periods of quiescence and re-emergence. For the first time after 1993, the 0139 isolates out numbered 01 isolates in 2001. The peculiar epidemiological pattern is compared with other reports.

Cholera↗
PubMedDate not supplied

The emergence of "emerging diseases": a lesson in holistic epidemiology.

The term "emerging diseases" is a loosely defined category of entities comprising resurgent or recurrent old diseases (usually caused by "new" or mutated previously known agents), diseases truly new to man, but caused by preexisting ("old") zoonotic agents, and syndromes newly defined by the discovery of new agents through advances in biotechnology. Identification and solution of these problems depends, first, on recognition of their differences, and then upon tailoring appropriate strategies for their control. Thus, new influenza viruses appear each year to challenge immunity to their antecedents, but evoke the unchanged and centuries old symptom complex of influenza. Tuberculosis, is resurgent because of mycobacterial mutation to antibiotic resistance, immunosuppression by AIDS, and laxity in public health surveillance. Parvovirus B19 and herpesvirus 6 were revealed as cryptic infectors of white blood cells in studies of hepatitis B and AIDS, but since have been shown to be important causes of childhood rashes, aplastic anemia, and neurologic disease. The encroachment of human habitation on wilderness perimeters (ecosystem change) has increased contact with vectors of zoonotic viruses and bacteria, as evidenced by Lyme disease, Ebola virus infection, and the hemorrhagic fevers. The term "holistic epidemiology" embraces all these problems, from the molecular to the macroenvironmental level. Humans, parasites, and their environment will continue their ancient, fluctuating, dynamic relationship in the future, and new diseases will continue to emerge.

Communicable Disease Control↗
PubMed1997

The emerging infections network: a new venture for the Infectious Diseases Society of America. Executive Committee of the Infectious Diseases Society of America Emerging Infections Network.

The Infectious Diseases Society of America (IDSA), in cooperation with the Centers for Disease Control and Prevention, has launched an Emerging Infections Network (EIN). This network of infectious diseases consultants was conceived as a sentinel system to monitor new or resurgent infectious diseases in a way that would complement other public health surveillance efforts. A pilot study with 169 participants recruited from 32 of the IDSA's state and regional societies confirmed the feasibility and potential value of this network. More than 300 infectious diseases consultants are currently participating in the IDSA EIN. Future plans include aggressive probing for clinical experiences that indicate or suggest the presence of emerging infections, initiation of prospective studies for selected infectious diseases, and other activities designed both to benefit consultants in infectious diseases and to make use of their services.

Communicable Disease Control↗
PubMed1997

[Emerging and re-emerging zoonoses. Local and worldwide threats].

Emerging or re-emerging zoonoses is a relatively complex topic. The concept covers not only new or recently identified zoonotic agents but also agents that are already known but appear in regions and/or species in which they have not been previously observed and agents that disappear then reappear in a country in the form of an epidemic outbreak. Many wild or domestic species and almost all infectious agents may be involved. In general intervention either by vaccination or by elimination of suspect or contaminated individuals is easier in domestic animals than in wild animals especially since the latter may belong to an endanger species. Because of the wide range of pathogenic agents, animal vectors and target populations, there are a wide variety of epidemiological patterns and adapted surveillance and control strategies must be used with various degrees of success.

Animals↗
PubMed1986

Ventilation skills of emergency medical technicians: A teaching challenge for emergency medicine.

We assessed the ability of 64 emergency medical technicians (EMTs) to ventilate a resuscitation manikin with a bag valve mask and with a pocket face mask to determine if their skill levels met the American Heart Association standard of 12 ventilations per minute, each with a tidal volume of 800 mL or more. All ventilation attempts were made during ongoing chest compressions (60 per minute). A successful ventilation was defined as a tidal volume of 800 mL +/- 40 mL. In a preliminary skills assessment, EMTs averaged 4.8 attempts with the bag valve mask and 2.9 attempts with the pocket face mask before a successful ventilation (P less than .01). In a formal skills assessment that lasted two minutes, successful ventilations per minute averaged 8.3 with the bag value mask and 9.9 with the pocket face mask (P less than 0.1). EMTs passed if they averaged ten or more successful ventilations per minute; 67% passed with the bag valve mask and 77% with the pocket face mask (NS). During a ten-minute extended skill assessment the EMTs averaged 9.6 ventilations per minute with the bag valve mask and 9.5 with the pocket face mask (NS). EMTs achieved initial success and maintained continued success better with the pocket face mask, but a reasonably high percentage (67%) met an objective standard when using the bag valve mask. We propose that objective standards be used to test the skills of EMTs for any ventilatory adjunct that they are permitted to use.

Allied Health Personnel↗
PubMed1998

Inconsistency of emergency department triage. Emergency Department Operations Research Working Group.

STUDY OBJECTIVE: To measure the interrater and intrarater agreement of existing emergency department triage systems. METHODS: This 2-phase experimental study of triage nurses' and EMTs ratings for 5 scripted patient scenarios used in-person interviews and follow-up written surveys. RESULTS: Eighty-seven participants (> 90% of those eligible) with 55 (63%) completed both phases of the study. Interrater agreement on triage category was poor (kappa = .347 overall). Only 13 of 55 (24%) participants rated the 5 cases the same severity in both phases; Kendall correlation (iota-B) comparing phases 1 and 2 varied from .145 to .554. Estimates of admission probability varied widely. Estimates of the appropriate time to physician evaluation (from immediate to 24 hours) was often incongruous with severity ratings (e.g., 54% of those participants rating a case the lowest severity recommended evaluation within 8 hours). There was good agreement on estimated need for an ED monitored bed or diagnostic studies. CONCLUSION: Triage assessments (both interrater and intrarater) by experienced personnel are inconsistent using these 5 standardized patient scenarios. These results challenge the reliability of current ED triage practice.

Emergency Medical Technicians↗
PubMed2005

Factors influencing emergency intubation in the pre-hospital setting--a multicentre study in the German Helicopter Emergency Medical Service.

BACKGROUND: Definitive airway control by endotracheal intubation (ETI) is standard of care in pre-hospital airway management. However, there are specific factors that may influence and complicate ETI. METHODS: Prospective, descriptive study at three German Helicopter Emergency Medical Services (HEMS) over a 1-yr period. We examined the success and complication rate for field intubation performed by trauma anaesthetists. RESULTS: In 342 patients (9.3%) ETI was performed. The overall success rate was 100%; in 87.4% the first attempt was successful, whereas in 11.1% a second and in 1.5% a third ETI attempt was necessary. No patient required a surgical intervention. Limited access to the patient was found upon arrival at the scene in 20.2% of the patients and in 9.6% of the patients at the time of ETI attempt. An orotracheal ETI technique was used in all patients. In the patients in whom only one ETI attempt was necessary for successful intubation, the assessment of ETI conditions was rated 'very good' or 'good' in 94.7%, but in those requiring a second or third ETI attempt this was reduced to 68.6 and 20.0%, respectively. Difficulties encountered during ETI included blood (19.9%), vomit/debris (15.8%) and secretions (13.8%) in the upper airway; anatomical reasons (11.7%), patient position (9.6%) and surrounding conditions (9.1%), making laryngoscopy more difficult. CONCLUSIONS: Despite various factors increasing the difficulties in managing the airway in the field, definitive airway control by ETI seems to be safe practice.

Adolescent↗
PubMed1985

Impact of improved emergency medical services and emergency trauma care on the reduction in mortality from trauma.

From 1972 to 1982 there was a 23.9% decline in the number of deaths due to trauma in Nebraska. During this time, an improved emergency medical services (EMS) system was being implemented, including training of EMT's and paramedics, physician education in advanced trauma life support (ATLS), establishment of three helicopter transport services, and designation of trauma centers in the two most populous (of six) EMS regions. Highway safety programs alone could not account for the decline in trauma deaths, since there was almost as great a fall in nonvehicular (21.4%) as vehicular (26.4%) trauma deaths. The much larger decline in prehospital (28.3%) than in-hospital (17.3%) trauma deaths suggested a relationship between the improving EMS system and decreased mortality from trauma. We found that growth of the EMS system, as measured by the cumulative number of EMT's trained, correlated strongly with the decline in prehospital (r = 0.95; p less than 0.001), in-hospital (r = 0.84; p less than 0.001), total (r = 0.95; p less than 0.001), vehicular (r = 0.86; p less than 0.001), and nonvehicular (r = 0.93; p less than 0.001) trauma deaths. Our findings suggest that improvements in the statewide EMS system along with better hospital care have caused a significant decline in the number of trauma deaths over a 14-year period.

Accidents, Traffic↗
PubMed1996

Rate of patient workups by non-emergency medicine residents in an academic emergency department.

OBJECTIVE: To quantify the number of patients seen per hour by non-emergency medicine (non-EM) residents in a university hospital ED. METHODS: This retrospective observational study was performed in a university hospital ED and level I trauma center. The facility had no EM residency, but was staffed with 24-hour EM faculty coverage. A computerized tracking system was searched for the number of patients seen by each of 93 non-EM residents for 12 nonconsecutive months. The ED schedule for each month was used to calculate the number of hours worked by each resident. From these figures, the number of patients seen per hour by each resident was calculated. RESULTS: The postgraduate years of training of the residents were as follows: 78 (84%) were PGY1, ten (11%) were PGY2, and five (5%) were PGY3. All the residents combined saw a mean 0.95 +/- 0.20 patients/hour, with a range from 0.58 to 1.75 patients/hour. There was no significant difference between the numbers of patients seen when compared by specialty using the Tukey-Kramer test (alpha = 0.05). CONCLUSION: The rate at which non-EM residents work up patients is consistent with previously reported rates for EM residents.

Education, Medical, Graduate↗
PubMed1999

Academic emergency medicine staffing nonacademic emergency department sites: a national survey.

UNLABELLED: Changing health care markets have threatened academic health centers and their traditional focus on teaching and research. OBJECTIVES: To determine the number of academic emergency medicine departments (AEMDs) that staff additional non-academic ED sites and to determine whether clinical reimbursement monies from those ED sites are used for academic purposes. METHODS: A two-part survey of all 119 academic EM programs listed in the 1997-1998 Graduate Medical Education Directory was conducted. Questionnaires were addressed to each AEMD chair. AEMDs and ED sites were characterized. Hiring difficulties, EM faculty academic productivity, and use of ED site reimbursement monies for academic activities were assessed. RESULTS: Ninety-nine of 119 (83%) AEMDs responded. Twenty-three (23%) AEMDs staffed 28 added ED sites. These sites tended to be urban (65%), with moderate volumes (25,000-35,000 patients/year), and had an equal or better reimbursement rate than the AEMD (89%). ED sites were commonly staffed by academic EM faculty (79%) and EM residents (29%). Ninety-six percent of the AEMDs had hired additional faculty; hiring new faculty was considered easy. Academic productivity at AEMDs with added ED sites was reported as unchanged. Reimbursement monies from these ED sites were commonly used for faculty salary support, faculty development, and EM research and residency activities. CONCLUSIONS: Academic EM departments are often affiliated with nonacademic ED sites. These additional sites are commonly staffed by academic EM faculty and EM residents. Academic productivity does not appear to decrease when additional ED sites are added. Reimbursement monies from these ED sites commonly supports academic activities.

Bed Occupancy↗
PubMed2000

Clinical errors in emergency medicine: experience at the emergency department of an Italian teaching hospital.

The level of commitment in the analysis of clinical errors made in the emergency department (ED) is currently focused on organization and processes rather than on individual action. Four major cases of clinical errors made in the ED of a teaching hospital were investigated. Analysis suggested that the process of clinical decision making and the overreliance on the use of patterns during the cognitive process had a major role in causing the errors, rather than factors related to procedures or organization. It appears hard to design system changes and tactics to significantly reduce the probability of making errors associated with the cognitive process involved in clinical decision making. The authors have initiated a systematic analysis of errors made during the diagnostic workup in their ED, and the rate of clinically significant errors is tracked. A file is being created with the purpose to use it for teaching and orientation of all new staff.

Aged↗
PubMed2001

Effect of an emergency department (ED) managed acute care unit on ED overcrowding and emergency medical services diversion.

OBJECTIVE: To determine the impact of an inpatient, emergency department (ED)-managed acute care unit (ACU) on ED overcrowding and use of ambulance diversion. METHODS: Descriptive observational study with prospectively collected data from a 14-bed ACU recently opened remote from the main ED. Rates of patients who left without being seen (LWBS) and ambulance diversion frequency and duration were adjusted for ED patient volumes and compared with those for the period immediately before the ACU was opened and with those for a matching time period during the previous year. RESULTS: There were 1,589 patients seen in the ACU during the first ten weeks of operation, representing about 14.5% of the ED volume (10,871). About 33% could be classified as post-ED management, 20% as admission processing, and the rest as primary evaluation. The number of patients who LWBS decreased from 10.1% of the ED census two weeks prior to opening of the ACU, and from 9.4% during the previous year, to 5.0% (range 4.2%-6.2%) during the ensuing ten weeks post opening. Ambulance diversion was a mean of 6.7 hours per 100 patients before the unit opened and 5.6 hours per 100 patients during the same time in the previous year, and decreased to 2.8 hours per 100 patients after the unit opened (p < 0.05, respectively). A six-month pre- and two-month post-examination revealed that the mean monthly hours of ambulance diversion for the ED decreased by 40% (202 hours vs 123 hours) (p < 0.05) in contrast to a mean increase of 44% (186 hours vs 266 hours) (p < 0.05) experienced by four proximate hospitals. CONCLUSIONS: An ED-managed ACU can have significant impact on ED overcrowding and ambulance diversion, and it need not be located proximate to the ED.

Ambulances↗
PubMed2002

Preventive care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review.

OBJECTIVE: To systematically review the medical literature in order to determine the strength of the recommendation for screening and brief intervention (SBI) for alcohol-related problems in the emergency department (ED) setting. METHODS: The review followed the methodology of systematic reviews and was facilitated through the use of a structured template, a companion explanatory piece, and a grading and methodological scoring system based on published criteria for critical appraisal. The primary outcome measure was the prevention of mortality and morbidity secondary to alcohol-related illnesses/injuries. The secondary outcome measures included: decreased consumption; fewer ED/outpatient visits and hospitalizations; a decrease in social consequences; and increased referrals for follow-up and/or treatment. Three Medline searches as well as a search of the Cochrane Library were performed. Two team members reviewed the abstracts and selected pertinent articles. References were screened for additional pertinent articles. RESULTS: Twenty-seven articles were identified and reviewed, in addition to the 14 primary articles included in the 1996 U.S. Preventive Services Task Force Report. The study populations were diverse, including inpatient, outpatient, and college settings, with ages ranging from 12 to 70 years. Four studies were ED-based and two included EDs as one of multiple sites. Thirty-nine studies on SBI, 30 randomized controlled and nine cohort, were used to formulate the current recommendation. A positive effect of the intervention was demonstrated in 32 of these studies. CONCLUSIONS: The authors recommend that SBI for alcohol-related problems in the ED be incorporated into clinical practice.

Alcoholism↗
PubMed2006

Emergency nurse practitioner care and emergency department patient flow: case-control study.

OBJECTIVE: The present study aimed to compare ED waiting times (for medical assessment and treatment), treatment times and length of stay (LOS) for patients managed by an emergency nurse practitioner candidate (ENPC) with patients managed via traditional ED care. METHODS: A case-control design was used. Patients were selected using the three most common ED discharge diagnoses for ENPC managed patients: hand/wrist wounds, hand/wrist fractures and removal of plaster of Paris. The ENPC group (n = 102) consisted of patients managed by the ENPC who had ED discharge diagnoses as mentioned above. The control group (n = 623) consisted of patients with the same ED discharge diagnoses who were managed via traditional ED care. RESULTS: There were no significant differences in median waiting times, treatment times and ED LOS between ENPC managed patients and patients managed via traditional ED processes. There appeared to be some variability between diagnostic subgroups in terms of treatment times and ED LOS. CONCLUSION: Patient flow outcomes for ENPC managed patients are comparable with those of patients managed via usual ED processes.

Adolescent↗
PubMed2006

Potential cervical spine injury and difficult airway management for emergency intubation of trauma adults in the emergency department--a systematic review.

BACKGROUND: Emergency airway management for trauma adults is practised by physicians from a range of training backgrounds and with differing levels of experience. The indications for intubation and technique employed are factors that vary within EDs and between hospitals. OBJECTIVES: To provide practical evidence based guidance for airway management in trauma resuscitation: first for the trauma adult with potential cervical spine injury and second the management when a difficult airway is encountered at intubation. SEARCH STRATEGY AND METHODOLOGY: Full literature search for relevant articles in Medline (1966-2003), EMBASE (1980-2003), and the Cochrane Central Register of Controlled Trials. Relevant articles relating to adults and written in English language were appraised. English language abstracts of foreign articles were included. Studies were critically appraised on a standardised data collection sheet to assess validity and quality of evidence. The level of evidence was allocated using the methods of the Australian National Health and Medical Research Council.

Adult↗
PubMed1992

Intracardiac therapy following emergency thoracotomy in the accident and emergency department: an experimental model.

For a select group of patients with penetrating chest trauma, immediate thoracotomy in the accident and emergency department offers the only chance of survival. Foley catheters have been used to achieve haemostasis in cardiac wounds but are not widely used for intracardiac fluid and drug administration during resuscitation. In an anatomical model designed to assess this procedure an average flow rate of 275 ml min-1 was achieved. The equipment required is readily available and easily assembled.

Animals↗
PubMedDate not supplied

Emergency department organisation for disasters: a review of emergency department disaster plans in public hospitals of Singapore.

Disaster management plans of emergency departments (EDs) in four major public hospitals were reviewed. A comparison was made between these plans, and they were analyzed to gain an understanding of the differing objectives and doctrines behind the practices. These were summarized into five major management concepts, which are considered to be critical to the success of a disaster plan: 1) staff mobilization systems (cascading vs batch mobilization); 2) staff deployment systems; 3) team organization (surgeons vs residents); 4) area management (the role of the area manager); 5) casualty volume management (accommodation vs expansion vs extension concepts). The concepts derived should serve as a useful guide to the development of an ED disaster plan and potentially influence how new ED facilities could be planned.

Disaster Planning↗
PubMed2004

JUST in time health emergency interventions: an innovative approach to training the citizen for emergency situations using virtual reality techniques and advanced IT tools (the Web-CD).

This paper reports the results of the first of the two systems developed by JUST, a collaborative project supported by the European Union under the Information Society Technologies (IST) Programme. The most innovative content of the project has been the design and development of a complementary training course for non-professional health emergency operators, which supports the traditional learning phase, and which purports to improve the retention capability of the trainees. This was achieved with the use of advanced information technology techniques, which provide adequate support and can help to overcome the present weaknesses of the existing training mechanisms.

Adolescent↗