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At least 1,009 records · Page 56Linked to original sources
PubMed2003

Pediatric red blood cell transfusions increase resource use.

OBJECTIVE: To test the hypothesis that red blood cell transfusions are associated with increased resource utilization and mortality in critically ill children. METHODS: Five pediatric intensive care units (PICUs) participated in a retrospective, cohort analysis (1996-1999). Children with a hemoglobin value <or=9 g/dL during their PICU stay were enrolled. Data consisted of descriptive information, hemoglobin values, use of blood products, PICU resource use, and hospital mortality rate. RESULTS: Among 240 children, 131 were transfused and 109 were not transfused. After controlling for the effects of other variables, transfusion was associated with an increase in days of oxygen use (4.48 +/- 1.37 days), days of mechanical ventilation (4.05 +/- 1.10 days), days of vasoactive agent infusions (1.27 +/- 0.44 days), and an increase of PICU and hospital lengths of stay (4.44 +/- 1.32, and 7.75 +/- 2.36 days, respectively). CONCLUSION: Red blood cell transfusions are associated with an increase in resource utilization in critically ill children. The decision to transfuse patients should incorporate this potential morbidity.

Anemia↗
PubMed2003

A randomized trial of visual impairment interventions for nursing home residents: study design, baseline characteristics and visual loss.

INTRODUCTION: Visual impairment among nursing home residents is higher than in community-dwelling elderly. The provision of eye care services may be beneficial to nursing home patients. Our project, a randomized trial of vision restoration and rehabilitation in nursing home residents, compares usual care to targeted interventions. In this paper, we present the baseline characteristics of our sample within the nursing homes. METHODS: Twenty-eight nursing homes on Maryland's Eastern Shore were matched in pairs by size and payment type. Each pair was randomized to usual care or targeted intervention. Habitual and best-corrected acuity was attempted, using standard letter symbol/charts and grating acuity charts. Visual impairment was vision in the better eye <20/40 on letter and/or grating acuity. The MiniMental State Examination (MMSE) was used to determine cognitive impairment. RESULTS: Of those participants eligible to be screened, 40% had severe cognitive impairment (MMSE score 0-9). No measure of acuity could be ascertained on 18% of eligibles. Among the 1305 persons with acuity data, 38% had presenting vision worse than 20/40. After refractive correction, 29% had visual impairment. There was no difference by race or gender in those with visual impairment, although they were older, compared to those without visual loss. CONCLUSIONS: The nursing home residents had high rates of both cognitive impairment and visual impairment, creating a challenging environment for visual intervention. By improving access to eye care within the context of the clinical trial, and changing either the magnitude of visual loss or the resultant impact on function, we hope to demonstrate a change in the quality of life for nursing home residents.

Aged↗
PubMed2002

Potential uses for geographic information system-based planning and decision support technology in intensive food animal production.

Although geographic information systems (GIS) have been used in many disciplines, the available technology in planning and decision support has only recently begun to be used in intensive animal production, in areas such as confined animal feeding operations. GIS-based planning and decision support systems have the potential to enhance many aspects of intensive animal production, such as disease monitoring and prevention, emergency management and nutrient waste disposal. Current uses of GIS in animal production are reviewed. Potential uses are illustrated using the example of the poultry industry on the Delmarva Peninsula, USA.

Animal Diseases↗
PubMed1991

Organizational evolution: a hospice case study.

An analysis of the maturation process of a large, multiple site hospice using Greiner's organizational development model is presented. Past and present growth phases and crises are described. The value of such an analysis lies in its insights into organizational growth and the resultant lessons for other, similar agencies. The ability to assess an organization's stage of development means that crises and needs can be anticipated and appropriate resolutions can be planned. Generalizations can be made to multiple site or regionally organized hospice development elsewhere.

Delaware↗
PubMedDate not supplied

The utilization of midazolam as a pharmacologic adjunct to endotracheal intubation by paramedics.

OBJECTIVE: Pharmacologic agents have been used in the prehospital setting for facilitating endotracheal intubation (ETI). The purpose of this study was to determine the utility of intravenous midazolam for prehospital patients who require pharmacologic relaxation to facilitate ETI. METHODS: Data were reviewed retrospectively using paramedic charts from an eight-month period for a three-county state EMS system. RESULTS: There were 26,133 paramedic dispatches during the study period. Six hundred eighty-three ETIs were attempted, including 72 midazolam-facilitated intubations (MFIs). The most common indications for MFI were "clenched teeth," "gag," and "combativeness." Successful MFI was achieved in 45 of 72 cases (62.5%). Midazolam-facilitated intubation was less successful for trauma patients (41.2%) than for medical patients (69.1 %) (p = 0.04). Of the 58 failed conventional ETIs that occurred during the study period, 25 (43.1%) were identified as having one or more indications for the use of MFI. Although the use of intravenous midazolam was effective in facilitating ETI, a high MFI failure rate (37.5%) was noted. CONCLUSION: Although it is of limited efficacy, MFI is underutilized and should be considered by medical direction as a pharmacologic adjunct to ETI in selected field patients.

Delaware↗
PubMedDate not supplied

Failed prehospital intubations: an analysis of emergency department courses and outcomes.

OBJECTIVE: To examine the reasons for failed prehospital endotracheal intubation (ETI) and to identify how the airway was subsequently managed in the emergency department (ED). METHODS: Data were collected from January to December 1998 for a county-wide paramedic system. Failed prehospital ETIs and perceived reasons for failure were identified. Subsequent ED airway management was reviewed. RESULTS: During the study period there were 13,112 patient contacts resulting in ETI attempts on 592 patients, of whom 536 (90.5%) were successfully intubated. Of the 56 failed field intubations, 49 (87.5%) had ED charts available for review. Endotracheal intubation failure was associated with inadequate relaxation in 24 (49%), difficult anatomy in ten (20%), and obstruction in five (10%). Successful ETI was achieved in the ED in 42 cases (86%). Twenty cases (41%) were facilitated by rapid-sequence intubation (RSI) in the ED. For those with incomplete relaxation in the field, 13 of 24 (54%) were intubated in the ED using RSI. Factors associated with the use of ED RSI include attempted prehospital nasotracheal intubation or attempted prehospital midazolam-facilitated intubation (p < 0.001). The predicted need for RSI in this prehospital system is approximately 3.9%. In eight cases, three or more ETI attempts or the use of rescue airways was required in the ED. The predicted minimum incidence of "truly difficult" intubation in this system is approximately 0.8-1.6%. CONCLUSIONS: Paramedic intubation failures result from a variety of factors. Less than half of field intubation failures were remedied in the ED by the use of neuromuscular-blocking agents. A similar number were intubated without the use of RSI. A fraction of failed field ETIs may have resulted from inadequate operator training or experience. A small percentage of field patients were "truly difficult" and required advanced resources in the ED to facilitate airway management. Medical directors should be cognizant of the numerous factors affecting intubation performance when designing and implementing approaches to difficult prehospital airways.

Adolescent↗
PubMedDate not supplied

Patient status and time to intubation in the assessment of prehospital intubation performance.

UNLABELLED: Assessment of paramedic endotracheal intubation (ETI) performance often does not account for varied clinical conditions or the time required to complete the procedure. OBJECTIVE: To demonstrate the utility of patient status and time to intubation (TTI) for evaluating prehospital ETI performance. METHODS: Paramedic charts were reviewed for the period January-December 1998. Patient clinical status was defined as cardiac arrest (absence of perfusing rhythm) or non-cardiac arrest (presence of perfusing rhythm). Method, route, and success of ETI were noted. The TTI was determined as the elapsed time from on-scene arrival to securing of the endotracheal tube. Time elapsed from on-scene arrival to emergency department arrival was noted for instances of failed ETI. Statistical analysis was performed using chi-square and survival analysis (Kaplan-Meier estimator). RESULTS: Computer records were available for 26,026 patient contacts. Of 893 documented ETI attempts, 771 (86%) were successful. The ETI success rate was significantly higher (p<0.001) for cardiac arrests (551 of 591, 93.2%) than for non-cardiac arrests (220 of 302, 72.9%). Median TTIs were 5 minutes (95% CI: 5, 5) for cardiac arrests and 17 minutes (95% CI: 14, 20) for non-cardiac arrests; this difference was significant (p<0.001). For non-cardiac arrests, ETI success was significantly (p = 0.002) higher for orotracheal intubation (OTI) (168 of 214, 78.5%) than for nasotracheal intubation (NTI) (52 of 88, 59.1%). Median TTIs were 15 minutes (95% CI: 13, 17) for OTI and 25 minutes (95% CI: 23, 27) for NTI; this difference was significant (p = 0.002). For non-cardiac arrests, the difference i

Delaware↗
PubMedDate not supplied

Effectiveness of a medical priority dispatch protocol for abdominal pain.

OBJECTIVE: Medical Priority Dispatch System (MPDS) protocols are used to determine the appropriate level of emergency medical services (EMS) response that is sent to care for patients in the prehospital setting. The objective of this study was to determine the proportion of patients with abdominal pain who would benefit from advanced life support (ALS) when called for by these protocols. METHODS: All 9-1-1 calls were processed using MPDS protocols to determine whether the patient required ALS or basic life support (BLS) services. Consecutive patients having an ALS response for a chief complaint of abdominal pain were included. Dispatch decisions that did not follow the MPDS protocols, and cases taken to facilities other than the primary study hospitals, were excluded. EMS run sheets and hospital records were reviewed to determine: 1) whether prehospital ALS interventions were required, 2) emergency department (ED) disposition, 3) hospital course, and 4) final diagnosis. Calls were classified according to the need for ALS and the seriousness of the subsequent diagnosis. Data analysis was performed by determining 95%, confidence intervals (CIs). RESULTS: Of the 343 patients classified as 1C1 or 1C2 who were transported by ALS during the time period, 227 (67%) were transported to the study hospitals. Nine (4%) were excluded because of inappropriate dispatch, leaving 218 for analysis. Hospital records were available for 186 (86%) cases, of which 12 (6%; CI 3%, 9%) were potentially life-threatening, requiring ALS intervention. Seventeen (9%; CI 5%, 1%) were non-life-threatening, but potentially benefited from ALS intervention. The remaining 157 (84%; CI 79%, 89%) were classified as not requiring ALS. CONCLUSIONS: Use of age- and gender-specific MPDS protocols for patients with a chief complaint of abdominal pain results in significant overtriage and overuse of ALS. Steps should be taken to develop key questions that provide more accurate classification of these patients that goes beyond age and gender classification alone.

Abdominal Pain↗
PubMedDate not supplied

The safety of a field termination-of-resuscitation protocol.

BACKGROUND: A 1999 National Association of EMS Physicians position paper recommends that termination of resuscitation (TOR) be considered if the adult nontraumatic out-of-hospital cardiac arrest (OOHCA) patient receives cardiopulmonary resuscitation, definitive airway management, intravenous access, and at least 20 minutes of resuscitative efforts, yet remains in asystole or pulseless electrical activity with no return of spontaneous circulation (ROSC) in the field. OBJECTIVE: To test the safety of this protocol, with survival to discharge as the primary endpoint. The study hypothesis was that the protocol is 100% specific: no patient who would be eligible for TOR survived to discharge. METHODS: Utstein template data were collected prospectively for all OOHCA patients received at two academic emergency departments between August 1999 and January 2003, and retrospective OOHCA data were collected at one of the hospitals covering the interval October 1993 to June 2002. Each case was examined to determine whether the patient would have been eligible for TOR, and whether he or she survived. RESULTS: Three hundred sixty-six prospective and 135 retrospective cases were included. Twelve patients survived to discharge, but none were eligible for TOR, as all had ROSC in the field (specificity 100%, sensitivity 58%). Of the 63 patients who survived to admission, four were eligible for TOR (specificity 94%, sensitivity 64%). None of these four survived to discharge, and not regained consciousness prior to death. CONCLUSIONS: The proposed protocol appears to be safe, with 100% specificity for lack of survival to discharge in this sample. A small number of patients eligible for TOR did survive to admission, but none survived to discharge.

Adult↗
PubMedDate not supplied

The impact of prehospital instant photography of motor vehicle crashes on receiving physician perception.

OBJECTIVES: The study was conducted to determine whether the use of prehospital instant photography of motor vehicle crashes (MVCs) by paramedics altered receiving physician (RP) perception of the magnitude of crash severity, as compared with verbal reports of vehicle damage. In addition, the study sought to determine whether altered RP perception resulted in any subsequent changes in emergency department (ED) management. METHODS: A prospective questionnaire and retrospective chart review were used at a Level I suburban trauma center receiving MVC patients from a single municipal paramedic agency. Patients injured in MVCs who required advanced life support (ALS) interventions and were subsequently evaluated by either surgical residents, emergency medicine residents, or attending emergency physicians in the ED were eligible for study enrollment. Instant photographs of interior and exterior vehicle damage were obtained by paramedics who then provided a verbal report of vehicle damage to the RP. Initially blinded from the photographs, the RP was then asked to rate the severity of the crash based on the verbal report and list planned interventions (laboratory tests, blood products, radiographs, and probable patient disposition). The RP was then shown the crash photographs and once again asked to rate the crash severity based on the addition of the photos and list changes in patient management based on any alterations in his or her perception. Hospital records were then examined to determine costs billed to patients and the length of hospital stay for those patients who were admitted. RESULTS: Instant photographs resulted in changes in physician perception in 47% (27 of 58) of the cases. Eighty-five percent of these physicians rated the MVC as more severe than the verbal report had indicated (p < 0.05 by multiple and logistic regression). The RPs who did alter their perceptions based upon the addition of MVC photos then changed their ED management in 59% (16 of 27) of the cases. Patients whose crash photographs altered RP perception of crash severity and who were subsequently released from the ED had average ED costs of $686, as compared with average ED charges of $595 for released patients whose crash photos did not alter physician perception of crash severity (p > 0.05 by Student's t-test). Inpatient charges and lengths of stay were also similar between the two groups for admitted patients: $21,363/14 days for the perception-change group and $24,726/8 days for the no-change-in-perception group (p > 0.05 for all comparisons). CONCLUSION: The augmentation of verbal paramedic reports with prehospital instant photographs frequently altered both physician perception of MVC severity and subsequent ED management of these trauma patients. However, cost to the patient and length of hospital stay were not significantly altered as a result of the change in physician perception.

Accidents, Traffic↗
PubMedDate not supplied

Emergency medical services transport of patients with headache: mode of arrival may indicate serious etiology.

OBJECTIVE: To determine whether mode of arrival is associated with seriousness of etiology and use of diagnostic testing in patients treated in the emergency department for headache. METHODS: This observational, retrospective study was conducted by consecutive review of the records of patients presenting to the emergency department with a chief complaint of headache from December 1994 through May 1995. Patients with altered mental status or seizures were excluded. Mode of arrival was classified as either by EMS or other (e.g., private vehicle). Patients with a final diagnosis of meningitis, intracranial hemorrhage, or central nervous system tumor were classified as having serious causes, whereas those with headache due to migraine, tension headache, or headache that was otherwise unspecified were classified as nonserious. The use of diagnostic studies, such as lumbar puncture or CT scan, and their results, was recorded. Patients were included in the category of patients having serious intracranial pathology even if the diagnosis was delayed. Statistical analysis was performed using the Yates-corrected chi-square test, and by determining odds ratios (ORs) with 95% confidence intervals. RESULTS: For 967 patients presenting with a chief complaint of headache, 837 charts were included in the analysis. A total of 102 patients arrived by EMS, and 735 arrived by other means. Patients arriving by EMS had a higher rate of serious cause of headache than did those arriving by other means (OR = 18.5, p < 0.0001). EMS patients tended to undergo additional diagnostic testing (OR = 4.4, p < 0.0001), and those tests were more likely to be abnormal than for those arriving by other means (OR = 9.4, p < 0.0001). Males had a somewhat higher rate of serious diagnosis (OR = 2.6, p < 0.05). CONCLUSIONS: In this EMS system, patients with headache who arrive by EMS are more likely to have serious causes. Mode of arrival may be of use to the clinician in assessing risk of serious illness among patients with headache. Whether this observation represents an element of self-triage or a combination of other factors remains to be determined.

Adult↗