Position of the mental foramen in a North American, white population

In Italy departments of emergency medicine and emergency medical service systems (EMS) were first set up at the end of the 1970s. Since that time many dramatic and significant changes have taken place in the care of the critically ill patient. In Italy the interest in emergency problems and the need for emergency intervention have increased considerably. Nevertheless several problems still have to be solved in order to obtain a standardized organization of the emergency system in Italy and uniform training of emergency care providers.     

Trauma mortality patterns in three nations at different economic levels: implications for global trauma system development

BACKGROUND: Whereas organized trauma care systems have decreased trauma mortality in the United States, trauma system design has not been well addressed in developing nations. We sought to determine areas in greatest need of improvement in the trauma systems of developing nations. METHODS: We compared outcome of all seriously injured (Injury Severity Score > or = 9 or dead), nontransferred, adults managed over 1 year in three cities in nations at different economic levels: (1) Kumasi, Ghana: low income, gross national product (GNP) per capita of $310, no emergency medical service (EMS); (2) Monterrey, Mexico: middle income, GNP $3,900, basic EMS; and (3) Seattle, Washington: high income, GNP $25,000, advanced EMS. Each city had one main trauma hospital, from which hospital data were obtained. Annual budgets (in US$) per bed for these hospitals were as follows: Kumasi, $4,100; Monterrey, $68,000; and Seattle, $606,000. Data on prehospital deaths were obtained from vital statistics registries in Monterrey and Seattle, and by an epidemiologic survey in Kumasi. RESULTS: Mean age (34 years) and injury mechanisms (79% blunt) were similar in all locations. Mortality declined with increased economic level: Kumasi (63% of all seriously injured persons died), Monterrey (55%), and Seattle (35%). This decline was primarily due to decreases in prehospital deaths. In Kumasi, 51% of all seriously injured persons died in the field; in Monterrey, 40%; and in Seattle, 21%. Mean prehospital time declined progressively: Kumasi (102 +/- 126 minutes) > Monterrey (73 +/- 38 minutes) > Seattle (31 +/- 10 minutes). Percent of trauma patients dying in the emergency room was higher for Monterrey (11%) than for either Kumasi (3%) or Seattle (6%). CONCLUSIONS: The majority of deaths occur in the prehospital setting, indicating the importance of injury prevention in nations at all economic levels. Additional efforts for trauma care improvement in both low-income and middle-income developing nations should focus on prehospital and emergency room care. Improved emergency room care is especially important in middle-income nations which have already established a basic EMS.     

Two-leaflet artificial heart valve with the common turn axis for leaflets

Quality improvement, measurement, and accountability pervade all health care, including the agendas of nursing, other care providers, and consumer groups. One new face of quality is unequivocal: data will be more equitably shared among all groups for data-based quality judgments. This will emphasize quality more than cost with greater involvement of the citizens compared to health care providers, payers, and health care product suppliers. Emphasis on quality will allow patients to have a voice heard and amplified through the implementation of patient-centered outcomes in the computerized patient care record. This article describes the implications of the Nursing Outcomes Classification (NOC) for nursing information systems and the computer-based patient record.     

Transition to a computer-based record using scannable, structured encounter forms

OBJECTIVE: To evaluate the quality of documentation and user satisfaction with a structured documentation system for pediatric health maintenance encounters, using scanned paper-based forms to generate an electronic medical record. DESIGN: (1) A retrospective medical record review comparing 16 structured (ST) records with 16 contemporaneously created unstructured records, (2) a questionnaire evaluation of user satisfaction, and (3) an electronic records review of patients seen 1 year following the full implementation of the system to evaluate persistence of the effect. SETTING: The Yale-New Haven Hospital Pediatric Primary Care Center, New Haven, Conn, an inner-city clinic in an academic center. PARTICIPANTS: (1) A random sample of 16 health maintenance records completed by first- and second-year residents in February 1996 matched for patient's age and provider training level with 16 contemporaneously documented visits, (2) 16 of 18 pediatric level 1 residents and 14 of 16 pediatric level 2 residents who completed questionnaires, and (3) all electronic records of health maintenance visits during February 1997. MAIN OUTCOME MEASURES: The number of data elements documented and the percentage of records that record specific components of the health maintenance encounter. User satisfaction was specified on a Likert scale. RESULTS: Overall, residents in the ST records group documented more data elements per visit than did those in the unstructured records group. The number of developmental items documented was 11.5 per visit in the ST records group and 4.8 per visit in the unstructured records group (P = .004). Likewise, anticipatory guidance was more thoroughly documented in the ST records group--8.3 items per visit vs 2.5 items per visit (P < .001). Ninety percent of the users preferred the ST records. One year after the adoption of the ST recording system, high levels of thoroughness persisted. CONCLUSIONS: Structured, scannable encounter forms can facilitate documentation of patient care and are well accepted by users. They can provide an effective mechanism to ease the transition to a computer-based patient record.     

Quality management in emergency medicine

Although the need for the implementation of a quality management concept for the German emergency medical system (EMS) has been discussed for more than 10 years, such a concept has not been realised on a broad scale. Standardised national data sheets were developed many years ago. They are used by many local agencies, but a data-gathering system on a state or national basis is still lacking. In times of reduced funds for health care expenditures, quality management could be a reliable way to ensure that the EMS provides safe services to the patient based on the current state of medical science in an efficient manner. Based on clear definitions, structure, process, and outcome quality can be analysed, and the results provide the basis for continuous quality-improvement strategies. As not all aspects of the system can be analysed continuously, one has to select areas of special importance. External and internal quality control are equally important. Quality control works on the basis that all EMS team members are motivated to perform on a professional level to ensure that each patient is treated adequately. It evaluates the system to create circumstances that enhance the achievement of this goal. Quality management is not only concerned with mishaps, because areas with documented good performance also provide important information.     

A method to reduce response times in prehospital care: the motorcycle experience

This study compared the response times of a motorcycle and a standard ambulance in a congested urban emergency medical services (EMS) setting. The study was performed in Taipei, Taiwan, a densely populated urban area. A basic life support (BLS) motorcycle (without defibrillation capability) and an advanced life support (ALS) ambulance were based at three study hospitals and simultaneously dispatched when there was a perceived need for ALS ambulance transport. Over a 3-month period, prehospital personnel evaluated 307 medical and trauma emergencies. Time data were insufficient for analysis in 33 cases, leaving a study population of 274. Response times of the motorcycle and the ambulance were prospectively assessed and compared. During rush hours, the response times of the motorcycle and ambulance were 4.9+/-3.0 minutes and 6.3+/-3.4 minutes (P < .05), respectively, and in non-rush hours, 4.2+/-2.1 minutes and 5.1+/-2.5 minutes (P < .05), respectively. Using motorcycles to transport EMTs to the emergency scene significantly reduced response time compared with a standard ambulance in a congested urban setting. Large prospective studies are required to determine the impact on patient outcome of shorter EMS response times using motorcycles. EMS motorcycles appear feasible and deserve consideration to help expedite prehospital care in other systems in densely populated cities.     

Implementing the Nursing Outcomes Classification in a clinical information system in a tertiary care setting

Implementing Nursing-Sensitive Outcomes Classification (NOC) is consistent with the goal of the Department of Nursing at this tertiary care center to include the Nursing Minimum Data Set in the electronic medical record (EMR). This article describes the implementation and evaluation of the NOC in selected patient care units where a clinical information system is used in conjunction with departmental patient care guidelines. In light of identified limitations, the NOC was determined to be useful and comprehensive as measured by the frequency of its use, the positive feedback by staff, and the minimal additions identified for the classification.     

Serum sialic acid and its relationship to various haematological parameters, including erythrocyte sedimentation rate

Policies regarding ambulance diversion are critical to ensuring that EMS providers are aware of appropriate patient destinations, even before patients enter the system. Field EMS personnel should never be requested to prolong transport time intervals to search for an available hospital at the potential expense of patients' conditions and the immediate availability of out-of-hospital emergency care for the community. The responsibility for providing efficient emergency care to the community rests with all those who contribute to EMS structures and processes. All EMS system participants, including hospitals, EMS providers, local and regional lead agencies, and medical oversight authorities, must work together to create comprehensive ambulance diversion policies that satisfactorily meet each other's needs, while maintaining the highest regard for the needs of EMS patients and the entire community.     

Ocular surface damage and tear lactoferrin in dry eye syndrome

Because falls are common among the elderly and are associated with high morbidity and mortality, community surveillance has been recommended. The purpose of this study was to characterize the impact of falls among the elderly on emergency medical transport services (EMS) and to explore the potential for community surveillance of falls through the use of computerized EMS data. Computerized EMS data and United States census data for 1990 for persons aged > or = 65 in Forsyth County, NC, were used to produce EMS transport rates for falls and to make comparisons by age, gender, race, and residence (nursing home vs community). A fall was reported as the cause for EMS summons in 15.1% (613 of 4,058) of cases. Transport rates in 1990 for falls were 7.8 per 1,000, 25.4 per 1,000, and 58.5 per 1,000 for the age groups of 65 to 74 years, 75 to 84 years, and 85 years and older. Rates were higher for females than for males (17.1 per 1,000 v 8.1 per 1,000) and higher for whites than for African-Americans (14.3 per 1,000 v 10.3 per 1,000). Rates for nursing home residents were four times that of community residents (70.6 per 1,000 v 16.0 per 1,000). Over 50% of nursing home fallers were transported between midnight and 0400 compared with 25% of community dwellers. EMS summons for older adults reporting a fall accounts for a significant portion (15%) of all transports in this county. Computerized EMS data demonstrated patterns of falls among the elderly that are consistent with known demographic factors. The potential for using computerized EMS data as a practical means of community surveillance should be further explored.     

Precisely defining high-risk operable head and neck tumors based on RTOG #85-03 and #88-24: targets for postoperative radiochemotherapy?

OBJECTIVE: In the German physician-based emergency medical system (EMS) psychiatric emergency situations (PES) rank on third place contradictory to it's importance during emergency physician training program. The aim of our study was to examine the relevance of PES and the stress which PES imposes upon EMS physicians. Further, the interest of training programs on that issue was determined. Knowledge about PES was investigated by a short test. METHODS: 952 emergency physicians were sent a questionnaire about following: demographic data, frequency of PES, strain by PES, own knowledge, interest about training programs. Further five typical PES were presented for diagnostic and therapeutic judgement. RESULTS: 222 responded (183 men/37 women/2 without gender data, average age: 40.1 +/- 6.7, qualification as emergency physician: 9.6 +/- 5.1 years, most frequent subspeciality in-hospital physicians: anaesthesiology 67.5%, in-practice physicians: general medicine 72.1%). PES frequence was estimated at 9.4%, personal knowledge judged only by 13% as sufficient, 14.2 felt incapable by PES. 73% saw importance of training, especially expressed by the more experienced (P < 0.05). Test presented 65% correct diagnoses, 33% correct therapy, 26% incorrect decision of hospital admission. CONCLUSION: PES are a frequent problem of pre-hospital patient care for emergency physicians. As personal knowledge was estimated to be insufficient, the interest for courses concerning PES issues is high.     

Predicting survival from out-of-hospital cardiac arrest: a graphic model

STUDY OBJECTIVE: To develop a graphic model that describes survival from sudden out-of-hospital cardiac arrest as a function of time intervals to critical prehospital interventions. PARTICIPANTS: From a cardiac arrest surveillance system in place since 1976 in King County, Washington, we selected 1,667 cardiac arrest patients with a high likelihood of survival: they had underlying heart disease, were in ventricular fibrillation, and had arrested before arrival of emergency medical services (EMS) personnel. METHODS: For each patient, we obtained the time intervals from collapse to CPR, to first defibrillatory shock, and to initiation of advanced cardiac life support (ACLS). RESULTS: A multiple linear regression model fitting the data gave the following equation: survival rate = 67%-2.3% per minute to CPR-1.1% per minute to defibrillation-2.1% per minute to ACLS, which was significant at P < .001. The first term, 67%, represents the survival rate if all three interventions were to occur immediately on collapse. Without treatment (CPR, defibrillatory shock, or definitive care), the decline in survival rate is the sum of the three coefficients, or 5.5% per minute. Survival rates predicted by the model for given EMS response times approximated published observed rates for EMS systems in which paramedics respond with or without emergency medical technicians. CONCLUSION: The model is useful in planning community EMS programs, comparing EMS systems, and showing how different arrival times within a system affect survival rate.     

Isoforms p69 and p100 of 2'',5''-oligoadenylate synthetase induced differentially by interferons in vivo and in vitro

There is no better place to test life-saving resuscitation interventions than in the prehospital setting. Patients rarely survive cardiac arrest if resuscitation techniques have failed before leaving the scene. Also, paramedics are usually very experienced in key initial resuscitative techniques, and they routinely operate under strict paramilitary protocol, resulting in better study compliance. In addition, the large study populations that are derived from emergency medical services (EMS) systems lead to faster study completion and statistically stronger data. Most important, by reinforcing standardized care, rigidly scrutinized trials improve patient care, regardless of the effect of the study intervention. The success of productive EMS research centers requires routine communication between hospital and EMS administrators and their medical directors, designation of mutually acceptable data collectors who guarantee confidentiality, reciprocal exchange of study data provided as educational seminars to the hospitals, commitments to support the budget requests of an EMS program and appropriate system modifications, inclusion of EMS personnel in study design from the very beginning, prospective education of the medical community and media before protocol implementation, an authoritative grassroots medical director, and a paramedic supervisor system.     

Review of studies that compare the quality of cardiovascular care in HMO versus non-HMO settings

OBJECTIVES: The authors compared the quality of cardiovascular care in health maintenance organizations (HMOs) versus traditional insurance arrangements through an analysis of existing literature. METHODS: Data were derived from all peer-reviewed studies published through November 1995 that used process or outcome measures to evaluate the quality of cardiovascular care in HMO versus non-HMO settings. A standardized form was used to extract information from each study on: condition studied, study time frame, type of study design, type of comparison groups, characteristics of patients and physicians, process and outcome measures used, data collection methods, reliability and validity of quality measurements, risk adjustment techniques, findings about quality of care, summary of other findings, study limitations, and other comments that explained the context of the research. RESULTS: Seven of the 11 studies that examined process measures for cardiovascular care in HMO versus non-HMO patients found more differences in one or more process measures that favored HMOs than non-HMOs. Seven of the 10 studies that examined outcome measures found no statistically significant differences in patient care between HMO and non-HMO settings. The other three studies presented contradictory results. CONCLUSIONS: The existing literature suggests that the outcomes of care for cardiovascular conditions do not differ between HMO and non-HMO settings, although selected measures of the process of cardiovascular care are actually better in HMO than in non-HMO settings.     

Computerized patient record: are we prepared for our future practice?

OBJECTIVE: To survey members of The American Dietetic Association (ADA) regarding care documentation systems, computerization of patient care records, and factors to be considered in developing a documentation system compatible with a computer-based patient record. DESIGN: The survey instrument was developed in conjunction with a survey consultant/statistician, then mailed to the study sample. SUBJECTS/SETTING: The sample of 500 was drawn from three ADA dietetic practice groups expected to include a high percentage of clinical practitioners. STATISTICAL ANALYSIS PERFORMED: Basic frequency displays were used on all questionnaire items. Pearson correlation coefficients were used among numeric variables, and oneway analysis of variance was used for categoric variables with quantitative variables. RESULTS: A total of 171 usable surveys were returned (34%), primarily from dietitians working in an acute-care inpatient environment. The SOAP format (subjective, objective, assessment, and plan) was used by 60% of respondents to document nutrition assessments, although a number of other documentation formats were reported. Most commonly used data in nutrition decision making were medical diagnosis, diet order, anthropometric data, and laboratory values. Most commonly used outcomes measures included laboratory values, tolerance of the nutrition regimen, weight changes, and intake changes. Only 15% of respondents reported that they currently used a computerized patient record. Ninety-three percent of respondents favored standardized nutrition diagnoses, and 95% believed standardized nutrition interventions would prove useful. APPLICATIONS/CONCLUSIONS: We recommend that dietitians evaluate, standardize, and streamline their documentation to prepare for implementation of computerized systems. The diagnoses and interventions presented in this study could be a starting point.     

Advantages and limitations of medical dispatching: the French view

One of the main features of the French emergency medical services (EMS) system as it has been developed during the last 40 years is the participation of a physician in each stage of the EMS organization. Thus, in the 100 French emergency medical dispatch centres, all calls received on 15, the national medical emergency phone number, are medically dispatched. The main advantages are: (i) better security for the caller; (ii) proper adaptation of the response to the emergency; (iii) a quicker and more efficient intervention time; (iv) the hospital is informed of the arrival of an emergency; (v) the respect of medical secrecy; (vi) a good cost-efficiency ratio in the use of intervention means. The main limitations are connected with: (i) the inaccuracy of certain calls and problems of dialogue with the caller; (ii) the poor acceptance of the system's obligations by some of the callers, patients, physicians or any other partners of the EMS organization. In the future the implementation of the multi-purpose European emergency number 112 will probably require the system's adaptation to it.     

Bedwetting and psychopathology in adolescents

OBJECTIVE: To document the incidence, source, and reasons for all complaints received by a large municipal emergency medical services (EMS) program. METHODS: A retrospective review of all complaints received during three consecutive years (1990-1992) in a centralized EMS system serving a large municipality (population 2 million). All cases were categorized by year, source, and nature of the complaint. RESULTS: In the three study years, EMS responded to 416,892 incidents with nearly a half-million patient contacts. Concurrently, 371 complaints were received (incidence of 1.12 per thousand); 132 in 1990, 129 in 1991, and 110 in 1992. Most complaints involved either: 1) allegations of "rude or unprofessional conduct" (34%), 2) "didn't take patient to the hospital" (19%), or 3) "problems with medical treatment" (13%). Only 1.6% (n = 6) were response-time complaints. Other complaints included "lost/damaged property," "taken to the wrong hospital," "inappropriate billing," and "poor driving habits." The most common sources were patient's families (39%) and the patients themselves (30%). Only 7.8% were from health care providers. CONCLUSION: Reviews of complaints provide information regarding EMS system performance and reveal targets for quality improvement. For the EMS system examined, this study suggests a future training focus on interpersonal skills and heightened sensitivities, not only toward patients, but also toward bystanders and family members.     

The efficiency of preoperative evaluation: a comparison of computerized and paper recording systems

OBJECTIVE: We designed and implemented a preoperative evaluation record system with seven networked computers for use by physicians and other medical staff. This study compared the efficiency of the new computerized system with that of the paper system. METHODS: We reviewed data from preoperative evaluations completed from November 1990 through December 1992. Data were analyzed automatically (Borland C program) for two intervals: (1) the waiting period, defined as the time the patient entered the waiting room until he or she entered the examination room; and (2) the examination period, defined as the time the patient entered the examination room until an evaluation form was printed. Data were obtained for 2,511 evaluations on paper and 8,342 by computer. RESULTS: The average waiting period with the paper system was 56.1 +/- 44.8 min; the average waiting period with the computerized system was 59.1 +/- 47.0 min. The average examination period was nearly identical for both systems: 27.5 +/- 23.6 min for the paper system; 28.5 +/- 22.7 min for the computerized system. CONCLUSION: The computerized system required no more examination time than the manual system. In addition, we speculate that time is saved at other points of patient care by the legible, instantly retrievable preoperative evaluations that the computerized system produces.     

Recommended guidelines for uniform reporting of pediatric advanced life support: the Pediatric Utstein Style. A statement for healthcare professionals from a task force of the American Academy of Pediatrics, the American Heart Association, and the European Resuscitation Council

This consensus document is an attempt to provide an organized method of reporting pediatric ALS data in out-of-hospital, emergency department, and in-hospital settings. For this methodology to gain wide acceptance, the task force encourages development of a common data set for both adult and pediatric ALS interventions. In addition, every effort should be made to ensure that consistent definitions are used in all age groups. As health care changes, we will all be challenged to document the effectiveness of what we currently do and show how new interventions or methods of treatment improve outcome and/or reduce cost. Only through collaborative research will we obtain the necessary data. For these reasons, and to improve the quality of care and patient outcomes, it is the hope of the task force that clinical researchers will follow the recommendations in this document. It is recognized that further refinements of this statement will be needed; these recommendations will improve only when researchers, clinicians, and EMS personnel use them, work with them, and modify them. Suggestions, recommendations, and other comments aimed at improving the reporting of pediatric resuscitation should be sent to Arno Zaritsky, MD, Eastern Virginia Medical School, Children's Hospital of The King's Daughter, Division of Critical Care Medicine, 601 Children's Lane, Norfolk, VA 23507.     

The principal physician in emergency medicine

The implementation of an experienced pre-hospital care emergency physician as an on the-scene medical command officer (MCO) within the emergency medical service (EMS) is an essential prerequisite to guarantee qualified medical supervision during mass-casuality incidents (MCI). The MCO has four basic functions. Within the administration of the EMS system, he is responsible for the medical aspects of strategic planning for the MCI response. During the MCI the MCO is responsible for the overall assessment of the situation, triage, and supervision of medical treatment by physician and non-physician providers. Aside from extensive personal experience in pre-hospital care, the MCO needs special training to be qualified for this position. State EMS laws provide the legal basis for the MCO within the EMS system.     

Finite element analysis of trabecular bone structure: a comparison of image-based meshing techniques

OBJECTIVE: To report a qualitative evaluation of the Partnerships in Health Care/EMS Project between Poland and the United States. The goal of the partnership was to strengthen the emergency medical services (EMS) system in three Polish cities, Krakow, Bialystok, and Lodz. METHODS: The Polish participants were interviewed in Poland approximately eight months after a U.S.-based training program. They were asked to evaluate the effectiveness of the partnership project and discuss their experiences incorporating U.S. emergency medicine (EM) knowledge and technology in the Polish EMS system. RESULTS: The Polish physicians identified three major factors that had the greatest impact on the implementation of U.S. EM knowledge in Poland. These factors were the substantive differences between Polish and U.S. EM knowledge and technology, staffing differences in Polish and U.S. ambulances, and the differing role the EMS system plays in the delivery of primary care in the two countries. CONCLUSIONS: The Polish physicians succeeded in training EM providers in the three cities, thus strengthening clinical skills of EMS providers. They also were able to adapt the principles of U.S. EM that they had learned to fit the specific circumstances that characterize Polish emergency care. As in the United States, the health care system in Poland is inseparable from the social, political, and economic realities of the nation.