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Biomedical subjects

David P Sklar

Publications and source records attributed to David P Sklar.

12 recordsLinked to original sources
PubMed2007

Unanticipated death after discharge home from the emergency department.

STUDY OBJECTIVE: We measured the frequency of unanticipated death among patients discharged from the emergency department (ED) and reviewed these cases for patterns of potential preventable medical error. METHODS: This was a retrospective cohort of ED patients who were discharged to home from an urban tertiary-care facility after their evaluation, with subsequent case review. Subjects were aged 10 years and older, representing 387,334 visits among 186,859 individuals, February 1994 through November 2004. The main outcome was mortality. Deaths were assessed for relatedness to the last ED visit, whether the death was expected, and whether there was possible medical error. Deaths that were unexpected and related to the ED visit were analyzed using grounded theory to identify common themes among these cases. Error cases were identified as a subset of this group. RESULTS: We identified and reviewed 117 patients, or 30.2 deaths within 7 days of discharge per 100,000 ED discharges home (95% confidence interval [CI] 25.2 to 36.2 deaths). Of the 117 cases, 58 (50%) were unexpected but related to the ED visit and 35 (60%) of these had a possible error. For the unexpected, related group, there were 15.0 deaths within 7 days per 100,000 discharges home (95% CI 11.6 to 19.4 deaths); for the possible error group, there were 9.0 (95% CI 6.5 to 12.6 deaths). Four themes repeatedly emerged: atypical presentation of an unusual problem, chronic disease with decompensation, abnormal vital signs, and mental disability or psychiatric problem or substance abuse that may have made it less likely that the patient would return for worsening symptoms. CONCLUSION: Monitoring of death records can identify unanticipated deaths after health care encounters. Further hypothesis-driven research is needed to identify, prevent, or mitigate problems in care and reduce the rate of death after ED visit.

Adolescent↗
PubMed2004

Previous emergency department use among homicide victims and offenders: a case-control study.

STUDY OBJECTIVE: We differentiate risk factors for future homicide victimization and offending, and we measure emergency department (ED) use among homicide victims, offenders, and controls. METHODS: The design was a matched case-control study conducted in Bernalillo County, NM, and its university-affiliated health sciences center and hospital. All Bernalillo County homicide victims (N=124) and offenders (N=138) identified between January 1996 and December 2001 who were linked to university physician billing records and who had health care use during the 3 years before the homicide incident were included as cases. Randomly selected age-matched (+/-1 year) and sex-matched subjects with health care use within 3 years of their matched pair's homicide were included as controls. Main outcome measures were the number and type of ED visits by cases and controls. RESULTS: Among the 124 victims and 138 offenders who used health care, most were men (80%) and averaged 27.7 years of age. Victims and offenders had similar health care use and were grouped for final analyses. Cases (victims and offenders) were more likely to have had an ED visit within 3 years of the homicide (85%) compared with controls (59%) (odds ratio [OR] 4.3; 95% confidence interval [CI] 3.0 to 6.2). Within previous ED visits, assault (OR 4.5; 95% CI 2.9 to 7.0), firearm injury (OR 13.6; 95% CI 4.9 to 37.7), and substance abuse (OR 3.7; 95% CI 2.2 to 6.0) were associated with future homicide. ED visits clustered closer to the homicide incident for cases (median days before the homicide -402 days; 95% CI -434 to -364) compared with controls (median -487 days; 95% CI -498 to -474). CONCLUSION: Patients with ED visits for assault, firearm injuries, and substance abuse are at increased risk for homicide and often have an escalating number of visits leading up to the homicide event. ED-based identification and referral programs similar to those used for intimate partner violence or other preventive strategies should be considered for this high-risk population.

Adolescent↗
PubMed2003

Creating the model of a clinical practice: the case of emergency medicine.

Medical schools and specialty societies have struggled to define a core content for medical students and practitioners but, to date, have been stymied by both political considerations and the sheer burden of the innumerable decisions that must be made to define the essence of a medical specialty. Six professional organizations representing the field of emergency medicine recently collaborated with the National Board of Medical Examiners to accomplish this objective by developing a Model of the Clinical Practice of Emergency Medicine. This document will provide support for the development of medical school and residency curricula, training program accreditation standards, board certification test specifications, and organizational agendas for postgraduate education, research, and patient advocacy for the specialty of emergency medicine. The authors present a description of the model and the process that was used to develop it with the belief that other medical disciplines that face similar issues and challenges could benefit from a similar undertaking.

Accreditation↗
PubMed2003

Rural and urban fatal pedestrian crashes among United States American Indians and Alaskan Natives.

The Fatality Analysis Reporting System (FARS) and the Web-based Injury Statistics Query and Reporting System (WISQARS) were used to compare fatal pedestrian crashes in American Indians and Alaskan Natives (AI/AN) between urban and rural locations for 2000-2001. There were significant differences between urban and rural crashes for driver, pedestrian, environmental, and engineering factors. Rural pedestrian crashes more often occurred on highways (p<0.0001) lacking traffic control devices (p<0.0001) and artificial lighting (p<0.0001). Alcohol was a significant cofactor in both environments (40% urban vs. 55% rural; p=0.0239). Prevention of AI/AN deaths should include engineering countermeasures specific to the needs of rural (lighting) and urban (medians with barriers) environments and address drinking behavior in both populations.

Accidents, Traffic↗
PubMed2002

Human simulation in emergency medicine training: a model curriculum.

The authors propose a three-year curriculum for emergency medicine residents using human simulation both to teach and to assess the Accreditation Council for Graduate Medical Education (ACGME) core competencies. Human simulation refers to a variety of technologies that allow residents to work through realistic patient problems so as to allow them to make mistakes, learn, and be evaluated without exposing a real patient to risk. This curriculum incorporates 15 simulated patient encounters with gradually increasing difficulty, complexity, and realism into a three-year emergency medicine residency. The core competencies are incorporated into each case, focusing on the areas of patient care, interpersonal skills and communication, professionalism, and practice based learning and improvement. Because of the limitations of current assessment tools, the demonstration of resident competence is used only for formative evaluations. Limitations of this proposal and difficulties in implementation are discussed, along with a description of the organization and initiation of the simulation program.

Clinical Competence↗
PubMed2002

An approach to fulfilling the systems-based practice competency requirement.

The Accreditation Council for Graduate Medical Education (ACGME)-identified core competency of systems-based practice requires the demonstration of an awareness of the larger context and system of health care, and the ability to call on system resources to provide optimum care. This article describes an approach to teaching and fulfilling the requirement of this core competency in an emergency medicine residency. Beginning residents are oriented to community resources that are important to the larger context of care outside the emergency department. Each resident completes a community project during his or her residency. Readings and discussions concerning community-oriented medical care and the literature of research and injury prevention in emergency medicine precede the project development. Several projects are described in detail. Such projects help to teach not only awareness of the community resources of the greater context of medical practice outside the emergency department, but also how to use those resources. Projects could be a main component of a resident portfolio. This approach to teaching the core competency of systems-based practice is proposed as an innovative and substantial contribution toward satisfying the requirement of the core competency.

Clinical Competence↗
PubMed2002

Teaching communications and professionalism through writing and humanities: reflections of ten years of experience.

Both professionalism and interpersonal communication are core competencies for emergency medicine residents as well as residents from other specialties. The authors describe a weekly, small-group seminar lasting one year for emergency medicine residents that incorporates didactic materials, case studies, narrative expression (stories and poems), and small-group discussion. Examples of cases and narrative expressions are provided and a rationale for utilizing the format is explained. A theoretical model for evaluation measures is also included.

Communications Media↗
PubMedDate not supplied

Prehospital administration of morphine for isolated extremity injuries: a change in protocol reduces time to medication.

OBJECTIVE: To evaluate the effect of a new protocol allowing paramedics to administer morphine without a physician order to patients with extremity trauma with respect to time of morphine administration, scene time, morphine amount and number of doses per patient, and proportion of patients receiving morphine. METHODS: Data were abstracted from transport forms for a ten-month period prior to the implementation of the new protocol and for nine months after implementation. Data elements included patient age and sex, date, time of EMS arrival on scene, amount and number of morphine doses, and total number of patients transported. RESULTS: Implementation of the new protocol was associated with a decrease in time between emergency medical services (EMS) arrival on scene and administration of the first dose of morphine from 18.8 to 16.7 minutes, a difference of 2.1 minutes [95% confidence interval (95%CI) 1.3, 2.9]. The proportion of patients receiving analgesia at the scene, rather than during transport, increased from 62.7% before the protocol change to 69.5% after, an increase of 6.8% (95% CI 2.7, 11.0). Transports before and after implementation of the new protocol did not differ with respect to patient sex, age, or chief complaint; number of morphine doses or total morphine administered per patient; or proportion of prehospital patients receiving morphine. CONCLUSIONS: A change in protocol that permits trained paramedics to administer morphine without physician approval reduces time to analgesia administration without influencing the amount of morphine delivered per patient or the rate of prehospital morphine use. Further study should measure the effect on base hospital physician interruptions and patient outcome.

Adolescent↗