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Biomedical subjects

Gabor D Kelen

Publications and source records attributed to Gabor D Kelen.

15 recordsLinked to original sources
PubMed2006

The national trend in quality of emergency department pain management for long bone fractures.

BACKGROUND: Despite national attention, there is little evidence that the quality of emergency department (ED) pain management is improving. OBJECTIVES: To compare the quality of ED pain management before and after implementation of the Joint Commission on the Accreditation of Healthcare Organizations' standards in 2001. METHODS: The authors performed a retrospective cohort study by using the National Hospital Ambulatory Medical Care Survey from 1998-2003. Patients who presented to the ED with a long bone fracture (femur, humerus, tibia, fibula, radius, or ulna) were compared. The authors extracted data on patient, visit, and hospital characteristics. The primary outcomes were the proportion of patients who received assessment of pain severity and who received analgesic treatment. RESULTS: There were 2,064 patients with a qualifying fracture in the study period, 834 from 1998-2000 and 1,230 from 2001-2003. Compared with the early period, a higher proportion of patients in the late period had their pain assessed (74% vs. 57%), received opiates (56% vs. 50%), and received any analgesic (76% vs. 56%). Patients in the late period had higher odds of receiving any analgesia (adjusted odds ratio [OR], 1.43) and opioid analgesia (adjusted OR, 1.27) compared with the early period. Patients in the middle age group (adjusted OR, 2.28) or those seen by physician assistants (adjusted OR, 2.05) were more likely, whereas those with Medicaid (adjusted OR, 0.58) and those in the Northeast were less likely, to receive opiates. CONCLUSIONS: Although the quality of ED pain management for acute fractures appears to be improving, there is still room for further improvement.

Adult↗
PubMed2006

Inpatient disposition classification for the creation of hospital surge capacity: a multiphase study.

BACKGROUND: The ability to provide medical care during sudden increases in patient volume during a disaster or other high-consequence event is a serious concern for health-care systems. Identification of inpatients for safe early discharge (ie, reverse triage) could create additional hospital surge capacity. We sought to develop a disposition classification system that categorises inpatients according to suitability for immediate discharge on the basis of risk tolerance for a subsequent consequential medical event. METHODS: We did a warfare analysis laboratory exercise using evidence-based techniques, combined with a consensus process of 39 expert panellists. These panellists were asked to define the categories of a disposition classification system, assign risk tolerance of a consequential medical event to each category, identify critical interventions, and rank each (using a scale of 1-10) according to the likelihood of a resultant consequential medical event if a critical intervention is withdrawn or withheld because of discharge. FINDINGS: The panellists unanimously agreed on a five-category disposition classification system. The upper limit of risk tolerance for a consequential medical event in the lowest risk group if discharged early was less than 4%. The next categories had upper limits of risk tolerance of about 12% (IQR 8-15%), 33% (25-50%), 60% (45-80%) and 100% (95-100%), respectively. The expert panellists identified 28 critical interventions with a likelihood of association with a consequential medical event if withdrawn, ranging from 3 to 10 on the 10-point scale. INTERPRETATION: The disposition classification system allows conceptual classification of patients for suitable disposition, including those deemed safe for early discharge home during surges in demand. Clinical criteria allowing real-time categorisation of patients are awaited.

Bed Occupancy↗
PubMed2006

The measurement of daily surge and its relevance to disaster preparedness.

This article reviews what is known about daily emergency department (ED) surge and ED surge capacity and illustrates its potential relevance during a catastrophic event. Daily ED surge is a sudden increase in the demand for ED services. There is no well-accepted, objective measure of daily ED surge. The authors propose that daily and catastrophic ED surge can be measured by the magnitude of the surge, as well as by the nature and severity of the illnesses and injuries that patients present with during the surge. The magnitude of an ED surge can be measured by the patient arrival rate per hour. The nature and severity of the surge can be measured by the type (e.g., trauma vs. infection vs. biohazard) and acuity (e.g., triage level) of the surge. Surge capacity is defined as the extent to which a system can respond to a rapid and sizeable increase in the demand for resources. ED surge capacity includes multiple dimensions, such as systems, space, staffing, and supplies. A multidimensional measure is needed that reflects both the core components and their relative contribution to ED surge capacity. Although many types of factors may influence ED surge capacity, relatively little formal research has been conducted in this area. A better understanding of daily ED surge capacity and influencing factors will improve our ability to simulate the potential impact that different types of catastrophic events may have on the surge capacity of hospital EDs nationwide.

Crowding↗
PubMed2006

Research priorities for surge capacity.

The 2006 Academic Emergency Medicine Consensus Conference discussed key concepts within the field of surge capacity. Within the breakout session on research priorities, experts in disaster medicine and other related fields used a structured nominal-group process to delineate five critical areas of research. Of the 14 potential areas of discovery identified by the group, the top five were the following: 1) defining criteria and methods for decision making regarding allocation of scarce resources, 2) determining effective triage protocols, 3) determining key decision makers for surge-capacity planning and means to evaluate response efficacy (e.g., incident command), 4) developing effective communication and information-sharing strategies (situational awareness) for public-health decision support, and 5) developing methods and evaluations for meeting workforce needs. Five working groups were formed to consider the above areas and to devise sample research questions that were refined further by the entire group of participants.

Disaster Planning↗
PubMed2006

Patients who leave without being seen: their characteristics and history of emergency department use.

STUDY OBJECTIVE: We identify patient characteristics associated with uncompleted visits to the emergency department (ED). METHODS: We used registration and billing data to conduct a pair-matched case-control study. ED patients who left without being seen (cases) between July 1 and December 31, 2004, were matched to patients who stayed and were treated (N=1,476 pairs) according to registration date and time (+/-2 hours) and triage level (controls). The association between sociodemographic characteristics, previous ED utilization, and proximity to the ED and the risk of an uncompleted visit was assessed by the odds ratio (OR) using conditional logistic regression. RESULTS: During the 6-month study period, the overall left-without-being-seen rate was 6.4%. Seventeen percent of cases compared with 5% of controls had at least 1 previous uncompleted visit during the previous year. After adjusting for all patient characteristics, younger age, being uninsured (adjusted OR=1.73; 95% confidence interval [CI] 1.35 to 2.21) or covered by Medicaid (adjusted OR=1.67; 95% CI 1.27 to 2.20), and a previous uncompleted visit (adjusted OR=3.60; 95% CI 2.67 to 4.85) were significantly associated with the risk of an uncompleted visit. CONCLUSION: Previous ED utilization is predictive of future ED utilization. EDs should make every effort to keep their left-without-being-seen rates to a minimum because patients who are the least likely to receive care elsewhere (ie, those uninsured or covered by Medicaid) are more likely to leave without being seen.

Adolescent↗
PubMed2006

Healthcare worker competencies for disaster training.

BACKGROUND: Although training and education have long been accepted as integral to disaster preparedness, many currently taught practices are neither evidence-based nor standardized. The need for effective evidence-based disaster training of healthcare staff at all levels, including the development of standards and guidelines for training in the multi-disciplinary health response to major events, has been designated by the disaster response community as a high priority. We describe the application of systematic evidence-based consensus building methods to derive educational competencies and objectives in criteria-based preparedness and response relevant to all hospital healthcare workers. METHODS: The conceptual development of cross-cutting competencies incorporated current evidence through a systematic consensus building process with the following steps: (1) review of peer-reviewed literature on relevant content areas and educational theory; (2) structured review of existing competencies, national level courses and published training objectives; (3) synthesis of new cross-cutting competencies; (4) expert panel review; (5) refinement of new competencies and; (6) development of testable terminal objectives for each competency using similar processes covering requisite knowledge, attitudes, and skills. RESULTS: Seven cross-cutting competencies were developed: (1) Recognize a potential critical event and implement initial actions; (2) Apply the principles of critical event management; (3) Demonstrate critical event safety principles; (4) Understand the institutional emergency operations plan; (5) Demonstrate effective critical event communications; (6) Understand the incident command system and your role in it; (7) Demonstrate the knowledge and skills needed to fulfill your role during a critical event. For each of the cross-cutting competencies, comprehensive terminal objectives are described. CONCLUSION: Cross-cutting competencies and objectives developed through a systematic evidence-based consensus building approach may serve as a foundation for future hospital healthcare worker training and education in disaster preparedness and response.

Community Health Planning↗
PubMed2006

Research ethics.

This article explores the tenets of the responsible conduct of research. The proper treatment of human and animal subjects, recognition and avoidance of conflicts of interest, management of data to ensure privacy and confidentiality, authorship, academic freedom, and scientific misconduct are discussed. Historically significant events that have influenced the ethical climate, along with a review of guiding principles and regulations that define the conduct of ethical research are presented. Circumstances more specific to emergency medicine are examined in detail to provide meaningful guidance to practicing emergency medicine researchers.

Animals↗
PubMed2006

Are regional hospital pharmacies prepared for public health emergencies?

INTRODUCTION: In the event of a major chemical, biological, radiological, nuclear, or explosive (CBRNE) attack or a natural disaster, large quantities of pharmaceuticals and medical supplies may be required with little or no warning. Pharmaceutical surge capacity for immediate response, before Strategic National Stockpile (SNS) supplies become available, remains a significant gap in emergency preparedness. To date, limited attempts have been made to assess collective regional hospital pharmaceutical response capabilities. In this project, we characterized the level of hospital pharmaceutical response preparedness in a major metropolitan region. METHODS: The Johns Hopkins Office of Critical Event Preparedness and Response (CEPAR) convened a collaborative partnership to assess hospital pharmaceutical response capabilities. A survey was developed to characterize pharmaceutical response preparedness to CBRNE threats. RESULTS: All 22 acute care hospitals in the Maryland region were sent pharmaceutical response surveys, and responses were received from 86% (19/22). Within the past year, 84% (16/19) of hospitals had implemented an exercise with pharmacy participation. More than half of the hospitals expect to receive assistance from the SNS in 48 hours or less. Seventy-four percent (14/19) of the hospitals reported an additional dedicated reserve supply for biological events, 74% (14/19) for chemical events, and 58% (11/19) for radiological events. CONCLUSION: Many hospitals in this metropolitan region have taken important steps toward enhancing pharmaceutical preparedness. However, hospitals generally remain underprepared for CBRNE threats and collectively have limited supplies of antibiotics to provide prophylaxis or treatment for hospital staff, their families, and patients in the event of a significant biological incident.

Disaster Planning↗
PubMed2003

Neighborhood characteristics and emergency department utilization.

OBJECTIVES: Neighborhood environments have been linked to the prevalence and incidence rates of a variety of diseases and injuries. This study assessed the relations between neighborhood demographic and socioeconomic characteristics and emergency department (ED) utilization. METHODS: Billing data for the calendar year 2000 for adult patients residing within a one-mile radius of the study ED were geo-coded based on home addresses and merged with neighborhood data from the U.S. Census Bureau. Annual ED visit rates per 100 population were computed for each census block within the study area and analyzed in relation to neighborhood characteristics. RESULTS: The study area consisted of 714 census blocks and 42,278 adult residents, with a total of 16,427 visits to the study ED. Annual ED visit rates increased from 17 visits per 100 population for neighborhoods where less than 50% of the population were African American to 51 visits per 100 population for neighborhoods where all residents were African American (p < 0.001). Annual ED visit rates decreased from 53% for neighborhoods where <20% of housing units were owner-occupied to 27% for neighborhoods with >45% owner-occupied housing units (p < 0.001). Multivariate linear regression modeling revealed that proportions of African American residents and owner-occupied housing units were significantly associated with ED utilization, independent of age and gender compositions and the distance between residence and the study ED. CONCLUSIONS: Even within a small geographic area, ED utilization may vary greatly by neighborhood characteristics. Neighborhood racial composition and housing tenure are independent predictors of ED visit rates in this urban community.

Adult↗
PubMed2003

Preventive care in the emergency department: should emergency departments conduct routine HIV screening? a systematic review.

OBJECTIVE: To perform a systematic review of the emergency medicine literature to assess the appropriateness of offering routine HIV screening to patients in the emergency department (ED). METHODS: The systematic review was conducted with the aid of a structured template, a companion explanatory guide, and a grading and methodological scoring system based on published criteria for critical appraisal. Two reviewers conducted independent searches using OvidR, PubMed, MD Consult, and Grateful Med. Relevant abstracts were reviewed; those most pertinent to the stated objective were selected for complete evaluation using the structured template. RESULTS: Fifty-two relevant abstracts were reviewed; of these, nine were selected for detailed evaluation. Seven ED-based prospective cross-sectional seroprevalence studies found HIV rates of 2-17%. Highest rates of infection were seen among patients with behavioral risks such as male homosexual activity and intravenous drug use. Two studies demonstrated feasibility of both standard and rapid HIV testing in the ED, with more than half of the patients approached consenting to testing by either method, consistent with voluntary testing acceptance rates described in other settings. Several cost-benefit analyses lend indirect support for HIV screening in the ED. CONCLUSIONS: Multiple ED-based studies meeting the Centers for Disease Control and Prevention Guideline threshold to recommend routine screening, in conjunction with limited feasibility trials and extrapolation from cost-benefit studies, provide evidence to recommend that EDs offer HIV screening to high-risk patients (i.e., those with identifiable risk factors) or high-risk populations (i.e., those where HIV seroprevelance is at least 1%).

AIDS Serodiagnosis↗
PubMed2002

Detection of bacteremia in emergency department patients at risk for infective endocarditis using universal 16S rRNA primers in a decontaminated polymerase chain reaction assay.

Prompt definitive diagnosis of acute bacterial endocarditis in febrile injection drug users (IDUs) remains problematic because of delays associated with blood culture. Rapid detection of bacteremia by polymerase chain reaction (PCR) by use of "universal" primers has been hampered by background bacterial contamination. Broad-range eubacterial primers selected from the 16S rRNA gene were used in a PCR assay coupled with a simple pre-PCR decontamination step. All PCR reagents were pretreated with the restriction enzyme AluI, which has multiple digestion sites in the amplicon but none in the primer sets. When 4 different bacterial species were spiked into healthy human blood specimens, the assay identified each pathogen with an analytic sensitivity of 5 bacteria/PCR reaction. A clinical trial with 51 febrile IDUs revealed that PCR had a sensitivity and specificity of 86.7% and 86.9%, respectively, versus blood culture. Importantly, all (8/8) patients with blood culture-positive infective endocarditis were determined to be positive by PCR. This assay provides a promising diagnostic for rapid identification of bacteremia, particularly valuable in acute care settings.

Bacteremia↗
PubMed2002

Quantitative multiprobe PCR assay for simultaneous detection and identification to species level of bacterial pathogens.

We describe a novel adaptation of the TaqMan PCR assay which potentially allows for highly sensitive detection of any eubacterial species with simultaneous species identification. Our system relies on a unique multiprobe design in which a single set of highly conserved sequences encoded by the 16S rRNA gene serves as the primer pair and is used in combination with both an internal highly conserved sequence, the universal probe, and an internal variable region, the species-specific probe. A pre-PCR ultrafiltration step effectively decontaminates or removes background DNA. The TaqMan system described reliabAly detected 14 common bacterial species with a detection limit of 50 fg. Further, highly sensitive and specific pathogen detection was demonstrated with a prototype species-specific probe designed to detect Staphylococcus aureus. This assay has broad potential in the clinical arena for rapid and specific diagnosis of infectious diseases.

Bacteria↗