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Biomedical subjects

J R Hedges

Publications and source records attributed to J R Hedges.

At least 55 records · Page 3Linked to original sources
PubMed1996

Community-wide emergency department visits by patients suspected of drug-seeking behavior.

OBJECTIVE: To measure community-wide ED use by patients at high risk for drug-seeking behavior. METHODS: A retrospective, observational study was performed to analyze a cohort of university hospital ED patients seen January 1 to June 30, 1990, for specific pain-related diagnoses (i.e., ureteral colic, toothache, back pain, abdominal pain, or headache) and either independently identified on at least one other local hospital's "patient alert" list or having a drug-related death during 1990. Patients with terminal illnesses were excluded. The frequency of ED (and affiliated urgent care clinic) visits and hospital admissions were determined for January 1 to December 31, 1990, at seven local hospitals. Detailed, supplemental chart review was performed for visits to three of these hospitals from 1990 to 1992. RESULTS: Thirty patients were identified as being at risk for drug-seeking behavior (mean age: 34.3 years; range: 21-55 years; 50% males). We identified 379 visits for this cohort (86% ED visits, 9.8% urgent care visits, 4.7% hospital admissions), for an average of 12.6 visits (range: 2-33) per patient per year. On average, each patient visited 4.1 (range: 1-7) different hospitals and used 2.2 (range: 1-6) different aliases. Two patients died of drug overdose. Supplemental chart review revealed 28 episodes (among 17 different patients) in which a patient was told that he or she "would receive no further 'narcotics'" from that facility; these patients subsequently received controlled substances from another hospital in 93% of these instances and from the same facility in 71%. CONCLUSIONS: Patients identified as being at high risk for drug-seeking behavior have high community-wide ED visit rates. Improving communication between and within hospitals may help identify patients who could benefit from more consistent community-wide care and appropriate treatment for addiction.

Adult↗
PubMed1995

Does out-of-hospital EMS time affect trauma survival?

To determine if out-of-hospital emergency medical services (EMS) time intervals are associated with unexpected survival and death in urban major trauma, a retrospective review was conducted of major trauma cases entered into an urban trauma system by an EMS system during a one-year period. Patients with unexpected death or unexpected survival were identified using TRISS methodology. The EMS response, on-scene time, transport time, and total EMS out-of-hospital time intervals were compared for the two groups using the unpaired t test (two-tailed analysis). Of 848 major trauma cases, there were 13 (1.5%) unexpected survivors and 20 (2.4%) unexpected deaths. Of those patients with complete EMS times, the mean out-of-hospital response time interval was significantly shorter for the unexpected survivors (3.5 +/- 1.2 minutes v 5.9 +/- 4.3 minutes; P = .04). The mean EMS on-scene time interval (7.8 +/- 4.1 minutes v 11.6 +/- 6.5 minutes; P = .06) and the mean transport time interval (9.5 +/- 4.4 minutes v 11.7 +/- 4.0 minutes; P = .17) also favored the unexpected survivor group. Overall, the total EMS time interval was significantly shorter for unexpected survivors (20.8 +/- 5.2 minutes v 29.3 +/- 12.4 minutes; P = .02). It was concluded that a short overall out-of-hospital time interval may positively affect patient survival in selected urban major trauma patients.

Adolescent↗
PubMed1995

Paramedic injury severity perception can aid trauma triage.

STUDY OBJECTIVE: To compare information contained in standard out-of-hospital trauma triage criteria and standard criteria plus advanced emergency medical technician (EMT) injury severity perception for determination of patient need for trauma center evaluation. DESIGN: Prospective, observational cohort analysis of trauma triage by advanced EMTs. PARTICIPANTS: Out-of-hospital, geographically stratified statewide sample of patients injured in Oregon. RESULTS: Advanced EMTs provided patient information on demographics, physiologic parameters, injury anatomy and mechanism, premorbid conditions, EMT injury severity perception, and trauma system entry status. A four-point scale was used to grade the injury severity perception. Need for trauma center evaluation was defined as major surgery within 6 hours of hospital arrival, admission to the ICU, death in the hospital, or Injury Severity Scale score of 16 or more. The relative triage information gain with injury severity perception was assessed by use of logistic regression, tree-based models, and receiver operating characteristic (ROC) curves. Of 1,063 patients, 307 (28.9%) warranted trauma center evaluation. With logistic regression modeling, the following standard triage parameters were associated (P < .05) with the need for trauma center evaluation after inclusion of injury severity perception: systolic blood pressure less than 90 mm Hg, abnormal respiratory rate (less than 10 or more than 29), Glasgow Coma Scale score less than 13, penetrating injury (midthigh to head), two or more obvious proximal long-bone fractures, and fall of more than 20 feet. The two largest injury severity perception categories had the greatest odds ratios (20:1 and 167:1). ROC curve areas improved with injury severity perception (.88 versus .83 without; P < .0001). CONCLUSION: Standard out-of-hospital triage criteria benefit from inclusion of advanced EMT injury severity perception information.

Emergency Medical Technicians↗
PubMed1995

Intracity regional demographics of major trauma.

STUDY OBJECTIVE: To report intracity, regional trauma, geographic, and demographic factors affecting risk of major intentional versus nonintentional trauma. DESIGN: One-year retrospective analysis of trauma-registry and census-tract databases. SETTING: Urban trauma system with patient entry by emergency medical services personnel. PARTICIPANTS: Major trauma cases grouped by presumed intent to injure. INTERVENTIONS: We examined age- and sex-adjusted trauma rates for seven geographic intracity regions (comprising of 144 census tracts) to identify associations with population density, median household income, and race data. Rates and risk factors for intentional versus nonintentional trauma were compared. RESULTS: Two hundred fifty-seven intentional and 575 nonintentional major trauma system cases were identified. Both intentional (relative risk [RR], 7.0; 95% CI, 5.1 to 9.7) and nonintentional (RR, 2.7; CI, 2.3 to 3.3) injury populations were predominately male. Intentional-trauma victims were disproportionately nonwhite (RR, 4.1; CI, 3.2 to 5.1). The 15- to 24-year-old (RR, 20.3; CI, 16.7 to 24.6) and 25- to 34-year-old (RR, 15.3; CI, 12.7 to 18.4) age groups were more likely to sustain intentional trauma than the 0- to 14-year-old age group. Regional differences in occurrence rates were most pronounced for intentional trauma; 52% of all intentional traumas occurred within a small area of 14 census tracts. Residents in low median income households were more commonly subject to intentional injury. CONCLUSION: Different demographic features affect intentional and nonintentional major trauma in Portland, Oregon. These features can be used to guide emergency medical services planning and injury-prevention measures.

Accidents, Traffic↗
PubMed1995

Triage in an established trauma system.

OBJECTIVE: The goal of this study was to determine patient and injury characteristics that predict undertriage and overtriage. DESIGN: This study was a retrospective analysis of admissions for acute injury. MATERIALS AND METHODS: All admissions for acute injuries in a 2 1/2-year period were included (N = 26,025). ICD-9 clinical modification codes were converted to Injury Severity Scores. MAIN RESULTS: Seventy-nine percent of severely injured patients were admitted to level I trauma centers. Severely injured patients admitted to other hospitals (undertriage) were more likely elderly (odds ratio = 5.44) and less likely had multisystem injuries (odds ratio = 0.55). One-fourth of patients with minor injuries were admitted to level I trauma centers (overtriage). Overtriaged patients were more likely intoxicated, obese, or had an injury to the head or face. CONCLUSIONS: In a developed trauma system, severely injured elderly trauma patients (especially females) are at risk for undertriage. The characteristics of patients at risk for overtriage reflect the difficulties of prospective out-of-hospital triage.

Adult↗
PubMed1995

An analysis of Hospital Discharge Index as a trauma data base.

STUDY OBJECTIVE: To document the validity of a Hospital Discharge Index (HDI) as a data base on injured patients. DESIGN: Patient information in trauma registries was compared with information in HDI. POPULATION: Injured patients admitted to trauma centers. METHODS: Patients in HDI were crossmatched with individuals in one or two trauma registries using deterministic matching techniques. Agreement regarding the presence and severity of injury was assessed. RESULTS: A comprehensive trauma registry from a level I trauma center and HDI agreed on the presence of an injury in each of 6 body regions over a range of kappa values from 0.17 to 0.71. The severity of injury score assigned by the two data bases demonstrated agreement over a range of intraclass correlation values from 0.12 to 0.82. CONCLUSION: HDI provides adequate information concerning injury for the majority of hospitalized patients, but was primarily limited by incomplete information. Efforts to improve HDI should focus on guidelines for data abstraction.

Hospital Information Systems↗
PubMed1995

Demographics of cardiac arrest: association with residence in a low-income area.

OBJECTIVE: To report cardiac arrest demographics and assess whether arrest rate is associated with differences in intracity regional population densities, incomes, or race distributions. METHODS: One-year retrospective review of out-of-hospital cardiac arrests in a city with a two-tier emergency medical service (EMS) system. Associations of population density, median income, and race data with age- and gender-adjusted cardiac arrest rates for seven city regions and groupings of high- and low-income census tracts were made. RESULTS: Median income, but not race or population density, was associated with sex- and age-adjusted intracity regional cardiac arrest rates (p = 0.034). This association of cardiac arrest rate with income status was magnified when the 20 lowest and the 20 highest income census tracts were compared. Cardiac arrest victims in these two income groups did not differ in regard to rate of witnessed arrest, bystander-administered CPR, or previous cardiac disease. Rates of survival to hospital discharge were not significantly different between the two groups. CONCLUSION: The association of lower income with cardiac arrest suggests that cardiac health promotion and EMS intervention measures, including CPR instruction, should be targeted to lower-income neighborhoods. These findings may help explain previous studies suggesting a racial or population density association with cardiac arrest rates.

Cardiopulmonary Resuscitation↗
PubMed1995

Applying the trauma triage rule to blunt trauma patients.

OBJECTIVE: To determine the accuracy of the Baxt Trauma Triage Rule (TTR: systolic blood pressure < 85 mm Hg; Glasgow Coma Scale-motor score < 5; or penetrating trauma to head, neck, or trunk) for prediction of major trauma in an independent data set of blunt trauma patients. METHODS: Retrospective evaluation of the TTR in a cohort of patients identified by Oregon Trauma System entry criteria. Accuracy for prediction of "major trauma" victims was measured using resource-based definitions of major trauma. Participants included 626 adult, blunt trauma patients at a level-I trauma center serving a metropolitan center of more than one million people. RESULTS: Of 524 patients with sufficient registry data to apply the TTR, 95 (18%) and 63 (12%) patients met the criteria for major trauma suggested by Baxt et al. and Emerman et al., respectively. Using the Baxt definition of major trauma, the TTR had a sensitivity of 74% (95% CI: 0.65-0.83) and a specificity of 84% (95% CI: 0.81-0.88). There were 25 significant false-negative results, including 12 patients requiring urgent laparotomy and four patients requiring emergency airway procedures. Using the Emerman definition of major trauma, sensitivity improved modestly to 76% (95% CI: 0.65-0.87) and specificity decreased slightly to 80% (95% CI: 0.77-0.84). CONCLUSIONS: In this blunt trauma population, the Baxt TTR failed to identify a significant number of severely injured patients. Slight alterations in the definition of "major trauma" can significantly affect the performance characteristics of triage instruments.

Adolescent↗
PubMed1995

Advances in the use of ancillary diagnostic testing in the emergency department evaluation of chest pain.

This article discusses the advances of ancillary studies used to evaluate the emergency department patient with chest pain caused by acute myocardial infarction (AMI) or ischemia. This article examines how these studies have improved the early detection of patients with AMI, improved differentiation of acute ischemic coronary events from nonischemic causes of chest pain, more accurately stratified patients for adverse outcome, and decreased the number of patients with AMI inadvertently discharged from the emergency department. Ancillary studies discussed include nonstandard ECGs, nuclear imaging, serum markers, and emergency department observation units. Emergency department echocardiography is discussed elsewhere in the issue.

Chest Pain↗
PubMed1994

Possible interactions with terfenadine or astemizole.

Concurrent use of terfenadine or astemizole with erythromycin or ketoconazole can prolong the QT interval and produce potentially fatal ventricular arrhythmias. We examine the frequency and patterns of concurrent prescribing and suggest methods to reduce the incidence of serious drug interactions. By retrospectively reviewing Oregon Medicaid prescription claims data over 22 months, we determined the frequency of concurrent prescribing of terfenadine or astemizole with macrolide antibiotics or ketoconazole. From 1991 to 1992, terfenadine use increased by 29%, with a seasonal peak in June of each year. Terfenadine was one of the most prescribed medications from March through July 1992. During the 22 months reviewed, there were 122 episodes of concurrent use of terfenadine or astemizole with macrolide antibiotics or ketoconazole. Most of these episodes (94%) involved terfenadine. The frequency of concurrent use increased more than threefold from 1991 to 1992. Although patients received prescriptions from different physicians in 48% of these episodes, they used different pharmacies only 3% of the time. We demonstrate that terfenadine use is extensive and increasing, thus increasing the possibility of serious interactions, and many physicians may remain unaware of this potential. Effective prospective screening by pharmacists could dramatically reduce the incidence of concurrent prescribing. Physicians must be aware of the potential for these drug interactions, avoid prescribing these medications concurrently, and consider these interactions in the evaluation of syncope and cardiac arrhythmias.

Adolescent↗
PubMed1993

Beyond Utstein: implementation of a multisource uniform data base for prehospital cardiac arrest research.

This article is an overview of the issues affecting the use of a multisource uniform data base for prehospital cardiac arrest research. The goals of data base standardization include improved communication between emergency medical services (EMS) systems and between EMS physicians and the lay public; improved quantification of EMS system performance and documentation of benefit; in-depth analysis of factors that contribute to outcome; and development of EMS system models that will enhance system planning. Challenges to developing a multisource research data base include establishing a concensus approach to data base development; enlisting EMS system cooperation; verifying the accuracy of the data collected; coordinating data storage and analysis; and obtaining fiscal support for such a project. One illustrative approach to initiating multisource data base research is outlined. The iterative nature of data base development, use, expansion, and refinement is emphasized. Future reports addressing the methodology of multisource data base development and application in EMS systems should build on these concepts.

Databases, Factual↗
PubMed1993

Role of the emergency medical services system in regionwide health monitoring and referral.

The emergency medical services (EMS) system of the future has the opportunity to serve as a regional community health monitoring and referral system. Such a system would shift attention from care of the individual to cost-effective community health efforts using community resource integration, while emphasizing individual responsibility for health. This health care system model requires the establishment of a centralized monitoring agency, the "regional center." The regional center would coordinate the monitoring of regional EMS use and linkage of patients with essential health promotion and behavior change organizations. Many of these supporting organizations are in place but are functioning without the benefit of communitywide health monitoring or effective referral and follow-up links with other resources. Coordination through the EMS system and a regional center would permit these resources to be used in an efficient and accountable fashion. We propose a model in which the EMS system could contribute to coordinated regional health monitoring and maintenance, timely and appropriate health care legislation and regulation, and high-impact health care education and intervention in the setting of self-destructive individual behavior.

Community Health Services↗