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Biomedical subjects

Jane H Brice

Publications and source records attributed to Jane H Brice.

16 recordsLinked to original sources
PubMed2005

Method for determining automatic external defibrillator need at mass gatherings.

OBJECTIVES: A method for determining the number of automatic external defibrillators (AEDs) required for a 3-min response at mass gatherings has been described previously. Our study sought to modify the method, replicate it, then validate the results. METHODS: Emergency medical technicians (EMTs) were timed walking defined courses in a football stadium. Velocities were obtained for a horizontal distance and ascending/descending upper and lower decks. This was replicated in a basketball arena. To validate, actual response times were compared to predicted times for predetermined distances in each venue. Predicted response times were calculated using the second standard deviation velocities as the most pessimistic. Numbers of AEDs needed were calculated using predicted response times for each venue's longest distance. RESULTS: Average velocities in m/s (football) were horizontal 1.7, lower deck 1.6 ascending and 1.4 descending, upper deck 1.0 ascending and 1.1 descending. Average velocities (basketball) were horizontal 1.7, lower deck 1.2 ascending and descending, upper deck 0.9 ascending and descending. In the validation phase, every EMT completed the four predetermined courses within the predicted intervals. Predicted response times were 363 s for the longest football stadium distance, and 187 s for the basketball arena. For a 3-min (180 s) response, the number of AEDs required can be calculated. CONCLUSION: This method was easily replicated and appears to be useful for determining the number of AEDs at mass gatherings. The number of AEDs needed for any desired response interval can be calculated using the predicted response time for the longest distance within an arena.

Adult↗
PubMed2005

Use of an emergency department by nonurgent patients.

OBJECTIVES: The objectives of this study are (1) to determine whether patients seeking emergency department (ED) nonurgent care have primary care providers (PCP) or know of other care sources and (2) to determine the reasons why they choose to use the ED. METHODS: A cross-sectional survey in a university ED was administered to self-referred nonurgent patients for 6 weeks. Use of a PCP, knowledge and attempts to seek other care, past use of the ED, urgency self-report, time of visit, and reasons for choosing an ED were recorded. RESULTS: Of the 563 approached subjects, 314 were eligible and 279 agreed to participate. One hundred fifty-seven (56%) had PCPs. For 183 (66%) subjects, the ED was the only place they knew to go for their present problem, and 75 (27%) reported that they depended on the ED for all medical care. Of those patients with a PCP, 73 (47%) rated the ED better for unscheduled care. Eighty-one (52%) subjects thought their PCP would be more efficient and 66 (42%) thought their PCP would be cheaper. CONCLUSIONS: Although most ED nonurgent patients were not dependent upon the ED, the majority was unaware of other places to go for their current health problem. Even those patients with a PCP sought care in the ED because the ED was believed to provide better care despite its perceived increase in both waiting time and cost.

Adult↗
PubMed2004

The accuracy of visual estimation of body weight in the ED.

Preventable medical errors may be due to incorrect drug dosage based on poor weight estimation. This study was to examine the accuracy of patient weight estimations in an emergency medical setting. This prospective study enrolled a convenience sample of medically stable adults. The patient's attending physician, resident physician, nurse, a paramedic, and the patient estimated the patient's weight. Of 394 patients enrolled, patients erred in the estimation of their weight by greater than 20% only 1.5% of the time. The group values were 14.7% for attending physicians, 13.4% for resident physicians, 15.9% for nurses, and 17.4% for paramedics. Our study suggests that emergency department staff estimation of a patient's weight is often inaccurate. When available, the patient's own estimate can be used as their actual weight. When the patient is incapacitated, measurement of the patient's weight is the proven method to avoid this type of dosage error.

Adult↗
PubMed2003

Impact of critical bed status on emergency department patient flow and overcrowding.

OBJECTIVE: To compare measurements of emergency department (ED) patient flow during periods of acute ED overcrowding and times of normal patient volume (NPV). METHODS: Retrospective ED chart review comparing ED flow for patients treated in a tertiary care teaching hospital during periods of ED overcrowding, defined as critical bed status (CBS), and NPV. All periods of CBS during July 2001 were identified. CBS time intervals were matched with NPV times by month, day of the week, time of day, and number of care providers. All patients registered during these matched time intervals were reviewed. Times were collected for each of the following activities: check-in, bed placement, physician assessment, first intervention, and disposition. Corresponding intervals were calculated in minutes. Triage category was used as a marker of illness severity (1 = most severe, 5 = least severe). Descriptive statistics were performed. RESULTS: One hundred eighteen patient charts were reviewed: 61 CBS and 57 NPV. There was no statistical difference in illness severity between the two groups. In the cumulative analysis, patients waited significantly longer for an ED bed (30.4 min, p = 0.01) but did not experience significant delays in other intervals. Triage category analysis revealed no significant difference in triage 2 patients. Intermediate-severity patients (triage 3) waited longer in every interval and significantly longer for physician assessment (30.8 min longer, p < 0.05). Low-severity patients (triage 4) waited longer for an ED bed (40 min, p = 0.02) but did not experience other significant delays. CONCLUSIONS: During times of acute overcrowding, the most significant delay occurs awaiting placement in the ED bed.

Bed Occupancy↗
PubMedDate not supplied

Ability of laypersons to use the Cincinnati Prehospital Stroke Scale.

OBJECTIVE: Early stroke recognition optimizes patients' opportunities to benefit from therapeutic options. Prehospital stroke recognition is suboptimal. If 9-1-1 dispatchers used stroke-identification tools, prehospital stroke recognition might occur more rapidly and accurately. The Cincinnati Prehospital Stroke Scale (CPSS) is a brief, effective tool used by emergency medical services and hospital personnel to identify stroke. The study's goal was to determine whether laypersons could be instructed to use the CPSS over the telephone. METHODS: Adult visitors (laypersons) to a tertiary care emergency department were enrolled. Using a mock patient, laypersons were instructed to use the CPSS via telephone by an investigator simulating a 9-1-1 dispatcher. The patient randomly portrayed clinically normal and abnormal patient types. The layperson's ability to convey CPSS instructions to the patient and relay findings to the investigator was scored. RESULTS: Seventy laypersons were enrolled (35 each for normal and abnormal patient types). Average age was 48 years, 63% were female, and 40% never attended college. Facial droop and speech instructions were administered with 100% accuracy. Arm drift instructions were administered with 99% accuracy. Layperson accuracies for interpreting findings were 93% for facial droop, 93% for arm drift, and 97% for speech. Overall, stroke symptoms were detected with 94% sensitivity (95% CI 87, 100) and 83% specificity (95% CI 70, 95). CONCLUSION: Laypersons correctly administered and interpreted the CPSS when directed to do so over the telephone by a trained investigator. These findings suggest that the CPSS may be a useful tool in early prehospital detection of stroke by dispatchers.

Emergency Medical Services↗
PubMedDate not supplied

Stroke: from recognition by the public to management by emergency medical services.

To improve the outcomes of stroke patients, public awareness of stroke must be increased and emergency medical services (EMS) response to stroke calls optimized. Rapid response to stroke is key, as emphasized in the American Stroke Association's "Stroke Chain of Survival," which consists of four components--rapid recognition of and reaction to stroke warning signs through immediate use of the 9-1-1 system; rapid EMS assessment; priority transport with prenotification of the receiving hospital; and rapid and accurate diagnosis and treatment at the hospital. Neither the risk factors for stroke nor the most common warning signs are adequately known to the public in general, and in particular, to the groups at highest risk for stroke. Effective education through mass media and health care professionals is paramount in increasing the public's awareness of stroke. Whether tools to aid dispatchers and paramedics in stroke diagnosis, assessment, and management can improve stroke patients' outcomes requires further study, as does the value of designated stroke centers. Overall, according stroke the same urgency as acute myocardial infarction, from both the public and the prehospital provider perspectives, might improve stroke patient outcomes.

Emergency Medical Services↗
PubMedDate not supplied

An analysis of paramedic verbal reports to physicians in the emergency department trauma room.

OBJECTIVE: To measure the verbal communication between emergency medical technician-paramedics (EMT-Ps) and physicians in an emergency department trauma room (EDTR) before and after an educational intervention. METHODS: Using a before-after design, we audio-recorded paramedic verbal trauma reports in a large EDTR over a 12-week period. Trained research assistants subsequently queried physicians about information from the paramedic report in a separate interview. Physician recall was quantified. Midway through the study, a web-based, educational intervention designed to enhance paramedic communication skills was administered to the three participating emergency medical services (EMS) systems. Physician recall of more severely injured trauma cases (red triage) was compared with their recall of less severely injured cases (yellow triage). Further comparisons were made between pre- and post-intervention physician recalls, and the extent to which physicians recalled three distinct categories of paramedic verbal information was measured. RESULTS: Overall, physicians accurately recalled 36% of the paramedic verbal report. Information from less severe "yellow" trauma reports was recalled more accurately than that from more severe "red" traumas (40% vs. 34% p = 0.02). Pre- and post-intervention recalls were not significantly different (33% vs. 38% p = 0.16). Physicians' recall of information about the crash scene (46%) was significantly greater than their recall of information about the patient's health status (34%) or information about prehospital patient care (30%) (p = 0.0012). CONCLUSION: Physicians appear to recall paramedic verbal reports about trauma patients poorly. Recall is probably multifactorial and will require further work to design appropriate interventions.

Emergency Medical Technicians↗
PubMedDate not supplied

Management of the violent patient.

Emergency medical services (EMS) providers must often manage violent or combative patients. The data regarding violence against EMS personnel are poor, but according to studies conducted thus far, between 0.8% and 5.0% of incidents to which EMS personnel respond involve violence or the threat of violence. Physical or chemical restraint is usually the only option available to emergency care providers to control violent patients. Physical restraint, however, can lead to sudden death in otherwise healthy patients, possibly as a result of positional asphyxia, severe acidosis, or a patient's excited delirium. Chemical restraint has traditionally consisted of either neuroleptics or benzodiazepines, but those drugs also have drawbacks. Haloperidol and droperidol, the neuroleptics most frequently used for restraint, can cause serious side effects such as extrapyramidal symptoms or QTc (QT interval corrected for heart rate) prolongation. The Food and Drug Administration recently issued a black box warning regarding the use of droperidol, because the QTc prolongation associated with the drug has led to fatal torsades de pointes in some patients. Benzodiazepines are also associated with adverse effects, such as sedation and respiratory depression, especially when the drugs are mixed with alcohol. The atypical antipsychotics, a new option that may be available soon, are less likely to cause such effects and therefore may be preferred over the neuroleptics. Liquid and injectable formulations of various atypical antipsychotics are currently in clinical trials. Because few options are currently available to EMS personnel for managing violent patients outside of the hospital, more research regarding violence against emergency care providers is necessary.

Antipsychotic Agents↗
PubMedDate not supplied

Do EMS personnel identify, report, and disclose medical errors?

OBJECTIVE: To evaluate self-reports of prehospital providers' error frequency, disclosure, and reporting in their actual practice and in hypothetical scenarios. METHODS: The authors surveyed a convenience sample of prehospital providers attending a statewide emergency medical services conference using a two-part instrument. Part 1 evaluated respondent demographics and actual practice patterns. Part 2 used hypothetic scenarios to assess error identification, disclosure, and reporting patterns. Descriptive statistics and Fisher's exact tests were used to characterize demographics and practice patterns. For hypothetical scenarios, the authors calculated mean responses with 95% confidence intervals (CIs) to assess error identification, anticipated disclosure, and reporting patterns. RESULTS: The response rate was 88% (372/425). Analysis was limited to 283 (75% of 372) respondents who were emergency medical technicians and had complete data. In the previous year, 157 (55%) providers identified no errors in practice, 100 (35%) reported one or two errors, and 26 (9%) identified more than two errors. In approximately half of cases, identified errors were reported to the receiving provider, or supervisor. In hypothetical cases, severe errors were identified 93% (95% CI 92-94) of the time, but the ability of providers to identify mild errors significantly varied. In all scenarios, respondents were much more likely to report errors to the receiving hospital, their supervisor, and their medical director than to patients. CONCLUSIONS: Prehospital providers demonstrate the capacity to identify, report, and, to a lesser extent, disclose errors in hypothetical scenarios but may not apply these skills uniformly in their own practices. Enhancing error management skills in prehospital clinical practice will require focused education and training.

Adolescent↗
PubMedDate not supplied

A simulation trial of traditional dispatcher-assisted CPR versus compressions--only dispatcher-assisted CPR.

OBJECTIVES: Growing evidence indicates that it may not be essential to deliver ventilations in the first few minutes of CPR. We compared time to delivery of first compression in traditional CPR with ventilations and compressions to compression-only CPR performed by untrained laypersons assisted by a mock 911 dispatcher. METHODS: This randomized-controlled simulation study included a convenience sample of English-speaking emergency department visitors during a 6-month period. Exclusion criteria were prior CPR training or physical incapacity. A cardiac arrest scenario was presented to subjects who were then provided with one of two sets of telephone CPR instructions by a mock 911 dispatcher. One group received traditional CPR instructions (TCPR) and the second group received compression only CPR instructions (COCPR). Subjects performed CPR on a Laerdal Resusci-Anne CPR manikin and recording strips were analyzed for frequency and quality measures. Pre-and post-test questionnaires assessed subject fatigue and telephone instruction understanding. The primary outcome was the time interval from 911 call to initiation of chest compressions. Analysis included Student t-test, Chi-square, and Wilcoxon Rank Sum. RESULTS: Of 377 potential subjects, 54 consented to randomization. The data from 50 subjects were analyzed. Compared to group TCPR, group COCPR initiated chest compressions faster (72 vs 117 sec, p < 0.0001), completed four cycles of CPR faster (168 vs. 250 sec, p < 0.0001), and paused for a smaller percentage of the resuscitation (13% vs. 36%, p < 0.0001). Only 9% of ventilation opportunities in the TCPR group yielded ventilations of the correct volume. There were no differences between groups in perceived understanding of CPR instruction or fatigue. CONCLUSIONS: We have identified the potential timesavings that may occur during compressions-only CPR. Bystander resuscitation may be more efficient when ventilations are excluded from the CPR sequence.

Adult↗
PubMedDate not supplied

Calling emergency medical services for acute stroke: a study of 9-1-1 tapes.

OBJECTIVE: To obtain a better understanding of how stroke events are communicated to 9-1-1 telecommunicators, and how telecommunicators and emergency medical services (EMS) personnel respond to such calls. METHODS: The authors identified 104 patients with a hospital discharge diagnosis of stroke or transient ischemic attack who were transported to hospital by ambulance in two North Carolina counties during 1999 and 2000. Ambulance call reports were abstracted and linked to 9-1-1 call center audiotapes, which were transcribed and verified. RESULTS: Of the 104 calls, 44 were made by medical personnel, 38 by a family member, eight by a bystander or neighbor, five undetermined, and three by other nonmedical personnel. In only six instances (6%) was the call placed by the patient. The most common symptoms reported were altered mental status (40%), trouble walking (32%), impaired speech (27%), and abnormal breathing (27%). Although the word "stroke" was often used (45%), 9-1-1 telecommunicators classified the calls as a stroke in only 31% of cases. However, in the majority of cases (79%), paramedics were dispatched at the highest priority. The median time from dispatch of EMS to patient arrival at the hospital was 41 minutes, approximately half of which was spent at the scene. CONCLUSION: Although typical stroke symptoms are commonly described, calls are often not classified as "strokes" by telecommunicators. Nevertheless, because of the symptoms reported during the calls, the majority of cases are treated as high priority by telecommunicators.

Aged↗
PubMedDate not supplied

Directed use of the Cincinnati Prehospital Stroke Scale by laypersons.

BACKGROUND: The Cincinnati Prehospital Stroke Scale (CPSS) is a three-item examination that has been effective in the identification of stroke victims by health care professionals. However, assessment of the patient earlier in the chain of care, specifically by a 9-1-1 telecommunicator, may improve stroke outcomes. OBJECTIVES: To modify the CPSS for over-the-phone administration and to assess whether untrained adults can follow the CPSS instructions, identify deficits in stroke survivors, and return these findings to an investigator. METHODS: One hundred nonpatient visitors to an academic tertiary care emergency department were recruited. Each participant was brought to a room with a stroke survivor possessing unresolved symptoms from a previous stroke. The participant was telephoned by an investigator and led through administering the CPSS to the stroke survivor. The investigator noted whether the participant accurately administered CPSS instructions and whether normal or abnormal findings were returned. RESULTS: Participants correctly administered CPSS directions 98% of the time. For facial weakness, the sensitivity of the participants' assessments was 74% and the specificity was 94%. For arm weakness, the sensitivity was 97% and the specificity was 72%. For speech deficits, the sensitivity was 96% and the specificity was 96%. CONCLUSIONS: Untrained adults can use the CPSS to accurately identify stroke symptoms and can relay these findings to an investigator. Telecommunicator administration of the CPSS may allow for expedited prehospital triage of the stroke patient and delivery of resources in a timely manner and, given the limited time window for efficacious treatment, may lead to improved patient outcome.

Emergency Medical Service Communication Systems↗
PubMedDate not supplied

Determination of infant-safe homes in a community injury prevention program.

BACKGROUND: The home is the most common site of childhood injury. To address this problem, Orange County Emergency Management developed the novel "Welcome to the World" program to provide paramedic-delivered home safety inspections and interventions to improve early childhood safety. OBJECTIVES: To determine the prevalence of infant-safe homes and to examine differences in home infant safety based on the number of children in the home. METHODS: Paramedics visited households with newborns or expectant mothers for a home visit at their request. Each visit included a home safety inspection, correction of certain safety practices, one-on-one teaching of injury prevention topics, and distribution of educational materials and safety devices. A retrospective analysis of data recorded during these visits included criteria used in defining an infant-safe home, including 1) presence of a functioning smoke detector, 2) bathwater temperature measured < 120 degrees F, 3) correct crib slat spacing, and 4) presence of a car seat. RESULTS: Paramedics conducted 110 home visits, of which 57% were first-time parents. Only 33% (n = 10) of multiple-child homes and 38% (n = 14) of one-child homes were defined as infant safe by meeting all four criteria. CONCLUSIONS: An alarmingly low number of homes were infant safe (n = 24) and the number of children in the home did not seem to affect home safety. Further research is needed to determine the efficacy of the "Welcome to the World" program.

Emergency Medical Technicians↗
PubMedDate not supplied

Use of ED diagnosis to determine medical necessity of EMS transports.

OBJECTIVE: To examine interrater agreement for classifying emergency medical services transports as medically unnecessary using emergency department diagnosis as the sole determining factor. METHODS: Three emergency physicians and two family medicine physicians classified 913 International Classification of Diseases, Ninth Revision (ICD-9) codes as medically necessary, unnecessary, or uncertain. Overall agreement, interrater agreement, and agreement within 17 major disease categories were measured using kappa statistics in SAS. RESULTS: Physicians rated between 25% and 65% of diagnoses codes as medically unnecessary. Overall agreement was fair (kappa = 0.31). Agreement within specialties was higher among family medicine-trained physicians than among emergency physicians (kappa = 0.52 and kappa = 0.22, respectively). Agreement across all raters was highest for diseases classified as symptoms, signs, and ill-defined conditions (kappa = 0.40) and lowest for diseases of the blood and blood-forming organs (kappa = -0.17). Agreement was observably better between physicians with more experience. CONCLUSIONS: Considerable doubts about the utility of emergency department diagnosis as a criterion are raised from study findings. Further development of Neely Conference criteria is needed. Priority should be given to testing and validation of criteria as well as exploration of differences in judgment between specialists representative of the medical director profession.

Consensus↗