PubMed Health⌕ Search

Biomedical subjects

L J Baraff

Publications and source records attributed to L J Baraff.

At least 19 recordsLinked to original sources
PubMed1992

Orthostatic vital signs: variation with age, specificity, and sensitivity in detecting a 450-mL blood loss.

The authors conducted this study to: (1) determine the effect of age on orthostatic vital signs; and (2) to define the sensitivity and specificity of alternative definitions of "abnormal" orthostatic vital signs in blood donors sustaining an acute 450-mL blood loss. The population studied were 100 healthy adult volunteer blood donors and 100 self-sufficient ambulatory citizens attending a senior citizens daytime activity center. Subjects with a history of orthostatic hypotension were excluded. Subjects were first placed in the recumbent position and their rate pulse and blood pressure were determined after 1 minute; these same parameters were measured in the same arm beginning 30 seconds after standing. In blood donors measurement of orthostatic vital signs was repeated immediately after blood donation. Blood donors served as their own controls in the determination of sensitivities and specificities. Mean orthostatic vital sign changes were as follows: pulse rate, 2 +/- 7 beats per minute; systolic blood pressure, -3 +/- 9 mm Hg; and diastolic blood pressure, 1 +/- 7 mm Hg. There was no clinically meaningful variance in orthostatic blood pressure changes with age. For a given specificity, pulse rate increase was the most sensitive of the orthostatic vital signs used alone; a pulse rise of greater than 20 beats per minute had a sensitivity of 9% with a specificity of 98%.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

The relationship of poison center contact and injury in children 2 to 6 years old.

STUDY OBJECTIVE: To determine if children from households that call a poison center are at increased risk of nonpoisoning injury. DESIGN: A blinded and controlled telephone survey of two groups of households with children between 2 and 6 years old: case households identified by a poison center as having requested information regarding a possible poisoning in a child in this age group in 1989, and control households that did not contact the poison center. The control group was matched by telephone area code and prefix; the last four digits were chosen by random digit dialing. TYPES OF PARTICIPANTS: Children from 2 to 6 years old. MEASUREMENTS AND MAIN RESULTS: One hundred twenty-nine households identified by the poison center and 136 control households completed the telephone interview. The number of children 2 to 6 years old in these households was 190 in the 129 poison control households and 209 in the 136 nonpoison control households. There were 45 injuries among the 190 children in the poison control group and 31 injuries among 209 children in the nonpoison control group. The annual rate of injuries per child was significantly greater in the poison control group (23.7%) than in the nonpoison control group (14.8%) (P less than .025; odds ratio, 1.6; 95% confidence interval, 1.1 to 2.4). CONCLUSION: Children 2 to 6 years old in households that contact a poison center for a possible poison exposure in a child in this age group are at increased risk of injury.

Bias↗
PubMed1992

Perceptions of emergency care by the elderly: results of multicenter focus group interviews.

STUDY OBJECTIVE: To determine the elderly's perception of emergency care and to identify specific problems and solutions. DESIGN: Focus group interviews. SETTING AND TYPE OF PARTICIPANTS: Community senior citizen centers in Boston; Los Angeles; Pittsburgh; Youngstown, Ohio; and Norwalk, Connecticut. Senior citizens who had had emergency care in the past year participated. MEASUREMENT AND RESULTS: Participants were satisfied with their overall medical care. Long waits were a hardship for patients and their families. The elderly are not familiar with the process of emergency care. They were frightened by their injury or illness. Their anxiety was not allayed until they were informed of the nature of their illness and what their treatment and disposition was to be. The emergency department environment frequently made them uncomfortable. There was considerable confusion caused by the billing process. CONCLUSIONS: The elderly would benefit from prior or concurrent education regarding emergency care. Staff should be more sensitive to the anxiety felt by the elderly, should explain the reasons for delays in care, and what to expect. Patients should be informed of the nature and seriousness of their illness as soon as possible. Family and friends may be encouraged to stay with patients. The billing process needs to be clarified and simplified.

Aged↗
PubMed1991

Prevalence of HIV antibody in a noninner-city university hospital emergency department.

STUDY HYPOTHESIS: To determine the prevalence of antibody to human immunodeficiency virus (HIV) in trauma and nontrauma patients not identified as having known HIV infection in a noninner-city university teaching hospital emergency department, and to determine the frequency with which treating emergency physicians are knowledgeable of patients' risk factors for HIV infection. POPULATION: ED patients between 18 and 59 years old with injuries that met trauma center triage criteria or with nontrauma-related illness who had blood drawn for physician-requested laboratory tests and for whom an extra aliquot of blood was available for HIV antibody testing. METHODS: All serum samples were first tested for antibody to HIV by enzyme-linked immunosorbent assay. If positive, the specimen was retested. All repeatedly reactive specimens were analyzed by Western blot test. The treating physician completed a questionnaire regarding the patient's illness and risk factors for HIV infection after the patient's care was completed. RESULTS: Two of 100 major trauma patients (confidence interval, 0% to 5%) and seven of 100 nontrauma patients (confidence interval, 2% to 12%) had antibody to HIV. The seropositive rate by age and clinical group varied from 0% to 12.5%, with the highest rates in the 30- to 39-year-old group of nontrauma patients. The difference in proportions of seropositivity between the sexes was not statistically significant. Physicians obtained information regarding homosexual or bisexual behavior, IV drug use, and hemophilia from 52% of the nontrauma patients and only 17% of trauma patients. None of 30 trauma patients for whom data were available and only two of the 100 nontrauma patients gave a history of any high-risk behavior. CONCLUSION: Although the sampling technique we used has limitations, the prevalence of HIV infection in our noninner-city ED is similar to that recently reported from inner-city EDs. This is in contrast to previous reports of low rates of HIV infection among ED patients in nonurban settings. Physician assessment of risk factors was incomplete in the majority of our patients. Patients rarely acknowledged any high-risk behavior. It is essential that emergency health care workers take maximum diligence to prevent exposure to blood and other body fluids from all ED patients.

Adult↗
PubMed1991

Management guidelines for health care workers exposed to blood and body fluids.

The purpose of this article is to propose specific management guidelines for the immediate emergency department and subsequent occupational health treatment of health care workers (HCWs) following accidental exposures to blood or body fluids. These guidelines are based on a collective review of the literature and the recommendations of the Advisory Committee on Immunization Practices (ACIP) and authorities expert in this knowledge domain. Guidelines are needed to assure appropriate treatment and coordinated efforts by ED and occupational health providers. Although numerous infections can potentially be transmitted by exposure to blood and body fluids, these guidelines are intended only for evaluation and postexposure prophylaxis of hepatitis B, hepatitis C, and infection with HIV.

Blood↗
PubMed1991

Direct costs of emergency medical care: a diagnosis-based case-mix classification system.

STUDY OBJECTIVE: To develop a diagnosis-based case mix classification system for emergency department patient visits based on direct costs of care designed for an outpatient setting. DESIGN: Prospective provider time study with collection of financial data from each hospital's accounts receivable system and medical information, including discharge diagnosis, from hospital medical records. SETTING: Three community hospital EDs in Los Angeles County during selected times in 1984. MEASUREMENTS AND MAIN RESULTS: Only direct costs of care were included: health care provider time, ED management and clerical personnel excluding registration, nonlabor ED expense including supplies, and ancillary hospital services. Indirect costs for hospitals and physicians, including depreciation and amortization, debt service, utilities, malpractice insurance, administration, billing, registration, and medical records were not included. Costs were derived by valuing provider time based on a formula using annual income or salary and fringe benefits, productivity and direct care factors, and using hospital direct cost to charge ratios. Physician costs were based on a national study of emergency physician income and excluded practice costs. Patients were classified into one of 216 emergency department groups (EDGs) on the basis of the discharge diagnosis, patient disposition, age, and the presence of a limited number of physician procedures. Total mean direct costs ranged from $23 for follow-up visit to $936 for trauma, admitted, with critical care procedure. The mean total direct costs for the 16,771 nonadmitted patients was $69. Of this, 34% was for ED costs, 45% was for ancillary service costs, and 21% was for physician costs. The mean total direct costs for the 1,955 admitted patients was $259. Of this, 23% was for ED costs, 63% was for ancillary service costs, and 14% was for physician costs. Laboratory and radiographic services accounted for approximately 85% of all ancillary service costs and 38% of total direct costs for nonadmitted patients versus 80% of ancillary service costs and 51% of total direct costs for admitted patients. CONCLUSION: We have developed a diagnosis-based case mix classification system for ED patient visits based on direct costs of care designed for an outpatient setting which, unlike diagnosis-related groups, includes the measurement of time-based cost for physician and nonphysician services. This classification system helps to define direct costs of hospital and physician emergency services by type of patient.

Adult↗
PubMed1991

Capillary refill--is it a useful predictor of hypovolemic states?

STUDY OBJECTIVES: To evaluate whether the capillary refill test can correctly differentiate between hypovolemic and euvolemic emergency department patients. DESIGN: A prospective, nonrandomized, nonblinded time series. SETTING: The orthostatic and hypotensive patients were seen in a university hospital ED with 44,000 visits per year. Blood donors were studied in the hospital's blood donor center. TYPE OF PARTICIPANTS: Thirty-two adult ED patients who presented with a history suggestive of hypovolemia and either abnormal orthostatic vital signs (19) or frank hypotension (13), and 47 volunteer blood donors who ranged in age from 19 to 83 participated. INTERVENTIONS: Capillary refill was measured before rehydration in the ED subjects and, in the donor group, before and after a 450-mL blood donation. MEASUREMENTS: Sensitivity, specificity, accuracy, and positive and negative predictive values were calculated. Analyses were stratified by age, sex, and study group. MAIN RESULTS: For the blood donor group, mean capillary refill time before donation was 1.4 seconds and after donation was 1.1 seconds. Mean capillary refill time for the orthostatic group was 1.9 seconds and for the hypotensive group was 2.8 seconds. When scored with age-sex specific upper limits of normal, the sensitivity of capillary refill in identifying hypovolemic patients was 6% for the 450-mL blood loss group, 26% for the orthostatic group, and 46% for the hypotensive group. The accuracy of capillary refill in a patient with a 50% prior probability of hypovolemia is 64%. Orthostatic vital signs were found to be more sensitive and specific than capillary refill in detecting the 450-mL blood loss. CONCLUSION: Capillary refill does not appear to be a useful test for detecting mild-to-moderate hypovolemia in adults.

Adult↗
PubMed1991

Management of the febrile child: a survey of pediatric and emergency medicine residency directors.

We conducted a survey to determine whether there is uniformity in the training of residents regarding the management of febrile children. One hundred forty-three (62%) of 231 pediatric and 39 (53%) of the 73 emergency medicine residency directors responded. There was no uniformity in the definition of a fever. Ninety-nine percent of the pediatric and 82% of the emergency medicine residency directors teach that all febrile infants less than 4 weeks of age should be hospitalized (P less than 0.0001). Forty-six percent of residency directors teach that a lumbar puncture should be performed for all children less than 12 months of age with their first febrile convulsion. Thirty percent of pediatric and 62% of emergency medicine residency directors teach that a blood culture should be obtained from a child with fever without source who is younger than 24 months of age (P less than 0.0005). Nonspecific tests are taught to be used to determine which febrile child should have a blood culture as follows: white blood cell count, 50%; differential, 20%; erythrocyte sedimentation rate, 13%; and C-reactive protein, 2%. There was little uniformity of teaching regarding the approach to the febrile child and there were significant differences in training by specialty.

Anti-Bacterial Agents↗
PubMed1990

A comparison of implicit and explicit methods of process quality assurance for blunt trauma patients.

We compared explicit (objective) and implicit (subjective) methods of process quality assurance to understand how the findings of each method are related. The charts of 100 blunt trauma patients who were admitted to the ICU, underwent surgery, or died in the emergency department were reviewed for compliance with six explicit process-of-care criteria previously established by the ED faculty. The results of this explicit review were compared with the results of an ongoing quality assurance program that uses implicit review. In the implicit review, a faculty member reviewed patients' charts and responded to three questions regarding the process of care. All blunt trauma patients who met the admission criteria were to be included in this review. Only 44 of the 100 charts were subjected to implicit review. Of these, 26 were judged satisfactory by both methods, two were judged unsatisfactory by both methods, two failed only the implicit review, and 14 failed only the explicit review. The null hypothesis, that the two methods were equivalent, was rejected (McNemar's test, P less than .003). These results suggest that process-of-care assessments of the quality of care must be interpreted with caution as they are method dependent and may not correlate with patient outcomes.

Adult↗
PubMed1990

Physician exposure to ionizing radiation during trauma resuscitation: a prospective clinical study.

A prospective study of emergency physician whole body and extremity exposure to ionizing radiation during trauma resuscitation over a three-month period was conducted. Radiation film badges and thermoluminescent dosimeter finger rings were permanently attached to leaded aprons worn by emergency medicine residents during all trauma resuscitations. One set of apron and finger ring dosimeters was designated for the resident who managed the airway and stabilized the neck, when necessary, during cervical spine radiography (A-CS resident). A separate set of dosimeters was designated for the resident supervising the resuscitation. During the study period, 150 major trauma patients requiring 481 radiographic studies were treated. The mean monthly cumulative whole body exposures were 136.7 +/- 85.0 and 103.3 +/- 60.3 mrem for A-CS and supervising residents, respectively. The mean weekly cumulative extremity exposures were 523.3 +/- 611.0 and 46.7 +/- 18.6 mrem for A-CS and supervising residents, respectively. Calculated whole body exposures per patient were 2.7 mrem for the A-CS resident and 2.1 mrem for the supervising resident. Calculated extremity exposures per patient were 41.9 +/- 48.9 and 3.7 +/- 1.5 mrem, respectively. To exceed the annual whole body exposure limit established by the National Council of Radiologic Protection, the A-CS resident, working 200 shifts per year, would have to treat 9.2 trauma patients per shift. To exceed the annual extremity exposure limit, the A-CS resident would have to treat 5.9 trauma patients per shift. Of note, European exposure limits are 10% of current US limits. We conclude that significant exposures may occur to physicians working in trauma centers and that the use of shielding devices is indicated.

Emergency Medicine↗
PubMed1990

Effect of education on the use of universal precautions in a university hospital emergency department.

STUDY OBJECTIVES: To determine if an educational program would improve both knowledge and practice of universal precautions by nursing personnel. DESIGN: Participants were given a 14-question test and observed for their, practice of universal precautions during routine IV catheter placement or phlebotomy and trauma care before and six months after an education in-service. SETTING: University hospital emergency department. TYPE OF PARTICIPANTS: Nursing personnel. INTERVENTIONS: One-hour lecture addressing the occupational risk of human immunodeficiency virus (HIV) infection and the recommended use of universal precautions. MEASUREMENTS AND MAIN RESULTS: The mean overall correct response rates to the questionnaire before and after the in-service were 70% and 73%, respectively (P = NS). The pattern of incorrect responses suggested that the perceived risks of HIV transmission are underestimated, particularly among healthy-appearing patients. For care of critical trauma patients, there were significant increases between the frequency rates before and after the in-service of glove and protective eyewear use (66.7% vs 87.7%, P less than .025; 0.0% vs 17.3%, P less than .05, respectively). The frequency rates of glove use for IV placement or phlebotomy in noncritical patients and of gown use for trauma patient care also increased (52.6% vs 65.2% and 25% vs 39.5%, respectively); however, these changes were not statistically significant. CONCLUSION: An intensive educational program was associated with a modest increase in the compliance of ED nursing personnel with universal precautions and had no long-term effect on their general knowledge of HIV risk. The practice of universal precautions is still far from universal in this ED.

Acquired Immunodeficiency Syndrome↗
PubMed1990

Compliance with a standard for the emergency department management of epileptics who present after an uncomplicated convulsion.

We conducted a retrospective chart review to determine whether the treatment of uncomplicated convulsions in emergency department patients with a history of epilepsy complied with a clinical standard and whether the degree of compliance with the standard was related to the treating physician's specialty or postgraduate year of training. The standard specified items to be included in the medical record and appropriate diagnostic tests. A medical record score was defined by the presence of seven essential and seven desirable items obtained from the history and the physical examination. Only anticonvulsant levels and a serum glucose, when not ordered as part of a chemistry profile, were considered appropriate for all patients when drawn. A computed tomography head scan was deemed appropriate for patients whose neurologic status deteriorated or failed to return to baseline within one hour or who had a recent history of significant head trauma. The appropriateness of all other tests was evaluated by review of the medical record. One hundred consecutive ED visits by adult epileptics for an uncomplicated convulsion were considered. Patients ranged in age from 18 to 88 years (median, 28 years). Medical record scores ranged from 7 to 82 (median, 43). ED time ranged from eight to 539 minutes (median, 174.5 minutes). Ancillary services charges ranged from +0 to +1,774 (median, +181.50). Only 27.4% of these charges were for tests deemed appropriate. There was a significant relationship between the ED time and ancillary services charges (Spearman correlation = .5152, P less than .0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Emergencies↗
PubMed1990

Case-mix classification for emergency departments.

This study developed a patient classification system for hospital emergency departments. Conducted at three Los Angeles area community hospitals, data collection included coding and abstracting medical records information, patient billing information detailing each patient's utilization of hospital services, and patient-specific provider time measuring each provider's time spent in direct patient care activities. A 20,000 patient sample was derived containing clinical and resource use variables, including physician, emergency department, and ancillary service direct costs. Patient visits were classified into 216 homogeneous groups, or patient clusters, using four types of variables: diagnoses, disposition, age, and physician procedures. The Emergency Department Groups (EDGs) appear to represent a clinically coherent system for classifying emergency department visits; moreover, the groups were found to explain 63% of the overall variance in resource use (total direct cost) suggesting that the EDGs may offer a useful tool for hospital cost control and reimbursement reform.

Accounts Payable and Receivable↗