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Biomedical subjects

N Clay Mann

Publications and source records attributed to N Clay Mann.

At least 19 recordsLinked to original sources
PubMed2006

Characteristics of volunteers responding to emergencies in the Public Access Defibrillation Trial.

OBJECTIVES: To evaluate the characteristics of volunteers responding to emergencies in the North American Public Access Defibrillation (PAD) Trial. METHODS: The PAD Trial was a prospective evaluation of cardiac arrest survival in community facilities randomized to cardiopulmonary resuscitation (CPR) or to CPR with automated external defibrillators (AEDs). The PAD volunteers' characteristics were analyzed using Poisson regression clustered on the facility and offset by the number of emergency episodes to which volunteers were exposed. RESULTS: A total of 19,320 volunteers in 1260 facilities were trained to provide emergency care. Of these, 8169 volunteers were participating actively at their facility during a time when one or more emergency episodes occurred. There were 1971 emergency episodes responded to by 1245 volunteers. The treatment arm (CPR-only versus CPR+AED) was not associated with the likelihood of volunteer participation in an episode. Likewise, the volunteers' age or sex did not affect response. Volunteers more likely to respond were supervisory/management or security personnel, non-minority participants, volunteers with previous CPR training, volunteers with previous experience in emergency care and those who passed the PAD CPR skills follow-up test. Volunteers who had a formal education beyond a high school level were less likely to respond. CONCLUSIONS: Volunteers with previous emergency training and positions of responsibility in their facility had a greater likelihood of participation in medical emergencies in the PAD Trial.

Adult↗
PubMed2006

Are statewide trauma registries comparable? Reaching for a national trauma dataset.

BACKGROUND: Statewide trauma registries have proliferated in the last decade, suggesting that information could be aggregated to provide an accurate depiction of serious injury in the United States. OBJECTIVES: To determine whether variability exists in the composition and content of statewide trauma registries, specifically addressing case-acquisition, case-definition (inclusion criteria), and registry-coding conventions. METHODS: A cross-sectional, two-part survey was administered to managers of all statewide trauma registries. State trauma registrars also provided inclusion and exclusion criteria from their state registry and abstracted a clinical vignette designed to identify coding inconsistencies. RESULTS: Thirty-two states maintain a centralized registry, but requirements for data submission vary significantly. Inclusion and exclusion criteria also vary, particularly for nontraumatic injuries. Coding conventions adopted by states for vague or missing information are dissimilar. When abstractions of the clinical vignette are compared, only 19% and 47% of states provided similar quantity or content for injury e-coding and diagnostic coding, respectively. Injury severity scores (based on diagnostic coding) demonstrated a range from 2 to 18. CONCLUSIONS: Statewide trauma registries are prevalent but vary significantly in composition and content. Standardizing inclusion criteria, variable definitions, and coding conventions would greatly enhance the usability of an aggregated, national trauma registry.

Cross-Sectional Studies↗
PubMed2006

Adverse events associated with lay emergency response programs: the public access defibrillation trial experience.

UNLABELLED: The adverse event (AE) profile of lay volunteer CPR and public access defibrillation (PAD) programs is unknown. We undertook to investigate the frequency, severity, and type of AE's occurring in widespread PAD implementation. DESIGN: A randomized-controlled clinical trial. SETTING: One thousand two hundred and sixty public and residential facilities in the US and Canada. PARTICIPANTS: On-site, volunteer, lay personnel trained in CPR only compared to CPR plus automated external defibrillators (AEDs). INTERVENTION: Persons experiencing possible cardiac arrest receiving lay volunteer first response with CPR+AED compared with CPR alone. MAIN OUTCOME MEASURE: An AE is defined as an event of significance that caused, or had the potential to cause, harm to a patient or volunteer, or a criminal act. AE data were collected prospectively. RESULTS: Twenty thousand three hundred and ninety six lay volunteers were trained in either CPR or CPR+AED. One thousand seven hundred and sixteen AEDs were placed in units randomized to the AED arm. There were 26,389 exposure months. Only 36 AE's were reported. There were two patient-related AEs: both patients experienced rib fractures. There were seven volunteer-related AE's: one had a muscle pull, four experienced significant emotional distress and two reported pressure by their employee to participate. There were 27 AED-related AEs: 17 episodes of theft involving 20 devices, three involved AEDs that were placed in locations inaccessible to the volunteer, four AEDs had mechanical problems not affecting patient safety, and three devices were improperly maintained by the facility. There were no inappropriate shocks and no failures to shock when indicated (95% upper bound for probability of inappropriate shock or failure to shock = 0.0012). CONCLUSIONS: AED use following widespread training of lay-persons in CPR and AED is generally safe for the volunteer and the patient. Lay volunteers may report significant, usually transient, emotional stress following response to a potential cardiac arrest. Within the context of this prospective, randomized multi-center study, AEDs have an exceptionally high safety profile when used by trained lay responders.

Canada↗
PubMed2006

Risk of pediatric back-over injuries in residential driveways by vehicle type.

OBJECTIVE: Research suggests that children experience driveway back-over injuries at a significant rate and the severity of the resulting injuries differ by type of vehicle. Yet, no US study attempted to quantify "back-over risk" for classes of vehicles because of the difficulties with determining exposure. Using vehicle registration information, we set out to estimate the relative risk of driveway back-over injuries to children by type of vehicle. METHODS: Driveway back-over events were identified from state police reports and medical records from the state level 1 pediatric trauma center and compared with vehicle registration information to estimate injury incidence for 4 classes of vehicles (passenger cars, trucks, sport utility vehicles, and minivans) over 6 years in the state of Utah. RESULTS: Reported driveway back-over injuries represent an incidence of 7.09 per 100,000 children (<10 years old) per year. Overall, passenger cars account for 1.62 injuries per 100,000 registered vehicles. Compared with passenger cars, children were 53% more likely to be injured by a truck (P = 0.01) and 2.4 times more likely to be injured by a minivan (P < 0.001). Among children transported to a trauma center, admission (P = 0.01) and need for surgery (P = 0.03) were greater among children backed over by trucks, sport utility vehicles, and minivans compared with passenger cars. CONCLUSIONS: Findings suggest that when assessing driveway back-over injuries, larger high-profile vehicles are associated with a higher incidence and severity of injuries when compared with injuries resulting from passenger cars.

Accidents, Home↗
PubMed2005

Underestimating injury mortality using statewide databases.

BACKGROUND: This study examines the potential for misclassifying injury-related deaths reported in Vital Statistics and assesses the rate of postdischarge death among injured patients released from hospital, emergency department (ED), and emergency medical services (EMS) care. METHODS: Statewide death certificate, inpatient, ED, and EMS databases for 1996 through 1997 were probabilistically linked and information in each database compared. RESULTS: One thousand two hundred ninety-four injured inpatients or ED patients were matched with a death certificate record that listed an injury (56.3%) or illness (43.7%) as the primary cause of death. Injured decedents with an illness-coded cause of death were older (p < 0.001), with causes of death indicative of chronic medical conditions. Few deaths occurred within 30 days of inpatient discharge (6%); however, 38% and 9% of deaths in ED and EMS databases occurred after discharge from health care, respectively. Many deaths among EMS and ED patients occur in subsequent phases of care. CONCLUSION: Estimates of injury mortality substantially increase when using multiple independent databases.

Adult↗
PubMed2005

Trauma system structure and viability in the current healthcare environment: a state-by-state assessment.

OBJECTIVE: Anecdotal reports suggest that some state trauma systems are struggling to remain solvent while others appear stable in the current health care environment. The purpose of this research is to characterize the current structure and viability of state trauma systems in the U.S. METHODS: Expert panels were convened in all 50 states to characterize the current structure of trauma care and to identify strengths, weakness, opportunities and threats facing trauma care delivery in each state. RESULTS: States continue to value the formalization of trauma systems. System operations, evaluation/research methods and trauma leadership are highly valued by states with mature systems. However, all states consider their trauma system severely threatened by inadequate funding and difficulty recruiting and retaining physicians and nurses. CONCLUSION: Trauma care systems are valued and demonstrate potential for future expansion. However, economic shortfalls and retention of medical personnel threaten the viability of current systems across the U.S.

Health Services Research↗
PubMed2005

Confronting the Ethical Conduct of Resuscitation Research: a consensus opinion.

An objective of the 2005 Academic Emergency Medicine Consensus Conference, "Ethical Conduct of Resuscitation Research," was to identify if consensus exists regarding application of the Food and Drug Administration (FDA) Final Rule allowing an exception from informed consent in resuscitation research. At the start of the consensus conference, 49 attendees participated in a survey containing three sections: 1) demographic questions characterizing respondents, 2) questions regarding application of the FDA Final Rule, and 3) complexities associated with seeking informed consent in an emergency setting. Consensus analysis was used to determine if a formal consensus was reached, relying on a Bayesian posterior probability of 0.99 to consider survey responses a "consensus." Respondents demonstrated consensus regarding the need to further refine and standardize application of the FDA Final Rule in resuscitation research. However, participants agreed that current regulations provide adequate and appropriate protection to safeguard patients. Complexities associated with seeking informed consent in emergency departments were prevalent among most institutions represented at the conference. There was general agreement that current efforts to safeguard human subjects are effective, but participants agreed that refinements to and standardization of the FDA Final Rule would facilitate resuscitation research and enhance patient safety.

Consensus Statements as Topic↗
PubMed2004

Resource utilization and its management in splenic trauma.

BACKGROUND: This study compared resource utilization and its management for splenic injury at 2 level-I trauma centers and a pediatric referral center with other facilities in a state currently developing a trauma system. METHODS: Management strategy, length of stay, and total charges for children were compared among the pediatric referral center, trauma centers, and other facilities. Adult management, length of stay, and total charges were compared between trauma centers and other facilities. RESULTS: Nonoperative management was more frequent in children at the pediatric referral center than trauma centers or other facilities and was more common in adults at trauma centers than at other facilities. Mean length of stay and total charges for children were significantly greater at the pediatric referral center and trauma centers than at other facilities and for adults at trauma centers than at other facilities. Facility type was associated with length of stay and total charges when injury type and severity were controlled. CONCLUSIONS: Nonoperative management of splenic injury is more common at trauma centers, and splenic trauma management may be more costly at trauma centers.

Adult↗
PubMed2004

Patients with chest pain calling 9-1-1 or self-transporting to reach definitive care: which mode is quicker?

OBJECTIVE: We examined differences in transport times for patients with chest pain who used private transportation compared with patients who used emergency medical services (EMS) to reach definitive medical care. METHODS: This was a retrospective cohort study with data used from the Rapid Early Action for Coronary Treatment (REACT) trial conducted in 20 US cities. Elapsed time to care was examined through the use of (1) decision to seek care to initial care (emergency department [ED] arrival versus EMS arrival on scene [n=1209]); (2) decision to ED arrival (for both groups [n=2388]); (3) time to thrombolytic therapy once admitted to the ED (for both groups [n=309]); and (4) decision to seek care to thrombolytic therapy (n=276). Elapsed travel times were ranked within Zip Codes and submitted to a nested analysis of variance model to determine if elapsed times were different between modes of transport. RESULTS: Private transportation (35 minutes) resulted in faster ED arrival than using EMS (39 minutes, P =.0014). However, if one considers EMS treatment to be initial care, calling 9-1-1 (6 minutes) resulted in much quicker care than patients using private transportation to the ED (32 minutes, P <.001). Transport by EMS resulted in a shorter elapsed time to thrombolytic administration compared with patients using private transportation when considering ED "door-to-needle" time (32 vs 49 minutes, respectively [P <.001]) or time from decision to seek care until administration of thrombolytic therapy (75 vs 92 minutes, respectively, [P =.042]). CONCLUSIONS: Although private transportation results in a faster trip to the ED, quicker care is obtained with the use of EMS.

Adult↗
PubMed2004

Repeat patients to the emergency department in a statewide database.

OBJECTIVES: To describe the epidemiology of repeat users of the emergency department (ED) using a statewide database. METHODS: Probabilistic linkage was used to convert three years of statewide ED visit data into a longitudinal, patient-based data set. Patients were classified as single, repeat (at least two visits within three years), or serial (four or more visits within a 365-day period) users of the ED. Serial patients were further stratified by the number of EDs attended. Descriptive statistics were used to assess differences between patient types. RESULTS: There were 1,370,607 separate visits associated with 780,074 patients from 1996 to 1998. While repeat and serial patients represented 33% of the patients, they accounted for 62% of the ED visits during the study period. Repeat and serial patients were younger and had smaller median ED charges per visit than single-use patients. Serial patients attending five or more EDs were more likely to be coded as self-pay than other serial patients. Diagnosis codes relating to sprains, back problems, and headaches were prevalent among serial patients who visited five or more EDs. Approximately 30% of serial patients during the first year remained serial patients in the second year. CONCLUSIONS: Due to the high turnover in serial patients, control groups in future studies are necessary to evaluate interventions aimed at decreasing serial ED use. The likelihood of serial ED users to use multiple EDs indicates that those studying serial ED use should collect data from multiple EDs.

Adolescent↗
PubMed2003

Against all advice: an analysis of out-of-hospital refusals of care.

STUDY OBJECTIVE: We examine the characteristics of patients involved in out-of-hospital emergency medical services (EMS) incidents that result in refusal of care and determine the rates of subsequent EMS, emergency department (ED), and inpatient care, as well as death within 7 days. METHODS: Utah statewide EMS data identifying refusals of care were probabilistically linked to Utah statewide ED, inpatient, and death certificate data within 7 days of the initial EMS refusals for 1996 to 1998. Refusals were defined as incidents in which field treatment or transport was refused and did not include incidents in which EMS providers deemed care or transport unnecessary. RESULTS: Of 277244 EMS incidents, 14109 (5.1%) resulted in refusals of care. For all age groups, motor vehicle crash dispatches resulted in the highest rate of refusal of care, ranging from 8.0% to 11.7%. Slightly more than 3% of patients involved in a refusal of care incident had a subsequent EMS dispatch within a week. One fifth of the patients involved in EMS refusals of care had a subsequent ED visit. Less than 2% of the EMS refusal patients were hospitalized; hospitalization was highest among children younger than 3 years and adults older than 64 years. Twenty-five adults died within a week of refusing EMS care, of whom 19 (76.0%) were older than 64 years. CONCLUSION: Refusal of care incidents are a small segment of all EMS incidents. They arise from a variety of situations, and the risk for missed intervention may be minimal.

Accidents, Traffic↗
PubMed2002

Survival of seriously injured patients first treated in rural hospitals.

BACKGROUND: Patients injured in rural counties are hypothesized to have improved survival if local hospitals are categorized as Level III, Level IV, and Level V trauma centers. METHODS: Data were abstracted on patients with brain, liver, or spleen injuries who were first treated in 16 rural hospitals in Oregon (with categorized trauma centers) and 16 hospitals in Washington (without categorized trauma centers). Logistic regression models evaluated survival up to 30 days after hospital discharge. RESULTS: Among Oregon's 642 study patients, 63% were transferred to another hospital. Among Washington's 624 patients, a higher proportion, 70%, were transferred. Risk-adjusted odds of death for Washington patients (reference odds, 1) were the same as for Oregon patients (odds ratio, 0.82; 95% confidence interval, 0.53-1.28). Most patients died after transfer to another hospital. CONCLUSION: In states with a prevailing practice of promptly transferring brain-injured patients, survival of these patients may not be enhanced by categorization of hospitals as rural trauma centers. To further improve the outcome of these patients, policy makers should adjust statewide trauma system guidelines to enhance integration and to perfect coordination among sequential decision makers.

Adult↗
PubMed2002

Injury mortality following the loss of air medical support for rural interhospital transport.

OBJECTIVES: This study evaluated variation in mortality among interfacility transfers three years before and after discontinuation of a rotor-wing transport service. METHODS: A retrospective cohort assessment was conducted among severely injured patients transferred from four rural hospitals to a single tertiary center in regions with continued versus discontinued rotor-wing service. Thirty-day mortality following discharge from the receiving tertiary facility served as the primary outcome measure. RESULTS: Discontinuation of rotor-wing transport decreased interfacility transfers and increased transfer time. Transferred patients were four times more likely to die after (compared with before) rotor-wing service was discontinued (p = 0.05). No difference was noted in the region with continued rotor-wing service [odds ratio (OR) = 0.53, p = 0.47]. CONCLUSIONS: Injury mortality increased with loss of air transport for interfacility transfer in a rural area.

Adolescent↗
PubMed2001

Mortality among seriously injured patients treated in remote rural trauma centers before and after implementation of a statewide trauma system.

BACKGROUND: Injury mortality in rural regions remains high with little evidence that trauma system implementation has benefited rural populations. OBJECTIVE: To evaluate risk-adjusted mortality in remote regions of Oregon before and after implementation of a statewide trauma system. RESEARCH DESIGN: A retrospective cohort study assessing injury mortality through 30 days after hospital discharge. SETTING: Nine rural Oregon hospitals serving counties with populations <18 persons per square mile. SUBJECTS: Severely injured patients presenting to four level-3 and five level-4 trauma hospitals 3 years before and 3 years after trauma system implementation. MEASURES: Interhospital transfer, hospital death, and demise within 30 days following hospital discharge. RESULTS: A total of 940 patients were analyzed. After trauma system implementation, patients presenting to level-4 hospitals were more likely transferred to level-2 facilities (P <0.001). Interhospital transfer times from level-3 hospitals lengthened significantly after system implementation (P <0.001). Overall mortality rates were higher in the postsystem period (8.3%) than the presystem period (6.7%), but not significantly. Controlling for covariates, no additional benefit to risk-adjusted mortality was associated with trauma system implementation. Additional deaths, occurring after trauma system implementation, included head-injured patients transferred from rural hospitals to nonlevel-1 trauma center hospitals. CONCLUSIONS: Increased injury survival after Oregon trauma system implementation, demonstrated in urban and statewide analyses, was not confirmed in remote regions of the state. Efforts to improve trauma systems in rural areas should focus on the processes of care for head-injured patients transferred to higher designation trauma centers.

Adult↗
PubMedDate not supplied

Developing research criteria to define medical necessity in emergency medical services.

"The Neely Conference: Developing Research Criteria to Define Medical Necessity in EMS" convened emergency medical services (EMS) physicians, researchers, administrators, providers, and federal agency representatives to begin the development of a set of uniform triage criteria and outcome measures that could be used to study and evaluate medical necessity among EMS patients. These standardized criteria might be used in research studies examining EMS dispatch and response (e.g., dispatch triage protocols, alternative response configurations), and EMS treatment and transport (e.g., field triage protocols, alternative care destinations). The conference process included review and analysis of the literature, expert judgment, and consensus building. There was general agreement on the following: 1. Any dispatch triage or field triage system that is developed must be designed to offer patients alternatives to EMS, not to refuse care to patients. 2. It is theoretically possible to develop a set of clinical criteria for need. Some groups of patients will clearly need a traditional EMS response and other groups will not, but this has yet to be defined. 3. In addition to clinical criteria, certain social and other nonclinical criteria such as pain or potential abuse may be used to justify a response. 4. Communication barriers, patient age, special needs, and other conditions complicate patient assessment but should not exclude patients from consideration for alternate triage or transport. 5. These research questions are important, and standard sets of outcome measures are needed so that different studies and innovative programs can be compared.

Adult↗
PubMedDate not supplied

Criteria currently used to evaluate dispatch triage systems: where do they leave us?

Some emergency medical services (EMS) systems are interested in considering the possibility of triaging some patients who call an emergency dispatch center to alternatives to the traditional emergency response, but concerns exist about the safety of that triage. In January 2003, the Neely Conference was held in association with the National Association of EMS Physicians annual meeting in Panama City, Florida. The Neely Conference began the process of developing criteria to be used in research studies evaluating dispatch and field triage systems. Various outcome measures have been used, including expert opinion, patient interviews, specific patient complaints, field findings and interventions, and emergency department or hospital outcomes. This commentary reviews the methods used in the current literature to evaluate dispatch triage systems.

Emergency Medical Service Communication Systems↗
PubMedDate not supplied

Field triage systems: methodologies from the literature.

The primary goal of the Neely Conference project is to work toward defining a set of research criteria for medical necessity in emergency medical services (EMS). This paper reviews the extant literature on triage and nontransport decisions made in the field by EMS personnel, with emphasis on the methodologies that have been used to date. Two types of medical necessity standards are considered. First, there are triage criteria for determining whether a given patient requires EMS transport to the hospital, or whether an alternative might be appropriate. These triage criteria might be incorporated into protocols that field personnel could apply on scene to determine the best disposition for a given patient. Second, there are the outcome measures against which the decisions made by the field personnel are judged. In some cases, the outcome measure is the judgment of a reviewing emergency physician or nurse, while in others specific outcome measures are used to judge the performance of the criteria and the decision making of the field providers. While review of the literature shows that no "standard" set of triage criteria have been generated or validated in determining medical necessity in EMS, there are certain themes that emerge from the literature, and these themes can likely form the basis of a consensus on elements of a medical necessity criteria that need to be validated and refined. These may include (for triage criteria) vital signs, chief complaints, and physical exam findings, and (for outcome measures) hospital admission, critical events, death, and diagnosis.

Emergency Medical Services↗