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Biomedical subjects

Robert E O'Connor

Publications and source records attributed to Robert E O'Connor.

At least 19 recordsLinked to original sources
PubMed2006

Automated external defibrillator program does not impair cardiopulmonary resuscitation initiation in the public access defibrillation trial.

OBJECTIVES: To evaluate whether automated external defibrillator (AED) training and AED availability affected the response of volunteer rescuers and performance of cardiopulmonary resuscitation (CPR) in presumed out-of-hospital cardiac arrest (OOH-CA) during the multicenter Public Access Defibrillation Trial. METHODS: The Public Access Defibrillation Trial recruited 1,260 facilities in 24 North American regional sites to participate in a trial addressing survival from OOH-CA when AED training and availability were added to a volunteer-based emergency response team. Volunteers at each facility were trained to perform either CPR alone (CPR) or CPR in conjunction with AED use (CPR+AED) according to randomized assignments. This study reports the frequency of response and initiation of CPR actions (chest compressions and/or ventilations) by volunteers in the CPR and CPR+AED study groups. RESULTS: A total of 314 presumed OOH-CA episodes occurred in CPR facilities, and 308 occurred in CPR+AED facilities. The volunteers were matched well for age, gender, and other features. Overall, ventilations (23.1% vs. 13.1%), chest compressions (24.4% vs. 12.1%), and both actions (19.8% vs. 10.5%; all p < 0.05) were more commonly performed in OOH-CA cases in the CPR+AED group. However, when only OOH-CA cases with volunteers responding were analyzed, the rates of CPR actions were similar. In the subgroup of CPR+AED cases with a responding volunteer, the AED was turned on for only 47% of cases. Volunteers initiated a CPR action more commonly when the AED was turned on (60.7% vs. 39.3%; p = 0.003). CONCLUSIONS: In the Public Access Defibrillation Trial, rates of CPR actions for presumed OOH-CA victims were low but similar for CPR and CPR+AED responding volunteer rescuers. Factors associated with volunteer response, CPR action initiation, and AED activation warrant further investigation.

Adult↗
PubMed2006

Differentiating large-scale surge versus daily surge.

This breakout session at the Academic Emergency Medicine 2006 Consensus Conference examined how baseline overcrowding impedes the ability of emergency departments to respond to sudden, unexpected surges in demand for patient care. Differences between daily and catastrophic surge were discussed, and the need to invoke a hospital-wide response to surge was explored.

Crowding↗
PubMed2006

Exercise-induced hyponatremia: causes, risks, prevention, and management.

Exercise-induced hyponatremia is most commonly associated with prolonged exertion during sustained, high-intensity endurance activities such as marathons or triathlons. In most cases, exercise-induced hyponatremia is attributable to excess free water intake, which fails to replete the sometimes massive sodium losses that result from sweating. The risk of hyponatremia can be lowered by strategies to ensure fluid balance during exercise by maintaining the proper volume and type of fluid intake. Treatment of exercise-induced hyponatremia is based on whether the patient is volume-depleted, euvolemic, or fluid-overloaded. Because therapy must be tailored to volume status, physicians must make this determination before initiating therapy. If hyponatremia is life-threatening, hypertonic saline may be warranted to increase sodium in the extracellular fluid compartment and restore the natural balance.

Acute Disease↗
PubMed2005

Are US informed consent requirements driving resuscitation research overseas?

Following a 2-year federally imposed moratorium on acute resuscitation research due to concern regarding the inability of patients in cardiac arrest to provide prospective, informed consent to participate in such research, the United States federal government in 1996 released regulations with provisions for exemption of prospective informed consent in certain types of emergency research. While very few acute resuscitation research studies have been attempted in the United States since that time, such research has continued overseas. We discuss one large multi-center, out-of-hospital trial of a device intended to improve the hemodynamics of cardiopulmonary resuscitation. After pilot implementation overseas, this trial could not be conducted in the United States, largely due to the difficulties and costs involved in implementing the requirements of the 1996 regulations. A recent European Union directive on the conduct of clinical trials may halt European research on patients who are unable to provide prospective, informed consent. The directive contains no provisions for exceptions or waiver of informed consent, and may hinder acute resuscitation research in Europe to an even greater degree than the 1996 regulations have in the United States.

Cardiopulmonary Resuscitation↗
PubMed2005

Feeling at risk matters: water managers and the decision to use forecasts.

Experts contend that weather and climate forecasts could have an important role in risk management strategies for community water systems. Yet, most water managers make minimal use of these forecasts. This research explores the determinants of the use of weather and climate forecasts by surveying managers of community water systems in two eastern American states (South Carolina and the Susquehanna River Basin of Pennsylvania). Assessments of the reliability of weather and climate forecasts are not driving their use as water managers who find forecasts reliable are no more likely to use them than are managers who find them unreliable. Although larger systems and those depending on surface water are more likely to use forecasts for some (but not all) purposes, the strongest determinant of forecast use is risk perceptions. Water managers who expect to face problems from weather events in the next decade are much more likely to use forecasts than are water managers who expect few problems. Their expectations of future problems are closely linked with past experience: water managers who have had problems with specific types of weather events (e.g., flood emergencies) in the last 5 years are likely to expect to experience problems in the next decade. Feeling at risk, regardless of the specific source of that weather-related risk, stimulates a decision to use weather and climate forecasts.

Journal Article↗
PubMed2005

Dangerous climate change: the role for risk research.

The notion of "dangerous climate change" constitutes an important development of the 1992 United Nations Framework Convention on Climate Change. It persists, however, as an ambiguous expression, sustained by multiple definitions of danger. It also implicitly contains the question of how to respond to the complex and multi-disciplinary risk issues that climate change poses. The invaluable role of the climate science community, which relies on risk assessments to characterize system uncertainties and to identify limits beyond which changes may become dangerous, is acknowledged. But this alone will not suffice to develop long-term policy. Decisions need to include other considerations, such as value judgments about potential risks, and societal and individual perceptions of "danger," which are often contested. This article explores links and cross-overs between the climate science and risk communication and perception approaches to defining danger. Drawing upon nine articles in this Special Issue of Risk Analysis, we examine a set of themes: limits of current scientific understanding; differentiated public perceptions of danger from climate change; social and cultural processes amplifying and attenuating perceptions of, and responses to, climate change; risk communication design; and new approaches to climate change decision making. The article reflects upon some of the difficulties inherent in responding to the issue in a coherent, interdisciplinary fashion, concluding nevertheless that action should be taken, while acknowledging the context-specificity of "danger." The need for new policy tools is emphasised, while research on nested solutions should be aimed at overcoming the disjunctures apparent in interpretations of climate change risks.

Journal Article↗
PubMed2004

Use of a portable forced air system to convert existing hospital space into a mass casualty isolation area.

STUDY OBJECTIVE: Patients with communicable diseases may require respiratory isolation to reduce the chance of transmission to health care workers and the public. This project was conducted to determine whether negative-pressure isolation for multiple patients can be achieved quickly and effectively using general hospital space not previously dedicated to respiratory isolation. METHODS: The physical therapy gymnasium was the area designated to test the ability to create a negative-pressure isolation environment in a large space. The conversion was planned in advance of an unscheduled drill to convert the space. Four high-efficiency particulate air (HEPA) filtered forced air machines were used to generate negative pressure. The units were vented to the outside air by a 25-foot length of 10-inch-diameter reusable duct. We evaluated the time needed for equipment setup and room conversion and noted any subjective difficulty with either setup or operation of the equipment. We measured the ability of the equipment to generate a negative air pressure relative to adjacent areas and determined the noise levels created during the use of different combinations of machines at various power settings. RESULTS: After drill activation and the request for equipment setup, 1 hour was required to convert the physical therapy gymnasium into an operational negative-pressure environment. The room pressure readings "high" power ranged from -1.5 to -13 Pa (-0.006 to -0.052 inches of water), and noise levels ranged from 70 to 76 dB. Calculated air changes per hour using 1, 2, 3, or 4 units running simultaneously at "high" power were 4.1, 8.2, 12.3, and 16.4, respectively. Using 4 units at once running at "low" power setting yielded 8.2 air changes per hour and generated a room pressure reading of -8.0 Pa, or -0.032 inches of water. CONCLUSION: Portable HEPA filtered forced air units are an effective means of creating large patient care areas with the negative-pressure environment required for respiratory isolation. This design results in a significantly lower-cost alternative compared with construction of individual rooms or units with similar capability and can be retrofitted to existing space. This type of unit would allow treatment of many more patients than current hospital capability would permit and would be an important asset in meeting the needs created by bioterrorism or a naturally occurring epidemic.

Feasibility Studies↗
PubMed2003

Disparities in emergency department health care: systems and administration.

Disparities are likely to present both in the emergency department and within the larger health care system; however, disparities must be recognized to be addressed. This article summarizes the proceedings from the AEM Consensus Conference 2003: Disparities in Emergency Health Care. The goals of the conference were to examine the presence, causes, and outcomes related to disparities of health care as they occur in emergency departments, and determine the degree to which external forces have an impact on our patients. Participants were asked to describe the means of defining, assessing, measuring, and investigating disparities that may occur in emergency care. The committee members who wrote this report were asked to examine the influence of health care systems and administration on disparities in health care, using the following series of questions to frame the discussion. 1) Are all disparities bad? 2) Are only the vulnerable served inadequately by our current health care system? 3) Are what appear to be inequities really systems incompetence? 4) We assume there should be no inequality in health care: does society also assume this? 5) What would be the systems costs of equality in health care?

Adult↗
PubMed2002

Validation of new trauma triage rules for trauma attending response to the emergency department.

INTRODUCTION: The American College of Surgeons Committee on Trauma has suggested triage criteria for the immediate attendance of a trauma surgeon to an injured patient in the emergency department. This study validates the accuracy of these criteria in identifying high-risk trauma patients and assesses the impact of trauma surgeon response time. METHODS: A study group of trauma patients with a systolic blood pressure (SBP) < 90 mm Hg, Glasgow Coma Scale (GCS) score < 8, airway compromise managed with endotracheal intubation (ETI) or surgical airway, or gunshot wound (GSW) to the neck or torso were compared with a control group of patients meeting none of these criteria. Outcome measurements included Injury Severity Score (ISS), duration of hospitalization (length of stay [LOS]), intensive care unit (ICU) days, direct transfer to the ICU or operating room, and mortality. For the study group, trauma surgeon response times, < or = 15 minutes and > 15 minutes, were compared for age, ISS, LOS, ICU days, mortality, and direct transfer to the ICU or operating room. Statistical analysis was performed using the t test and the Yates-corrected chi(2) test (p < 0.05), with odds ratios calculated on the basis of trauma activation criteria and outcome measures. Multiple logistic regression was used to assess the relation between the independent variables SBP, GCS, ETI, and GSW with direct transfer to the ICU or operating room and mortality. RESULTS: A total of 4,910 patients were identified, including 791 study group patients. The mean ISS, LOS, ICU days, and mortality were significantly higher in the study group (p < 0.01). Odds ratios of the study group for direct transfer to the ICU or operating room were 91 and 2 for ETI, 23 and 1.4 for GCS score < 8, 8 and 2.2 for GSW, and 7 and 1.6 for SBP < 90 mm Hg, respectively. The odds ratios for mortality were 39 for ETI, 104 for GCS score < 8, 12 for GSW, and 74 for SBP < 90 mm Hg. Regression analysis demonstrated that GSW, SBP < 90 mm Hg, and ETI predicted ICU admission; GSW, SBP < 90 mm Hg, and ETI predicted operative intervention; and GCS score < 8, SBP < 90 mm Hg, and ETI were associated with mortality. Trauma surgeon response times were available for 658 (83%) of the study group patients. No significant differences were found between the two response groups. CONCLUSION: Trauma patients meeting the triage criteria proposed by the American College of Surgeons Committee on Trauma have more severe injuries, a higher mortality rate, and longer hospital and ICU stays than control patients. SBP < 90 mm Hg, ETI, and GSW are predictive of urgent operating room use and ICU admission. A significantly higher mortality rate is associated with SBP < 90 mm Hg, ETI, and GCS score < 8. Incorporating these criteria into trauma center triage rules to identify high-risk injured patients is warranted. However, trauma surgeon response time < or = 15 minutes was not associated with improved patient outcome, and optimal response time remains uncertain.

Adult↗
PubMed2002

Emergency department personnel use seatbelts almost all the time: what do they know that average Delawareans don't?

A survey was sent to each emergency department in Delaware and each county Emergency Medical Service (EMS) Advanced Life Support (paramedic) service asking seven questions on risk-taking behavior. Within the survey were the following four questions regarding seatbelt use: a) Do you wear a seatbelt while driving? b) Do you require others in your car to wear seatbelts? c) When you are a passenger in a car, do you wear a seatbelt? d) Has the seatbelt law in Delaware impacted your seatbelt use? The three possible responses were "never," "sometimes," and "always." The remaining three questions were confouders and asked about cigarette smoking and driving under the influence of alcohol. Replies were divided into the following job categories: 1) emergency physician (EP), emergency department (ED) physician assistant (PA) or nurse practitioner (NP), 2) emergency nurse, 3) paramedic, or 4) ED clerk, respiratory therapist (RT), or other emergency support personnel. A total of 313 surveys was returned by 78 physicians, NPs and PAs; 115 paramedics; and 115 clerks, RTs, and other support personnel. Overall, 86 percent of respondent stated that they always wear seatbelts with 99 percent of EPs/PAs and NPs responding always. Overall, 83 percent stated that they require others to wear seatbelts in their automobiles. Eighty-four percent wear seatbelts while a passenger in someone else's car. The physician, PA, and NP group had the greatest "always" response rate as compared to the other groups.

Allied Health Personnel↗
PubMedDate not supplied

Eliminating errors in emergency medical services: realities and recommendations.

Errors in health care can have serious consequences, not only for patients but for society as a whole, given the considerable national expenditures required to address these errors. Because of the number of patients treated and the acuity of emergency situations, eliminating errors should be a priority in emergency medical services (EMS) systems. In a recent report, the Institute of Medicine called for improvements in patient safety, which it defined as freedom from accidental injury. Recent efforts have focused on integrating EMS systems into error analyses of the total health care system. However, EMS systems must take the initiative in addressing their own major error-prone areas using the best and most current data available. Unfortunately, addressing the problem of medical errors in EMS systems still suffers from a paucity of data, owing to a lack of organized, funded programs backed by legislation and dedicated government coordination. We recommend that EMS medical directors consider specific error audits to decrease sources of errors and to be better able to identify EMS providers who would benefit from retraining. Error audits might first be focused on the following potentially serious errors: equipment malfunction, failure to check oxygen saturation, failure to immobilize the patient, use of incorrect protocol or algorithm, failure to check glucose levels, failure to recognize patient deterioration, failure to detect misplaced endotracheal tubes, and use of wrong drug or drug dose.

Emergency Medical Services↗
PubMedDate not supplied

Alternative cardiopulmonary resuscitation devices.

Cardiopulmonary resuscitation (CPR) involving manual external chest compression combined with artificial respiration was first described in 1960 by Kouwenhoven et al. (Kouwenhoven W, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA. 1960; 173:1064-7). In the four decades since then, there have been no widely accepted alternatives for this technique. Even with the subsequent worldwide adoption of CPR and other advanced cardiac life support measures, long-term survival after prehospital cardiac arrest is still typically only 5%, to 10%. The performance of CPR must therefore be improved to increase the rate of long-term survival. Currently under development are new, alternative techniques such as interposed abdominal compression (IAC), active compression-decompression (ACD), pneumatic and nonpneumatic circumferential chest compression, and minimally invasive cardiac massage. Many of these newer techniques, compared with standard manual CPR, appear to provide superior vital organ blood flow and increased blood pressure. To date, only IAC (in-hospital only) and ACD have been shown to improve long-term survival in clinical studies. Circumferential chest compression and minimally invasive cardiac massage, on the other hand, have not yet been adequately tested in large clinical trials. Despite the difficulty and expense in studying these CPR techniques, additional research is necessary to evaluate their effectiveness in improving survival after sudden cardiac arrest.

Advanced Cardiac Life Support↗
PubMedDate not supplied

Effectiveness of a medical priority dispatch protocol for abdominal pain.

OBJECTIVE: Medical Priority Dispatch System (MPDS) protocols are used to determine the appropriate level of emergency medical services (EMS) response that is sent to care for patients in the prehospital setting. The objective of this study was to determine the proportion of patients with abdominal pain who would benefit from advanced life support (ALS) when called for by these protocols. METHODS: All 9-1-1 calls were processed using MPDS protocols to determine whether the patient required ALS or basic life support (BLS) services. Consecutive patients having an ALS response for a chief complaint of abdominal pain were included. Dispatch decisions that did not follow the MPDS protocols, and cases taken to facilities other than the primary study hospitals, were excluded. EMS run sheets and hospital records were reviewed to determine: 1) whether prehospital ALS interventions were required, 2) emergency department (ED) disposition, 3) hospital course, and 4) final diagnosis. Calls were classified according to the need for ALS and the seriousness of the subsequent diagnosis. Data analysis was performed by determining 95%, confidence intervals (CIs). RESULTS: Of the 343 patients classified as 1C1 or 1C2 who were transported by ALS during the time period, 227 (67%) were transported to the study hospitals. Nine (4%) were excluded because of inappropriate dispatch, leaving 218 for analysis. Hospital records were available for 186 (86%) cases, of which 12 (6%; CI 3%, 9%) were potentially life-threatening, requiring ALS intervention. Seventeen (9%; CI 5%, 1%) were non-life-threatening, but potentially benefited from ALS intervention. The remaining 157 (84%; CI 79%, 89%) were classified as not requiring ALS. CONCLUSIONS: Use of age- and gender-specific MPDS protocols for patients with a chief complaint of abdominal pain results in significant overtriage and overuse of ALS. Steps should be taken to develop key questions that provide more accurate classification of these patients that goes beyond age and gender classification alone.

Abdominal Pain↗
PubMedDate not supplied

Location of cardiac arrests in the public access defibrillation trial.

BACKGROUND: The Public Access Defibrillation (PAD) Trial found an overall doubling in the number of out-of-hospital cardiac arrest (CA) survivors when a lay responder team was equipped with an automated external defibrillator (AED), compared with cardiopulmonary resuscitation (CPR) alone. OBJECTIVES: To describe the types of facilities that participated in the trial and to report the incidence of CA and survival in these different types of facilities. METHODS: In this post-hoc analysis of PAD Trial data, the physical characteristics of the participating facilities and the numbers of presumed CAs, treatable CAs, and survivors are reported for each category of facilities. RESULTS: There were 625 presumed CAs at 1,260 participating facilities. Just under half (n = 291) of the presumed CAs were classified as treatable CAs. Treatable CAs occurred at a rate of 2.9 per 1,000 person-years of exposure; rates were highest in fitness centers (5.1) and golf courses (4.8) and lowest in office complexes (0.7) and hotels (0.7). Survival from treatable CA was highest in recreational complexes (0.5), public transportation sites (0.4), and fitness centers (0.4) and lowest in office complexes (0.1) and residential facilities (0.0). CONCLUSIONS: During the PAD Trial, the exposure-adjusted rate of treatable CA was highest in fitness centers and golf courses, but the incidence per facility was low to moderate. Survival from treatable cardiac arrest was highest in recreational complexes, public transportation facilities, and fitness centers.

Age Distribution↗
PubMedDate not supplied

Facilitating EMS turnaround intervals at hospitals in the face of receiving facility overcrowding.

The escalating national problem of oversaturated hospital beds and emergency departments (EDs) has resulted in serious operational impediments within patient-receiving facilities. It has also had a growing impact on the 9-1-1 emergency care system. Beyond the long-standing difficulties arising from ambulance diversion practices, many emergency medical services (EMS) crews are now finding themselves detained in EDs for protracted periods, unable to transfer care of their transported patients to ED staff members. Key factors have included a lack of beds or stretcher space, and, in some cases, EMS personnel are used transiently for ED patient care services. In other circumstances, ED staff members no longer prioritize rapid turnaround of EMS-transported patients because of the increasing volume and acuity of patients already in their care. The resulting detention of EMS crews confounds concurrent ambulance availability problems, creates concrete risks for delayed EMS responses to impending critical cases, and incurs regulatory jeopardy for hospitals. Communities should take appropriate steps to ensure that delivery intervals (time elapsing from entry into the hospital to physical transfer of patient care to ED staff) remain extremely brief (less than a few minutes) and that they rarely exceed 10 minutes. While recognizing that the root causes of these issues will require far-reaching national health care policy changes, EMS and local government officials should still maintain ongoing dialogues with hospital chief administrators to mitigate this mutual crisis of escalating service demands. Federal and state health officials should also play an active role in monitoring progress and compliance.

Bed Occupancy↗
PubMedDate not supplied

Trauma triage: concepts in prehospital trauma care.

This report examines the efficacy of current trauma triage rules to determine the exigency of field care and transport of severely injured patients from a variety of medical populations.

Emergency Medical Services↗