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Biomedical subjects

Ronald F Maio

Publications and source records attributed to Ronald F Maio.

28 records · Page 2Linked to original sources
PubMed2002

Emergency Medical Services Outcomes Project III (EMSOP III): the role of risk adjustment in out-of-hospital outcomes research.

The purpose of the Emergency Medical Services Outcomes Project (EMSOP) is to develop a foundation and framework for out-of-hospital outcomes research. Fundamental to that purpose is the identification of priority conditions, risk-adjustment measures (RAMs), and outcome measures. In this third EMSOP article, we examine the topic of risk adjustment, discuss the relevance of risk adjustment for out-of-hospital outcomes research, and recommend RAMs that should be evaluated for potential use in emergency medical services (EMS) research. Risk adjustment allows better judgment about the effectiveness and quality of alternative therapies; it fosters a better comparison of potentially dissimilar groups of patients. By measuring RAMs, researchers account for an important source of variation in their studies. Core RAMs are those measures that might be necessary for out-of-hospital outcomes research involving any EMS condition. Potential core RAMs that should be evaluated for their feasibility, validity, and utility in out-of-hospital research include patient age and sex, race and ethnicity, vital signs, level of responsiveness, Glasgow Coma Scale, standardized time intervals, and EMS provider impression of the presenting condition. Potential core RAMs that could be obtained through linkage to other data sources and that should be evaluated for their feasibility, validity, and utility include principal diagnosis and patient comorbidity. We recommend that these potential core RAMs be systematically evaluated for use in risk adjustment of out-of-hospital patient groups that might be used for outcomes research

Adult↗
PubMed2002

Prevalence of domestic violence and associated factors among women on a trauma service.

BACKGROUND: Despite the increasing recognition of the problem of domestic violence (DV), it has not been studied in surgical populations. METHODS: Eligible patients underwent screening for a recent history of DV and alcohol abuse (AA). Other demographic, health, and injury-related data were also collected. RESULTS: Of 127 subjects entered into the study, 18% screened positive for DV and 21% screened positive for AA. Of those screening positive for DV, 65% screened positive for AA compared with 12% of those screening negative for DV (p < 0.001.) Screening for DV was recommended by a vast majority of subjects, with only 6% of subjects responding that it was not appropriate. CONCLUSION: Both DV and AA have a high prevalence among female trauma patients admitted to trauma centers. Nearly all subjects recommended screening for DV. Screening for DV should be incorporated into the routine care of female trauma patients.

Adult↗
PubMed2002

Guidelines for the management of severe head injury: are emergency physicians following them?

UNLABELLED: The Brain Trauma Foundation published "Guidelines for the Management of Severe Head Injury" in 1995. These evidence-based clinical guidelines (CGs) recommended against prophylactic hyperventilation and glucocorticoid use and advocated for aggressive blood pressure (BP) resuscitation, and the careful use of mannitol. OBJECTIVE: To survey Michigan emergency physicians (MEPs) to test their adherence to these guidelines. METHODS: An anonymous mail survey was sent to all 566 MEPs who are members of the American College of Emergency Physicians. Three clinical scenarios involving severe head injury were presented, all with Glasgow Coma Scale (GCS) scores of 8 or less. The physicians were asked to choose from 15 diagnostic and treatment options, which included: intubation and hyperventilation, BP resuscitation, intravenous (IV) mannitol administration, and IV glucocorticoid administration. RESULTS: Three hundred nineteen (56%) surveys were returned. Forty-six percent [95% confidence interval (95% CI) = 40% to 51%] of the MEPs elected to use prophylactic hyperventilation; very few administered IV glucocorticoids. Seventy-eight percent (95% CI = 75% to 81%) corrected hypotension with systolic BP < 90 mm Hg; 83% (95% CI = 80% to 86%) also administered mannitol appropriately. CONCLUSIONS: A majority of MEPs are managing severe head injury patients in accordance with the "Guidelines for the Management of Severe Head Injury," with the exception of avoiding prophylactic hyperventilation. More education and/or exposure to the evidence regarding prophylactic hyperventilation of severely head injured patients may improve adherence to the guidelines.

Adult↗
PubMedDate not supplied

The feasibility of pain assessment in the prehospital setting.

OBJECTIVE: To determine the feasibility of prehospital pain measurement among patients 13 years of age or older using a verbal and numeric rating scale and to assess the severity of pain in a prehospital patient population. METHODS: Retrospective cross-sectional study of emergency medical services (EMS) run sheets after the adoption of a universal prehospital pain assessment protocol. Data were abstracted from a sequential (1:4) sample of run sheets from the first three months after adoption of the protocol. Verbal rating scale (VRS) and numeric rating scale (NRS) pain assessment information was obtained, along with demographic, location, and call information. Run sheets without pain assessment underwent structured review and classification according to predefined protocol. Descriptive statistics and 95% confidence intervals were calculated. RESULTS: A total of 1,227 run sheets were reviewed, 582 (47%) of patients were male, and 452 (36%) were 65 years of age or older. A total of 907 (75%) were nontrauma transports and 27 (2%) were unconscious. Among conscious patients, pain was assessed using the protocol in 1,002 of 1,200 (84% [range, 81%-86%]). Among patients reporting pain, 104 of 518 (20% [range, 17%-24%] completed a VRS but not an NRS. The greatest risk factor for no pain assessment was altered mental status (39% of patients not assessed). Forty-eight percent (23 of 48) of patients with altered mental status reporting pain completed a VRS only. Thirty-one percent (range, 28%-34%) of all patients in the sample reported moderate or severe pain. CONCLUSION: Prehospital pain assessment using a VRS and NRS was feasible in this patient population. Further studies are needed to confirm this finding in other settings. Moderate or severe pain was present in approximately 31% of patients.

Adolescent↗
PubMedDate not supplied

The epidemiology of pain in the prehospital setting.

OBJECTIVE: To develop national estimates of the epidemiology of pain in the prehospital setting. METHODS: Cross-sectional data on a probability sample of 21,103 emergency department (ED) visits from the 1999 National Hospital Ambulatory Medical Care Survey were analyzed. For patients arriving by ambulance, the frequencies (95% confidence intervals) of patients presenting with no level of pain reported (data unknown or missing) and those reporting no, mild, and moderate or severe pain were determined. The reasons for visit among those with moderate or severe pain, and the ED narcotic analgesic use among those with pain information reported and not reported, were also determined. RESULTS: Of the 102.8 million patients visiting the ED in 1999, 14.5 million arrived by ambulance. Fifty-three percent (49-58%) were female. Seven million six hundred thousand [52% (48-56%)] had no information on presenting level of pain reported, 2.0 million [14% (2-25%)] had no pain, 2.0 million [14% (3-25%)] had mild pain, and 2.9 million 120% (12-29%)] had moderate or severe pain. Among those with moderate or severe pain, the most common reasons for visit were injuries 27% (11-43%) and non-injury musculoskeletal symptoms 18% (0-39%). Narcotic analgesics were ordered or continued in 13% (0-29%) of those with no presenting level of pain recorded and 21% (9-34%) of those for whom the presenting level of pain was recorded. CONCLUSION: Pain is a common condition among prehospital patients: 20% reported moderate to severe pain. Given the use of narcotic analgesics among those for whom pain information was not reported, this is likely a conservative estimate.

Adolescent↗
PubMedDate not supplied

Long-term air medical services system performance using APACHE-II and mortality benchmarking.

OBJECTIVE: Air medical transport programs have been in existence for two decades. During this time, no outcome measures have been developed for these services. The authors examined severity scoring and mortality data from their air medical service to characterize its performance and to identify trends in acuity and mortality over a 15-year period. METHODS: APACHE-II scores derived at the time of transport and hospital mortality data have been concurrently recorded in the flight database for adult transports since 1986. The authors analyzed these data and examined the correlation between APACHE-II score at the time of transport and hospital mortality for the 15-year period 1986-2001. RESULTS: 13,808 adult transports were identified. APACHE data were available for 8,204 patients (59%) and mortality for 10,845 (79%), respectively. The number of transports increased from 935 to 1,231 per year. Mean APACHE-II for all patients was 11.6 +/- 8.4. Overall mortality was 22%. Both patient acuity and mortality were trending upward over time. The correlation between APACHE-II and mortality was close and linear (mortality = 0.018 x APACHE-II -0.0243, R2 = 0.97). CONCLUSIONS: Both severity of illness and mortality of air-transported patients appear to be increasing slowly over time in response to changes in the health care system. The strong correlation between APACHE-II performed at the time of transport and mortality validates this technique for benchmarking. The slope of this correlation is an outcome-based characteristic of system performance that may allow monitoring of a system over time and comparisons between systems.

APACHE↗
PubMedDate not supplied

The effects of alcohol on head injury in the motor vehicle crash victim.

The objective of this study was to determine if alcohol potentiates the severity of traumatic brain injury (TBI) in motor vehicle crash (MVC) victims, controlling for crash severity characteristics. Prior studies evaluating effects of alcohol on TBI have not accounted for severity of crash. We evaluated severity of head injury by Marshall score [a classification scale of intracranial pathology on head computed axial tomogram (CT)], and blood-alcohol concentration (BAC), while controlling for crash characteristics [traffic accident deformity score (TAD) and belt use]. Marshall scores were determined from initial CT or autopsy reports, by a neurosurgeon, and were categorized into less severe injury (<3) and more severe (> or =3). Logistic regression using this variable as the outcome parameter and crash characteristics, age and BAC as predictors was done, and the odds ratio (OR) and 0.95 confidence interval (0.95 CI) calculated. Fifty-eight patients were analysed: 41% were BAC positive, 30% had a modified Marshall score of > or =3. Patients with positive BAC were 2.1-fold more likely to have a more severe head injury as measured on CT scan by the Marshall scores. We suggest that alcohol potentiates severity of TBI as determined from head CT among MVC victims. Further research will be needed to substantiate this finding as well as to determine its long-term effect on clinical outcome.

Accidents, Traffic↗
PubMedDate not supplied

Alcohol and/or other drug use among adult non-occupant motor vehicle crash victims.

AIMS: To identify the frequency of current or lifetime history of alcohol and/or other drug (AOD) use among the full range (admitted and discharged) of injured bicyclists and pedestrians involved in motor vehicle crashes. METHODS: In a prospective study of non-occupant motor vehicle crash (NOMVC) victims >or=18 years over a 29-month period, blood was obtained for alcohol and drug testing. Current alcohol abuse/alcohol dependence (AA/AD) or drug abuse/drug dependence (DA/DD) was based on the Diagnostic Interview Survey. RESULTS: In all, there were 108 NOMVC victims. Eleven per cent were alcohol (+), 7% drug (+), and 3% both. Sixteen per cent were AA/AD (+), 2.7% DA/DD (+), and 1.4% both. CONCLUSIONS: A substantial portion of patients with NOMVC injuries tested AOD (+) and had a current or lifetime substance abuse (AA/AD; DA/DD) diagnosis.

Accidents, Traffic↗
PubMedDate not supplied

Application of measurement tools to pediatric emergency medicine.

A focus on children and the limited time frame of the emergency care setting makes pediatric emergency medicine (EM) outcomes research a challenging endeavor. To address the challenges, pediatric EM researchers must choose their risk adjustment and outcomes measures carefully. This article provides guidance to those researchers through a series of questions and answers, with an emphasis on present and future measurement tools and the steps needed to further develop the field.

Child↗