EMS medical direction and prehospital practices for acute cardiovascular events.

OBJECTIVE: The purpose of this analysis was to determine whether there is an association between type of emergency medical services (EMS) medical direction and local EMS agency practices and characteristics specifically related to emergency response for acute cardiovascular events. METHODS: We surveyed 1,292 EMS agencies in nine states. For each cardiovascular prehospital procedure or practice, we compared the proportion of agencies that employed paid (full- or part-time) medical directors with the proportion of agencies that employed volunteer medical directors. We also compared the proportion of EMS agencies who reported direct interaction between emergency medical technicians (EMTs) and their medical director within the previous four weeks with the proportion of agencies who reported no direct interaction. Chi-square tests were used to assess statistical differences in proportion of agencies with a specific procedure by medical director employment status and medical director interaction. We repeated these comparisons using t-tests to evaluate mean differences in call volume. RESULTS: The EMS agencies with prehospital cardiovascular response policies were more likely to report employment of a paid medical director and less likely to report employment of a volunteer medical director. Similarly, agencies with prehospital cardiovascular response practices were more likely to report recent medical director interaction and less likely to report absence of recent medical director interaction. Mean call volumes for chest pain, cardiac arrest, and stroke were higher among agencies having paid medical directors (compared with agencies having volunteer medical directors) and agencies having recent medical director interaction (compared with agencies not having recent medical director interaction). CONCLUSIONS: Our study demonstrated that EMS agencies with a paid medical director and agencies with medical director interaction with EMTs in the previous four weeks were more likely to have prehospital cardiovascular procedures in place. Given the strong relationship that both employment status and direct interaction have with the presence of these practices, agencies with limited resources to provide a paid medical director or a medical director that can be actively involved with EMTs should be supported through partnerships and other interventions to ensure that they receive the necessary levels of medical director oversight.

Factors associated with emergency medical services scope of practice for acute cardiovascular events.

OBJECTIVES: To examine prehospital emergency medical services (EMS) scope of practice for acute cardiovascular events and characteristics that may affect scope of practice; and to describe variations in EMS scope of practice for these events and the characteristics associated with that variability. METHODS: In 2008, we conducted a telephone survey of 1,939 eligible EMS providers in nine states to measure EMS agency characteristics, medical director involvement, and 18 interventions authorized for prehospital care of acute cardiovascular events by three levels of emergency medical technician (EMT) personnel. RESULTS: A total of 1,292 providers responded to the survey, for a response rate of 67%. EMS scope of practice interventions varied by EMT personnel level, with the proportion of authorized interventions increasing as expected from EMT-Basic to EMT-Paramedic. Seven of eight statistically significant associations indicated that EMS agencies in urban settings were less likely to authorize interventions (odds ratios <0.7) for any level of EMS personnel. Based on the subset of six statistically significant associations, fire department-based EMS agencies were two to three times more likely to authorize interventions for EMT-Intermediate personnel. Volunteer EMS agencies were more than twice as likely as nonvolunteer agencies to authorize interventions for EMT-Basic and EMT-Intermediate personnel but were less likely to authorize any one of the 11 interventions for EMT-Paramedics. Greater medical director involvement was associated with greater likelihood of authorization of seven of the 18 interventions for EMT-Basic and EMT-Paramedic personnel but had no association with EMT-Intermediate personnel. CONCLUSIONS: We noted statistically significant variations in scope of practice by rural vs. urban setting, medical director involvement, and type of EMS service (fire department-based/non-fire department-based; volunteer/paid). These variations highlight local differences in the composition and capacity of EMS providers and offer important information for the transition towards the implementation of a national scope of practice model.

Practical considerations optically sensing rhodamine WT in water impacted by municipal biosolids.

Rhodamine WT (RWT) is an adsorptive flourescent dye tracer that is used in hydrological and hydrogeological studies. Municipal biosolids (sewage) are rich in organic matter and have a variety of chemical constituents that can interact to confound optical sensing of RWT florescence in water (e.g., quenching, interference, adsorption). Laboratory studies were conducted to evaluate optical sensing constraints associated with quantifying known RWT concentrations in a suite of RWT-spiked distilled water/liquid municipal biosolid (LMB) mixes. RWT flourescence decreased with an increase in LMB total suspended solids (TSS) in decay function form (R2=0.98). A method was then described to correct the undersensed RWT readings based on knowledge of TSS and/or turbidity. This study also found that, for samples agitated by stirring, RWT readings increased in logarithmic form over time. In addition, sample agitation augmented the undersensing of known RWT concentrations, but when agitation ceased, optical readings immediately approached more closely the known RWT values. Studies that use RWT as a tracer to assess the fate and transport of biosolid impacted water in hydrological environments should be aware of some of the optical sensing limitations identified here.

Pathways to ambulatory sensitive hospitalisations for Maori in the Auckland and Waitemata regions.

AIM: Ambulatory Sensitive Hospitalisations (ASH) are a group of conditions potentially preventable through interventions delivered in the primary health care setting. ASH rates are consistently higher for Maori compared with non-Maori. This study aimed to establish Maori experience of factors driving the use of hospital services for ASH conditions, including barriers to accessing primary care. METHOD: A telephone questionnaire exploring pathways to ASH was administered to Maori (n=150) admitted to Auckland and Waitemata District Health Board (DHB) hospitals with an ASH condition between January 1st-June 30th 2015. RESULTS: A cohort of 1,013 participants were identified; 842 (83.1%) were unable to be contacted. Of the 171 people contactable, 150 agreed to participate, giving an overall response rate of 14.8% and response rate of contactable patients of 87.7%. Results demonstrated high rates of self-reported enrolment, utilisation and preference for primary care. Many participants demonstrated appropriate health seeking behaviour and accurate recall of diagnoses. While financial barriers to accessing primary care were reported, non-financial barriers including lack of after-hours provision (12.6% adults, 37.7% children), appointment availability (7.4% adults, 17.0% children) and lack of transport (13.7% adults, 20.8% children) also featured in participant responses. CONCLUSIONS: Interventions to reduce Maori ASH include: timely access to primary care through electronic communications, increased appointment availability, extended opening hours, low cost after-hours care and consistent best management of ASH conditions in general practice through clinical pathways. Facilitated enrolment of ASH patients with no general practitioner could also reduce ASH. Research into transport barriers and enablers for Maori accessing primary care is required to support future interventions.

Role of fertility treatments in multiple pregnancy at National Women's Hospital from 1996 to 2001.

OBJECTIVE: To determine the influence of fertility treatments on multiple pregnancy rates. STUDY DESIGN: A retrospective audit of women with multiple pregnancies from 1996 to 2001 at National Women's Hospital (NWH), Auckland, New Zealand was conducted. Information was collected regarding the demographics, fertility treatment, outcome of the pregnancy and complications experienced by women discharged with multiple births as an discharge diagnosis. RESULTS: For the years 1996-2001 there were 1136 multiple births at NWH. Of these births, 201 (18%) were conceived following fertility treatment. Seventeen percent of twin births and 44% of triplet births were conceived following fertility treatment. There was a statistically significant increase in the number of births conceived following fertility treatment, from 9%, in 1996 to 24%, in 2001, although the proportion of births that were multiple overall did not change (20% in 1996 and 2.3%, in 2001). Sixty-three percent of all fertility conceived multiple births were following in vitro fertilization/intracytoplasmic sperm injection treatment. Sixty percent of these women had two embryos transferred and 31% had three embryos transferred. Ovulation induction with follicle-stimulating hormone accounted for 19% of all fertility conceived multiple births. Nineteen percent of fertility conceived multiple births followed clomiphene treatment alone. CONCLUSIONS: The proportion of multiple pregnancies as a result of fertility treatments has increased over the 6 years studied.

Recovery in Nicaragua and the USA

Family recovery from natural disasters is examined in an cross-cultural framework. A longitudinal design was used, gathering survey data from respondents in Rapid City, South Dakota, U.S.A.,(N 25), and Managua, Nicaragua (N 275) where extensive disasters occurred in 1972. A model of family recovery is developed and its fit with the data is tested using path analysis. In Rapid City, perception of recovery is best explained by losses, aid received, and recovery of predisaster income levels. In Managua aid--at least that type reported by Nicaraguan respondents--had little effect; employment continuity took precedence over other variables. The data suggest that in order to recover predisaster levels of satisfaction with life style families reach beyond their immediate boundaries for help, but the institutionalized manner in which this is done differs across cultures. (AU)