When the safety net is unsafe: real-time assessment of the overcrowded emergency department.

Although much work has been done evaluating causes for increased demand for emergency department (ED) services, few ways are available to help determine that an individual ED is overcrowded. Four calculations are proposed using real-time data for accurately diagnosing an ED with potential for failing both as a safety net and as a source for quality health care. The bed ratio (BR) accounts for the number of patients in relation to the available treatment spaces. The BR is obtained by adding the current number of ED patients to the predicted arrivals minus the predicted departures and dividing the result by the total number of treatment spaces. The acuity ratio (AR) measures the relative burden of illness in the ED. The AR is the average triage category of all patients in the ED. The provider ratio (PR) determines the volume of patients that can be evaluated and treated by the physician providers. The PR is found by dividing the arrivals per hour by the sum of the average patients per hour usually disposed for each provider on duty. From these ratios, the demand value (DV) is calculated, which gives an overall measure of current demand. The DV is found by taking the sum of the BR and PR and multiplying by the AR. A DV of more than 7 should initiate a specific assessment of the individual ratios in order to accurately diagnose the problem and institute action. Based on the values, predetermined processes can be instituted to help remedy the overcrowded situation. Trended over time, the ratios can provide the data needed for better resource assessment, planning, and allocation.

Public expectations of survival following cardiopulmonary resuscitation.

UNLABELLED: Previous studies have demonstrated that the public maintains unrealistic expectations of the potential for successful recovery following administration of cardiopulmonary resuscitation (CPR). Others have attributed this phenomenon to misrepresentation of CPR outcomes on television and other sources of public information. OBJECTIVES: To determine public expectations of CPR and correlate these expectations with various sources of information regarding CPR, including age, television, personal medical training, public programs, friends/family with medical training, and personal experience with CPR. METHODS: A written survey was randomly distributed to local church congregations and completed on a voluntary basis. RESULTS: Ninety-six percent of the respondents expected CPR to be unrealistically effective. Those factors found to increase predicted CPR survival rate were as follows: 1) being under 50 years of age, 2) use of television as a source of information regarding CPR, 3) personal medical training, and 4) use of public programs about CPR. Neither exposure to friends or family with medical training nor personal experience with CPR resulted in increased CPR survival predictions. CONCLUSIONS: Regardless of the source, the public is not accurately informed about the effectiveness of CPR. This creates a situation in which people may elect CPR for themselves or for family members when survival, not to mention recovery, is unlikely. Without dissemination of realistic statistics regarding survival and recovery following CPR, the public will maintain unrealistic expectations of CPR, and be unable to make well-informed decisions concerning its use.

The potential of using billing data for emergency department injury surveillance.

OBJECTIVE: To determine the availability of and sample statewide ED injury information obtained from hospital billing data for the purpose of demonstrating the feasibility of information acquisition for subsequent data linkage. METHODS: A retrospective, database investigation was conducted to obtain data describing a statewide stratified sample of ED patients. The aim was to collect a computerized billing summary record for each injured ED patient seen at each sampled hospital over a 1-year period. All 215 Pennsylvania acute care hospitals in 1991 were eligible for sample selection. Data collection for the project was conducted in 1993. Participants included directors of hospital medical records and billing departments. RESULTS: Twenty-four hospitals contributed data sets from the original target goal of 31 strata. The final combined data set contained 187,404 records with injury diagnoses from approximately 616,000 ED patient visits, representing a 12% sample of all annual statewide ED visits. Age, sex, date of visit, and primary diagnosis fields were completed from the retrieved data > 99% of the time. More than two-thirds of the sampled records had a social security number, and total charges were recorded > 90% of the time. Other variables such as name and address were contained in < 50% of the records submitted. E-codes were usually not available. CONCLUSIONS: Retrospective compilation of multihospital ED billing data to create a statewide ED data sample-with the potential for injury research and probabilistic database linkage-can be accomplished; there are, however, important limitations.

Injury prevention: is there a role for out-of-hospital emergency medical services?

OBJECTIVE: To review the literature for options for integrating injury prevention into the role of out-of-hospital emergency medical services (EMS). DATA SOURCES: Computerized searches of the English-language literature from 1966 through 1994 were conducted using the MEDLINE and National Association of EMS Physicians (NAEMSP) databases. These were supplemented by hand searches of pertinent journals not indexed on MEDLINE or by NAEMSP and the reference lists of retrieved articles. Key words searched included emergency medical services, accident, injury, prevention, and safety. ARTICLE SELECTION: The review included all articles that described the experience of EMS organizations or individuals providing primary injury prevention (PIP) services or that proposed EMS PIP activities. SYNTHESIS: PIP EMS experiences and PIP activities proposed for EMS included: preventing injuries in EMS providers, serving as role models, identifying persons at risk for injury, providing prevention counseling, collecting injury data, surveying residences and institutions for injury risks and hazards, conducting educational programs and media campaigns, and advocating legislative changes that promote injury prevention. Few studies have evaluated the effectiveness of EMS PIP activities. CONCLUSION: As changes in the market compel health care systems to focus more on prevention, EMS organizations and individual providers may be assuming new injury prevention roles. Some EMS systems in many parts of the country have incorporated PIP into their work. It is necessary, however, to determine which PIP roles are effective and how they will be supported.

Development of new methods to assess the outcomes of emergency care.

This article provides information supporting the need for new outcome measures in emergency care. It also addresses the use of these measures in emergency care, the impact of emergency care, identification of at-risk groups, new approaches to measuring patient satisfaction, quality of life, and cost-effectiveness, and the related unique implications for emergency medicine.

Alteration of aminoglycoside antibiotic ototoxicity: effect of semistarvation.

The effect of semistarvation on the toxicity and ototoxicity of tobramycin sulfate (TO) and gentamicin sulfate (GE) was investigated in guinea pigs by electrophysiological and histopathological methods. The presented data has shown that the toxicity and ototoxicity of aminoglycoside antibiotics is substantially increased when guinea pigs were semistarved. Our results should also warn researchers using semistarvation in their conditioning experiments which investigate the toxicity of different chemicals. Toxicity was greater in GE- than TO-treated animals, which caused the GE-treated animals to die during treatment or shortly after treatment. Thus, TO should be preferentially used because it has been shown to be less toxic and ototoxic in normal and altered nutritional conditions.

Clinical procedures performed by emergency medicine resident physicians: a computer-based model for documentation.

To facilitate documentation and assess the number and types of clinical procedures actually performed by resident physicians, we developed a microcomputer-based recording process. After completing a procedure, including resuscitations, residents recorded in a precoded book issued for each monthly rotation. At the end of each rotation, the books were collected and the information was transferred to a database program by the clerical staff. During 1989, 17 emergency medicine resident physicians at PGY levels 1 through 3 utilized this system. Completed procedure record books were submitted for 124 of 148 clinically active months for a compliance rate of 84%. Of 1,857 procedures recorded, the most frequent were resuscitation (20%), orotrachael intubation (12%), and percutaneous central vein cannulation (12%). Commonly recorded were lumbar puncture (7%), diagnostic peritoneal lavage (5%), nasotrachael intubation (4%), and newborn delivery (4%). The high compliance rate suggests resident physicians acceptance. This system enables residency directors to closely monitor individual and group procedure experiences and to make curriculum changes based on objective findings. It also provides a means of storing and retrieving data for review organizations and credentials committees.

Determination of prehospital blood glucose: a prospective, controlled study.

STUDY OBJECTIVE: To determine if emergency medical personnel can effectively rule out hypoglycemia in the prehospital setting. DESIGN: During a 10-week period, emergency medical personnel determined the fingerstick glucose on all prehospital patients with altered mental status using the Chemstrip bG. Statistical comparisons were made to serum glucose levels performed by hospital laboratory personnel on blood samples obtained prior to glucose administration. A serum glucose level less than 60 mg/dL was considered a positive test for hypoglycemia. PARTICIPANTS: 170 consecutive patients with altered mental status (AMS) ranging in age from 13 to 90 years were enrolled. MEASUREMENTS AND MAIN RESULTS: Of these patients, 158 were normal or hyperglycemic, 12 were hypoglycemic, and one patient was hypoglycemic but had only a borderline negative fingerstick test. Thus, a sensitivity of 91.7% and a negative predictive value of 99.3% were obtained. The specificity was 92.4%, and positive predictive value was 47.8%. CONCLUSION: The Chemstrip bG may be used safely in the prehospital setting to rule out hypoglycemia.

EMS knowledge and skills in rural North Carolina: a comparison with the National EMS Education and Practice Blueprint.

INTRODUCTION: Many state and local emergency medical services (EMS) systems may wish to modify provider levels and their scope of practice to align their systems with the recommendations of the National Emergency Medical Services Education and Practice Blueprint. To determine any changes that may be needed in a typical EMS system, the knowledge and skills of EMS providers in one rural area of North Carolina were compared with the knowledge and skills recommended in the National Emergency Medical Services Education and Practice Blueprint. METHODS: A survey listing 175 items of patient care-oriented knowledge and skills described in the National Emergency Medical Services Education and Practice Blueprint was developed. EMS providers from five rural eastern North Carolina counties were asked to identify on the survey those items of knowledge and skills they believed they possessed. The skills and knowledge selected by the respondents at the five different North Carolina levels of certification were compared with the knowledge and skills listed for comparable provider levels delineated by the National Emergency Medical Services Education and Practice Blueprint. The proportions of the recommended skills reported to be possessed by the respondents were compared to determine which North Carolina certification levels best correlate with the Blueprint. RESULTS: One hundred forty-five EMS providers completed the survey. The proportion of recommended skills and knowledge reported to be possessed by Emergency Medical Technicians (EMTs) ranked significantly lower than did the skills and knowledge reported to be possessed by respondents at other levels in five of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Defibrillator-level personnel ranked lower than did those reported to be possessed by respondents at other levels in seven of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Intermediates ranked lower than did those reported to be possessed by respondents at other levels in nine of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Advanced Intermediates ranked lower than were the skills and knowledge reported to be possessed by respondents at other levels in two of the 10 Blueprint elements. Finally, the proportion of recommended skills and knowledge reported to be possessed by EMT-Paramedics ranked lower than were those reported to be possessed by respondents at other levels in one of the 10 Blueprint elements. CONCLUSION: In North Carolina, combining the EMT and EMT-Defibrillator levels and eliminating the EMT-Intermediate level would create three levels of certification, which would be more consistent with levels recommended by the Blueprint. The results of this study should be considered in any effort to revise the levels of EMS certification in North Carolina and in planning the training curricula for bridging those levels. Other states may require similar action to align with the National Emergency Medical Services Education and Practice Blueprint.

Acute ethanol intoxication decreases the likelihood of resuscitation from cardiac arrest in rats.

BACKGROUND AND METHODS: Acute ethanol intoxication has been shown to depress myocardial performance in both laboratory and clinical studies. The present study was designed to examine the effect of acute ethanol intoxication on resuscitation of rats subjected to cardiac arrest. Rats were given 1.2 g ("moderately intoxicated") or 2.4 g ("highly intoxicated") of ethanol/kg, or distilled water ("nonintoxicated" rats). Using a standardized technique, we induced cardiac arrest. CPR was then attempted using chest compressions interposed with abdominal compressions. Resuscitation was said to be successful if BP returned spontaneously within 6 mins of institution of chest compressions interposed with abdominal compressions, and if systolic BP was 50% of its prearrest level within 10 mins of discontinuation of chest compressions interposed with abdominal compressions. Mean +/- SD serum ethanol levels were 121.3 +/- 12.9 mg/dL (26.3 +/- 2.8 mmol/L) (moderately intoxicated rats) and 254.4 +/- 34.6 mg/dL (55.2 +/- 7.5 mmol/L) (highly intoxicated rats). RESULTS: Resuscitation was successful in 75% (15/20) of nonintoxicated rats, 46.7% (7/15) of moderately intoxicated rats, and 33.3% (5/15) of highly intoxicated rats. The difference in resuscitation rates was significant for nonintoxicated rats compared with either intoxicated rats as a group (p = .021) or highly intoxicated rats (p = .019), but was not significant for nonintoxicated rats compared with moderately intoxicated rats. CONCLUSION: Acute ethanol intoxication appears to decrease the likelihood of successful resuscitation in a dose-dependent fashion.

Ambulance diversion. Standards and Clinical Practices Committee, National Association of EMS Physicians.

Policies regarding ambulance diversion are critical to ensuring that EMS providers are aware of appropriate patient destinations, even before patients enter the system. Field EMS personnel should never be requested to prolong transport time intervals to search for an available hospital at the potential expense of patients' conditions and the immediate availability of out-of-hospital emergency care for the community. The responsibility for providing efficient emergency care to the community rests with all those who contribute to EMS structures and processes. All EMS system participants, including hospitals, EMS providers, local and regional lead agencies, and medical oversight authorities, must work together to create comprehensive ambulance diversion policies that satisfactorily meet each other's needs, while maintaining the highest regard for the needs of EMS patients and the entire community.

Study design and outcomes in out-of-hospital emergency medicine research: a ten-year analysis.

OBJECTIVE: Lack of rigorous study design and failure to follow diverse patient outcomes have been identified as critical gaps in the medical research literature. This study sought to determine whether similar gaps exist in the literature for out-of-hospital interventions. METHODS: A computerized MEDLINE search was conducted for the ten-year period 1985 through 1994 using the MeSH terms "emergency medical services," "prehospital," and "transportation of patients." Using a standard abstraction form, two investigators independently analyzed articles meeting these inclusion criteria: original research evaluating an out-of-hospital intervention and measuring a patient outcome. Study design was categorized in order of scientific rigor, moving from case series to randomized trial. Measures of outcomes were classified into the six Ds: death, disease, discomfort, disability, dissatisfaction, and debt (cost). RESULTS: Interobserver agreement was high (kappa = 0.80). For the ten-year period, 3,686 titles, 1,454 abstracts, and 373 articles were examined serially; all 285 studies meeting inclusion criteria were analyzed. Case series (44%) was the most frequently used design, while only 15% were randomized trials. The majority of the studies were retrospective (53%). A single outcome was assessed in 45% of the articles; 41% measured two outcomes, 13% three outcomes, and 1% four outcomes. Death and disease were the most common outcomes evaluated. Disability, debt, discomfort, and dissatisfaction were infrequently measured. CONCLUSION: Studies of out-of-hospital emergency medical interventions are limited in the scientific rigor of study design and the diversity of patient outcomes measured. To adequately assess the effectiveness of out-of-hospital care, efforts should be directed toward strengthening study designs and examining the full range of patient outcomes.

Helicopter use by rural emergency departments to transfer trauma victims: a study of time-to-request intervals.

To assess how soon rural emergency departments (EDs) call for helicopters to transport seriously injured patients, the records of all trauma victims (excluding isolated CNS trauma) transported by an emergency helicopter service from referring hospitals to a trauma center over an 18-month period were studied. Admission time to the referring ED was compared with the exact time a call for the helicopter was received and a time-to-request interval (TTR) was calculated. A total of 64 cases were studied. Fifty (78%) of the patients had blunt trauma; 14 (22%) had penetrating trauma. The average TTR for the helicopter was 69.8 minutes, with a range from 17 minutes before arrival at the referring ED to 337 minutes after arrival. Children (aged less than or equal to 16 years) had an average TTR of 34.1 minutes compared with 76.4 minutes for adults (aged greater than 16 years). Of the variables examined, patient age was the only factor significantly associated with TTR. These observations suggest that, except in children, there frequently is a lengthy time interval between the time trauma patients arrive at EDs in rural eastern North Carolina and the time an emergency helicopter service is called to transport them to a trauma center.

Effect of ethanol on lactic acidosis in experimental hemorrhagic shock.

Many trauma victims who have hemorrhagic shock are also intoxicated. Ethanol could worsen the severity of shock and decrease the amount of blood loss necessary to reach or maintain the shock state, perhaps by increasing lactic acidosis. We examined the effect of ethanol on lactic acidosis in a group of rats that were intoxicated, then put in a state of hemorrhagic shock (MAP = 40 mm Hg). These animals were compared to a control group that were in a similar state of hemorrhagic shock but not intoxicated. The volumes of blood necessary to reach and maintain the predetermined model state of shock for two hours in each group were also measured. The animals were paralyzed and placed on controlled ventilation. The ethanol produced an expected baseline lactic acidosis, and it took significantly less blood volume loss to keep the intoxicated group in shock. However, during shock there was no significant difference in the state of lactic acidosis. These results suggest that acute ethanol intoxication made the animals more sensitive to hemorrhage. This effect was not mediated by an increase in lactic acidosis in our model.

Factors associated with prolongation of transport times of emergency pediatric patients requiring transfer to a tertiary care center.

PURPOSE: The purpose of this study was to determine factors associated with longer times to transport of emergency pediatric patients requiring tertiary care. DESIGN: Retrospective case series. SETTING: Emergency pediatric transport service. PARTICIPANTS: Infants and children transported by the transport service at the University of North Carolina Hospitals at Chapel Hill from January 1, 1988, to December 31, 1990. MAIN MEASUREMENTS: The time-to-request, the time from patient arrival at the referring hospital to the time when the request for transfer was received, and the ground time, defined as the time between the transport team's arrival at the referring hospital and their departure, were recorded for each transported patient. RESULTS: Three hundred consecutive children 0 to 16 years (61% male) were transferred. Time-to-request was shorter for trauma patients (median 62 minutes, quartiles 29 and 153 minutes) than for medical patients (median 172 minutes, quartiles 83 and 508 minutes) (P = 0.0001). Infants, children, and adolescents had similar times-to-request of 147 minutes, 129 minutes, and 128 minutes, respectively (P = 0.91). Increased ground times were associated with diagnosis category (median of 40 minutes for medical patients vs 29 minutes for trauma patients) (P = 0.0001), with younger age (median of 46 minutes for infants, 35 minutes for children, and 28 minutes for adolescents) (P = 0.0001), and with the performance of major procedures (median of 35 minutes if no procedures were performed, 38 minutes if one procedure was performed, and 54 minutes if two procedures were performed) (P = 0.039). After the transport team arrived, 13% (40/300) of patients required at least one major procedure prior to transport. CONCLUSIONS: Increased time-to-request for patients with medical diagnoses, increased ground times for younger patients and patients with medical diagnoses, and failure to perform necessary procedures contribute to a prolongation of the time-to-transport of emergency pediatric patients. The magnitude of the impact of these longer transport times on outcome is unknown.

Unexpected emergency department death: incidence, causes, and relationship to presentation and time in the department.

STUDY OBJECTIVE: To determine the incidence and causes of unexpected death in emergency department patients and its relationship to initial ED presentation. To determine if length of ED stay is directly related to unexpected death. DESIGN: Retrospective chart review of all patients dying in the study ED during a three-year period. Patients receiving CPR on admission or who had "do not resuscitate" orders were classified as expected deaths. Vital signs, level of consciousness, length of time in the ED, and cause of death were recorded for all unexpected deaths. SETTING: Five hundred sixty-six-bed medical center with an ED volume of 45,000 patients per year. PARTICIPANTS: Four hundred eleven patients were pronounced dead from 1987 to 1989, and 403 (98%) charts were available. RESULTS: Fifty-seven (14%) patients met the unexpected death criteria. Abnormal vital signs or altered level of consciousness was observed in 56 (98%) patients on presentation. Medical causes accounted for 42 (74%) of the unexpected deaths. Five (9%) surgical and ten (18%) trauma-related deaths were identified. The yearly incidence of unexpected death was 4.9 (per 10,000 ED visits) in 1987 and 4.1 in both 1988 and 1989. Average length of time in the ED before unexpected death increased during the study period (1987, 91 minutes; 1988, 110 minutes; 1989, 116 minutes). CONCLUSION: Unexpected ED death was uncommon, usually nontraumatic, and occurred in patients with evidence of significant illness. Although average length of stay in the ED increased, there was no increase in the incidence of unexpected ED death. If lengths of ED stay continue to increase, this situation will require further study.