Impact of trauma centre capacity and volume on the mortality risk of incoming new admissions.

INTRODUCTION: Trauma centre capacity and surge volume may affect decisions on where to transport a critically injured patient and whether to bypass the closest facility. Our hypothesis was that overcrowding and high patient acuity would contribute to increase the mortality risk for incoming admissions. METHODS: For a 6-year period, we merged and cross-correlated our institutional trauma registry with a database on Trauma Resuscitation Unit (TRU) patient admissions, movement and discharges, with average capacity of 12 trauma bays. The outcomes of overall hospital and 24 hours mortality for new trauma admissions (NEW) were assessed by multivariate logistic regression. RESULTS: There were 42 003 (mean=7000/year) admissions having complete data sets, with 36 354 (87%) patients who were primary trauma admissions, age ≥18 and survival ≥15 min. In the logistic regression model for the entire cohort, NEW admission hospital mortality was only associated with NEW admission age and prehospital Glasgow Coma Scale (GCS) and Shock Index (SI) (all p<0.05). When TRU occupancy reached ≥16 patients, the factors associated with increased NEW admission hospital mortality were existing patients (TRU >1 hour) with SI ≥0.9, recent admissions (TRU ≤1 hour) with age ≥65, NEW admission age and prehospital GCS and SI (all p<0.05). CONCLUSION: The mortality of incoming patients is not impacted by routine trauma centre overcapacity. In conditions of severe overcrowding, the number of admitted patients with shock physiology and a recent surge of elderly/debilitated patients may influence the mortality risk of a new trauma admission.

Admission delays' magnitude of traumatized patients in the emergency department of a hospital in Egypt: a cross-sectional study.

BACKGROUND: Injury is an escalating public health problem, representing about 9% of global mortality, which disproportionately impacts lower- and middle-income countries. There are approximately 12,000 annual fatalities from road traffic injuries in Egypt, but a little information about delays in seeking emergent care is available. OBJECTIVES: To measure the time interval between sustaining an injury and presentation to the emergency department of Ain Shams University Surgery Hospital and to identify possible causes of these delays. METHODS: We conducted a cross-sectional, facilitated survey of a convenience sample of trauma patients presenting to the emergency department of Ain Shams University Surgery Hospital from 1 February to 31 May 2014. Data obtained included: demographic information, trauma incident details, and injury assessment. RESULTS: The average reported transport time for patients from injury to hospital arrival was 3.8 h, while the mean ambulance response time was 45 min. Referral from other hospitals was revealed to be a significant cause of delay (P = 0.004), while ignorance of the local ambulance phone number could not be confirmed as a cause (P = 0.2). CONCLUSION: This study demonstrated that trauma patients at our hospital experience more than 3 h of delay until they reach the ED. It also identified the possible causes accounting for that delay. However, additional nationwide research is needed to establish the clear causation or association of these causes with the delay intervals.

Hospital discharge instructions: comprehension and compliance among older adults.

BACKGROUND: Little is known regarding the prevalence or risk factors for non-comprehension and non-compliance with discharge instructions among older adults. OBJECTIVE: To quantify the prevalence of non-comprehension and non-compliance with discharge instructions and to identify associated patient characteristics. RESEARCH DESIGN: Prospective cohort study. SUBJECTS: Four hundred and fifty adults aged ≥ 65 admitted to medical and surgical units of a tertiary care facility and meeting inclusion criteria. MEASURES: We collected information on demographics, psycho-social factors, discharge diagnoses, and medications using surveys and patient medical records. Domains within discharge instructions included medications, follow-up appointments, diet, and exercise. At 5 days post-discharge, we assessed comprehension by asking patients about their discharge instructions, and compared responses to written instructions from medical charts. We assessed compliance among patients who understood their instructions. RESULTS: Prevalence of non-comprehension was 5 % for follow-up appointments, 27 % for medications, 48 % for exercise and 50 % for diet recommendations. Age was associated with non-comprehension of medication [odds ratio (OR) 1.07; 95 % confidence interval (CI) 1.04, 1.12] and follow-up appointment (OR 1.08; 95 % CI 1.00, 1.17) instructions. Male sex was associated with non-comprehension of diet instructions (OR 1.91; 95 % CI 1.10, 3.31). Social isolation was associated with non-comprehension of exercise instructions (OR 9.42; 95 % CI 1.50, 59.11) Depression was associated with non-compliance with medication (OR 2.29; 95 % CI 1.02, 5.10) and diet instructions (OR 3.30; 95 % CI 1.24, 8.83). CONCLUSIONS: Non-comprehension of discharge instructions among older adults is prevalent, multi-factorial, and varies by domain.

The rationale for developing public health surveillance systems based on emergency department data.

Emergency departments (EDs) are well positioned to provide national data on several aspects of public health. The large volume of patients seen annually, improving medical record technology, and emergency uniform data sets make the development of public health surveillance systems a realistic opportunity for emergency medicine. Such data could identify public health concerns and suggest interventions to improve the health of the nation. This article describes current concepts and status of ED surveillance systems, their advantages and disadvantages, the rationale for their existence, and recommendations to allow their continued consideration and development.

Proposed curriculum for an "observational" international emergency medicine fellowship program.

This article presents information on considerations involved in setting up and conducting fellowship training programs in emergency medicine (EM) for physicians from other countries. General goals for these programs are to assist in providing physicians from other countries with the knowledge and skills needed to further develop EM in their home countries. The authors report their opinions, based on their cumulative extensive experiences, on the necessary and optional structural elements to consider for international EM fellowship programs. Because of U.S. medical licensing restrictions, much of the proposed programs' content would be "observational" rather than involving direct "hands-on" clinical EM training. Due to the very recent initiation of these programs in the United States, there has not yet been reported any scientific evaluation of their structure or efficacy. International EM fellowship programs involving mainly observational EM experience can serve as one method to assist in EM development in other countries. Future studies should assess the impact and efficacy of these programs.

Jamaica's measles elimination experience.

OBJECTIVES: This article describes the effort to eliminate measles from Jamaica and its impact on measles incidence. METHODS: In addition to routine measles vaccination, the Jamaican Ministry of Health implemented a strategy of a 1-time-only catch-up vaccination campaign, conducted in 1991, and periodic follow-up campaigns, the first of which occurred in 1995. RESULTS: Since 1991, despite careful surveillance, no serologically confirmed indigenous cases of measles have occurred in Jamaica. CONCLUSIONS: Measles virus circulation has been interrupted in Jamaica. The Jamaican experience provides further evidence that global measles eradication is achievable.

The development of international emergency medicine: a role for U.S. emergency physicians and organizations. SAEM International Interest Group.

There is a rapidly growing interest in emergency medicine (EM) and emergency out-of-hospital care throughout the world. In most countries, the specialty of EM is either nonexistent or in an early stage of development. Many countries have recognized the need for, and value of, establishing a quality emergency health care system and are striving to create the specialty. These systems do not have to be high tech and expense but can focus on providing appropriate emergency training to physicians and other health care workers. Rather than repeatedly "reinventing the wheel" with the start of each new emergency care system, the preexisting knowledge base of EM can be shared with these countries. Since the United States has an advanced emergency health care system and the longest history of recognizing EM as a distinct medical specialty, lessons learned in the United States may benefit other countries. In order to provide appropriate advice to countries in the early phase of emergency health care development, careful assessment of national resources, governmental structure, population demographics, culture, and health care needs is necessary. This paper lists specific recommendations for EM organizations and physicians seeking to assist the development of the specialty of EM internationally.

Effect of rotational patient assignment on emergency department length of stay.

The study evaluated the impact of rotational assignment of emergency department (ED) patients to residents on patient's length of stay (LOS) and resident satisfaction. The study was conducted in a university, inner-city, adult ED. Prior to the intervention, residents saw patients at their own rate as patient charts were placed into a common rack waiting to be seen. The intervention involved directly assigning patients with medical emergencies in sequential rotation to residents. Patients with surgical conditions were seen under the old self-paced system for comparison. A retrospective chart review of LOS of all ED visits for a period of 2 wks before, 6 wks after, and 1 yr after the intervention was conducted. ED administration and staffing during the study were unchanged. Comparisons excluded critical cases and nonurgent cases triaged away. A postintervention survey of physician satisfaction was conducted. During the study period, demographic characteristics of medical and surgical patients did not differ significantly between the time periods. The average total ED LOS for moderately ill medical patients decreased significantly from 7.11 to 5.86 h at 6 wks and remained significantly improved 1 yr later at 6.21 h. During the same periods, the average total LOS increased significantly for the surgical patients. Residents reported that the new system was more fair and did not affect teaching quality. The rotational assignment of patients to resident physicians led to significantly less ED LOS while improving resident satisfaction without affecting education.

Tuberculosis in the workplace: OSHA's compliance experience.

OBJECTIVE: Inspections of 272 facilities were performed between May 1992 and October 1994 to determine compliance with applicable Occupational Safety and Health Administration (OSHA) requirements for prevention of tuberculosis (TB) transmission. DESIGN: Retrospective record review of two data sources: (1) OSHA's Computerized Integrated Management Information System and (2) an inspector-completed questionnaire on inspection results. SETTING/PARTICIPANTS: Inspections of five types of facilities: healthcare institutions, correctional facilities, homeless shelters, long-term-care facilities for the elderly, and others, including drug treatment centers that the Centers for Disease Control and Prevention (CDC) identified as having a higher than expected rate of TB. METHODS: The OSHA Compliance Memorandum, based on the 1990 CDC Guidelines, which outlined elements of a TB prevention program, was used in performing 272 inspections of facilities between May 1992 and October 1994. Elements of compliance were recorded and reviewed from the IMIS database and inspectors' questionnaires. RESULTS: Regulated facilities were not fully compliant with OSHA guidance. Generally, healthcare facilities performed better than other facilities. Most facilities (79%) were compliant with administrative elements of a comprehensive TB control program, such as early identification of known or suspected infectious TB patients and skin testing of workers. Only 29% of inspected facilities were found to have acceptable respiratory protection programs for the prevention of occupational TB. CONCLUSION: Facilities have not been fully compliant with the OSHA memorandum describing protection of workers from TB. Facility compliance was better with some traditionally recognized TB infection control elements, but was weaker in the area of respiratory protection programs. This may reflect a lack of familiarity with the latter type of hazard protection.