Parental perceptions regarding mandatory mouthguard use in competitive youth soccer.

OBJECTIVE: To understand factors that influence parental perceptions regarding mandatory mouthguard use in competitive youth soccer. SETTING AND SUBJECTS: A web based survey of parents whose 8-14 year old children participated in outdoor competitive youth soccer during the fall of 2002. Questions focused on: previous injury, education provided, dentist/physician recommendations, and parental perceptions of mouthguard use. MAIN OUTCOME MEASURE: The outcome variable was parental agreement with the statement "mouthguards should be mandatory for competitive youth soccer". Logistic regression and chi(2) were performed using STATA 8.0. RESULTS: Altogether 120 parents participated. The children had a mean (SD) age of 11.8 (1.5) years and 48% were female; 14% wore mouthguards and 11% suffered orofacial injuries. Nineteen percent of parents reported receiving educational material from the youth soccer organization. Although 92% of parents believed that mouthguards were effective in reducing orofacial injuries, only one half agreed that mouthguards should be mandatory. Thirty percent of respondents reported that their dentist/physician recommended mouthguards for competitive youth soccer. Logistic regression showed that dentist/physician recommendation and parental female gender were independently associated with parental agreement for mandatory mouthguard use (odds ratio 2.9, 95% confidence interval (CI) 1.2 to 7.3; odds ratio 3.0, 95% CI 1.1 to 6.5). CONCLUSIONS: Few athletes wear mouthguards during competitive youth soccer. Health care professionals in this study did not capitalize on the apparent influence they have on parental beliefs regarding mouthguard use. Efforts are needed by both health professionals and soccer organizations to educate parents about orofacial injuries and mouthguard use in competitive youth soccer.

A comparison of data sources for motor vehicle crash characteristic accuracy.

OBJECTIVE: To determine the accuracy of police reports (PRs), ambulance reports (ARs), and emergency department records (EDRs) in describing motor vehicle crash (MVC) characteristics when compared with an investigation performed by an experienced crash investigator trained in impact biomechanics. METHODS: This was a cross-sectional, observational study. Ninety-one patients transported by ambulance to a university emergency department (ED) directly from the scene of an MVC from August 1997 to April 1998 were enrolled. Potential patients were identified from the ED log and consent was obtained to investigate the crash vehicle. Data describing MVC characteristics were abstracted from the PR, AR, and medical record. Variables of interest included restraint use (RU), air bag deployment (AD), and type of impact (TI). Agreements between the variables and the independent crash investigation were compared using kappa. Interrater reliability was determined using kappa by comparing a random sample of 20 abstracted reports for each data source with the originally abstracted data. RESULTS: Agreement using kappa between the crash investigation and each data source was 0.588 (95% CI = 0.508 to 0.667) for the PR, 0.330 (95% CI = 0.252 to 0.407) for the AR, and 0.492 (95% CI = 0.413 to 0.572) for the EDR. Variable agreement was 0.239 (95% CI = 0.164 to 0.314) for RU, 0.350 (95% CI = 0.268 to 0.432) for AD, and 0.631 (95% = 0.563 to 0.698) for TI. Interrater reliability was excellent (kappa > 0.8) for all data sources. CONCLUSIONS: The strength of the agreement between the independent crash investigation and the data sources that were measured by kappa was fair to moderate, indicating inaccuracies. This presents ramifications for researchers and necessitates consideration of the validity and accuracy of crash characteristics contained in these data sources.

Effects of alcohol on the geographic variation of driver fatalities in motor vehicle crashes.

OBJECTIVE: To determine whether the increased risk of dying in a rural vs nonrural motor vehicle crash (MVC) can be attributed to driver demographics, crash characteristics, or police-reported alcohol use. METHODS: A retrospective cohort study was conducted, comparing all rural (116,242) and a 20% random sample of nonrural (104,197) Michigan drivers involved in an MVC during 1994-1996. Data consisted of all police-reported traffic crashes on public roadways. A logistic regression model was created, using survival as the dependent variable and gender, age, crash characteristics, and rural or nonrural county as independent variables. Driver alcohol use, as reported by the investigating officer, was introduced into the model, and the effect was analyzed. RESULTS: Nonsurvivors represented 0.2% of the total; 99.8% were survivors. Police-reported alcohol use was reported for 3.9% of drivers. Drivers in rural MVCs were more likely to be male, to be more than 50 years of age, to have been drinking alcohol, and to have more severe vehicle deformation as a result of the MVC. The relative risk (RR) for MVC nonsurvivors was 1.69 [95% confidence interval (CI) = 1.3 to 2.1] times higher for drivers in rural than nonrural counties. After adjusting for demographic and crash characteristics, the RR was 1.56 (95% CI = 1.2 to 1.9). Controlling for alcohol and its interactions decreased the RR to 1.26 (95% CI = 0.6 to 2.4), a nonsignificant difference between rural and nonrural MVC mortalities. CONCLUSIONS: Alcohol use by drivers in Michigan was a significant contributor for nonsurvivors of rural crashes. Efforts to decrease rural MVC mortality must address alcohol use.

Emergency physician attitudes concerning intervention for alcohol abuse/dependence delivered in the emergency department: a brief report.

Emergency Medicine (EM) physicians frequently see patients with alcohol abuse or dependence (AA/AD). Brief interventions delivered in the Emergency Department (ED) have been advocated for these patients, however, little is known regarding EM physician willingness to support such interventions. We conducted a study to determine EM physicians' attitudes toward the use of interventions for AA/AD in the ED. All members of the Michigan College of Emergency Physicians (n = 569) were mailed a survey to assess their attitudes toward the use of intervention for AA/AD in the ED. Of the 257 respondents (45.9%), a total of 76% agreed that AA/AD is a treatable illness and only 15% would not agree to support of ED interventions. Both supporters and non-supporters thought that the lack of sufficient time was an impediment to treating AA/AD in the ED. Our study suggests that the majority of ED physicians would support the implementation of brief intervention for AA/AD in the ED.

Adolescent injury in the emergency department: opportunity for alcohol interventions?

STUDY OBJECTIVE: Alcohol, the most commonly used substance among adolescents, is frequently associated with injury. Little is known regarding the drinking characteristics of injured adolescents. Such data are critical for developing emergency department interventions to decrease alcohol-related injury among adolescents. We sought to describe the drinking characteristics of injured adolescents and to describe the relationship of injury severity and mechanisms with drinking characteristics. METHODS: This study was a prospective cohort study performed in a university hospital (sampled May 1, 1995, to July 15, 1995) and a large urban teaching hospital (sampled May 1, 1996, to August 1, 1996). The participants were aged 12 to 20 years, presenting within 6 hours of an injury. We performed a saliva alcohol test and self-administered questionnaire. Age, sex, E-code, injury severity score (ISS), and ED disposition were recorded. An alcohol frequency/quantity index was calculated. Descriptive statistics and 95% confidence intervals were calculated. RESULTS: Two hundred sixty-three patients with a mean age of 17 years and a mean ISS of 2.1 (SD 3.5) were recruited. One hundred fifty-two (50%) were males, and 33 (13%) were admitted. Ten (4%) patients had a positive saliva alcohol test response. On average, within the last year, these adolescents had 1.7 adverse alcohol consequences. Sixty percent drank in unsupervised settings, and 36% reported drinking 5 or more drinks in a row. CONCLUSION: Alcohol use/misuse is a substantial problem among injured adolescents regardless of severity or mechanism of injury. ED physicians should consider screening/intervention or primary prevention of alcohol problems for all injured adolescents.

Does acute alcohol ingestion and/or chronic alcohol use among motor vehicle crash victims lead to a more complicated hospital course?

Given a certain severity of crash and of injury, it is unclear whether acute and/or chronic alcohol use leads to increased morbidity, mortality or a more complicated hospital course after motor vehicle collisions. 496 patients admitted to a trauma service were retrospectively evaluated to assess the effects of acute alcohol ingestion and chronic alcohol use on outcome. Results suggest that patients with acute or chronic alcohol abuse have increased needs for nursing services in the hospital. Alcohol use did not play a role in modifying other outcome measures.

Emergency medical services outcomes project I (EMSOP I): prioritizing conditions for outcomes research.

Over the past several years, out-of-hospital EMS have come under increased scrutiny regarding the value of the range of EMS as currently provided. We used frequency data and expert opinion to rank-order EMS conditions for children and adults based on their potential value for the study of effectiveness of EMS care. Relief of discomfort was the outcome parameter EMS professionals identified as having the most potential impact for the majority of children and adults in the top quartile conditions. Future work from this project will identify appropriate severity and outcome measures that can be used to study these priority conditions. The results from the first year of this project will assist those interested in EMS outcomes research to focus their efforts. Furthermore, the results suggest that nonmortality out-come measures, such as relief of discomfort, may be important parameters in determining EMS effectiveness.

The accuracy of medical records and police reports in determining motor vehicle crash characteristics.

OBJECTIVE: To determine the accuracy of police, emergency department, and ambulance records in describing motor vehicle crash (MVC) characteristics when compared with a crash investigation report (CIR). METHODS: This study was a retrospective record review. Sixty-three motor vehicle crash (MVC) patients transported to a university hospital emergency department via ambulance and also reported in a crash investigation record (CIR) during the period January 1993 to December 1995 comprised the study population. The crash characteristics analyzed were occupant position (OP), restraint use (RU), air bag deployment (AD), type of impact (TI), ejection (EJ), and external cause-of-injury code (EC). The accuracies of the police report (PR), the emergency department record (EDR), and the ambulance report (AR) for each patient were compared with the CIR by computing percent agreement, with 95% confidence intervals (95% CIs) for each variable and for each data source. RESULTS: Overall average agreement was 92.9% for PR, 89.7% for EDR, and 80.7% for AR. The overall average agreement for each variable was 98.9% for EJ, 92.1% for AD, 91.5% for OP, 90.5% for EC, 77.2% for RU, and 76.2% for TI. For all but one variable (RU), 95% CIs overlapped between data sources. CONCLUSIONS: The accuracy of data sources used to determine crash characteristics varies. Using a CIR as the standard, the PR was the most accurate. Inaccuracies occurred most frequently for RU and TI. Researchers and clinicians need to be aware of these inaccuracies.

Crash characteristics and injuries of victims impaired by alcohol versus illicit drugs.

Alcohol has long been associated with injury, but the relationship between other drugs and injury is less clear. Blood samples from 894 patients presenting to two Emergency Departments for treatment of motor vehicle injury sustained in passenger cars, station wagons, vans and pickup trucks, were tested for alcohol and other drugs. Results were related to demographic characteristics, including prior history of alcohol and drug use; crash characteristics; and injury characteristics. Alcohol was associated with more severe crashes, but other drugs, in the absence of alcohol, were not. The crashes involving drugs but no alcohol were very similar to those involving neither alcohol nor drugs.

The wake-effect--emergency vehicle-related collisions.

INTRODUCTION: Emergency medical vehicle collisions (EMVCs) occurring during initial response and with patient transport have been a long-standing problem for emergency medical services (EMS) systems. Experience suggests "wake-effect" collisions occur as a result of an EMS vehicle's transit, but do not involve the emergency medical vehicle (EMV). Substantiating the existence and magnitude of wake-effect collisions may have major implications regarding the manner of EMV response. HYPOTHESIS: Paramedics will report that wake-effect collisions do occur and that they occur more frequently than do EMVCs. DESIGN: Survey analysis. PARTICIPANTS: Thirty paramedics employed by the Salt Lake City (Utah) Fire Department and 45 paramedics employed by Salt Lake County Fire Department. Geographic Area: Service area has population of 650,000 and is urban, suburban, and rural. MEASUREMENTS: The survey consisted of three open-ended questions concerning years on the job, EMVCs, and wake-effect collisions. ANALYSIS: The mean value for the number of EMVCs and wake-effect EMVCs, along with the 0.95 confidence intervals (0.95 CI) were determined. RESULTS: Seventy-three surveys were analyzed. Sixty EMVCs and 255 wake-effect collisions were reported. Overall, the mean value for the number EMVCs per respondent was 0.82 (0.60-1.05) and for wake-effect collisions 3.49 (2.42-4.55). The mean values for EMVC's for each service were 0.86 (0.50-1.38); 0.80 (0.50-11.0). For wake-effect collisions the mean values were 4.59 (2.83-6.35); and 2.76 (1.46-4.06) respectively. CONCLUSIONS: This study suggests that the wake-effect collision is real and may occur with greater frequency than do EMVCs. Significant limitations of this study are recall bias and misclassification bias. Future studies are needed to define more precisely wake-effect collision prevalence and the resulting "cost" in regards to injury and vehicle/property damage.

Alcohol abuse/dependence in motor vehicle crash victims presenting to the emergency department.

OBJECTIVE: 1) To determine the prevalence of current alcohol abuse/alcohol dependence (AA/AD) among the full injury range of ED motor vehicle crash (MVC) patients; and 2) compare AA/AD and non-AA/AD patient characteristics. METHODS: This was a prospective cohort study using a stratified random sample of MVC patients aged > or = 18 years presenting to a university hospital and university-affiliated community hospital ED from May 1, 1992, to August 30, 1994. A diagnosis of current AA/AD was based on the alcohol section of the Diagnostic Interview Survey (DIS). Other measurements included the presence of blood alcohol (BAC+), Injury Severity Score (ISS-85), occupant status (driver/passenger), age, gender, seat belt use, culpability for crash, and ED disposition (admitted vs released). A weighted prevalence was determined; subgroups were compared using t-tests, chi 2, 2-factor analysis, and logistic regression modeling; alpha = 0.05. RESULTS: 1,161 patients were studied. The weighted prevalence of current AA/AD was 22.5%; 53% of these patients were released from the ED. Almost 45% of the patients with current AA/AD were BAC-. When controlling for BAC and AA/AD, greater injury severity and culpability were associated with a BAC+, but not with current AA/AD. CONCLUSION: Almost 23% of ED MVC patients have current AA/AD; BAC testing does not accurately identify these patients. Intervention strategies must be directed to both admitted and released patients.

Derivation and validation of criteria for determining the appropriateness of nonemergency ambulance transports.

OBJECTIVE: Nonemergency ambulance transports (NETs) represent a substantial proportion of all ambulance transports. Recently, the medical necessity of a substantial number of NETs has been questioned. The purpose of the study was threefold: 1) to formulate criteria for NET using a multidisciplinary panel; 2) to develop a structured implicit review instrument (SIRI) for the evaluation of NET from the criteria formulated; and 3) to evaluate the reliability and validity of the SIRI. Previously, a validated instrument has not been available to assess NET appropriateness. METHODS: Using a modified Delphi process and scale development techniques, a panel of ten multidisciplinary health care professionals determined criteria for NET and developed a SIRI consisting of two dimensions: 1) ambulation status and 2) medical care requirements. A convenience sample of 50 cases (occurring January through May 1996) were retrospectively reviewed by individual panel members and two panels, and categorized as either: 1) definitely appropriate NET; 2) possibly appropriate NET; 3) patient did not require ambulance transport; 4) patient required emergency transport; and 5) indeterminate. Reliability of the SIRI was assessed using percent agreement among individual panels and weighted kappa for the two panels. Interitem consistency of the SIRI was measured by Cronbach's alpha. Criterion validity was assessed by comparing percent agreements between the SIRI and Medicare reimbursement guidelines. RESULTS: Percent agreement among individual panel members was 62%. Percent agreement among the two panels was 74%, with a kappa of 0.43. Cronbach's alpha for individual panel member item response ranged from 0.647 to 0.960. Percent agreement with Medicare reimbursement guidelines was 92%. CONCLUSION: Consensus criteria and an associated SIRI were developed for determining the appropriateness of NETs. Further research is needed to build on the validity and reliability of this instrument.

Alcohol, central nervous system injury, and time to death in fatal motor vehicle crashes.

OBJECTIVES: Motor vehicle crash (MVC) studies have found that alcohol (ALC) is associated with increased mortality and decreased time to death (TTD). Clinical and experimental data suggest that ALC potentiates central nervous system injury (CNSI). We hypothesize that ALC-intoxicated, MVC fatalities with CNSI are more likely to die in the immediate postinjury period than are sober victims with CNSI. Methods; DESIGN: A retrospective cohort of 401 MVC fatalities from four Michigan counties for the time period 1985 to 1991 was studied. MEASUREMENTS: Medical examiner records were reviewed to determine age, blood alcohol concentration (BAC), and TTD. Injury severity was calculated with the Abbreviated injury Scale (1985 version). Anatomical profile scores and G scores were also calculated and used to identify CNSI subjects. ANALYSIS: chi 2 and Student's t test were used, and odds ratios with 0.95 confidence intervals (CIs) were calculated. RESULTS: ALC(+) cases (BAC > or = 100 mg/dl) (n = 99) were significantly younger and more frequently had TTD < 1 hr than ALC(-) cases (n = 233): odds ratio 1.62[0.95 CI (1.02 to 2.58)]. Overall, CNSI cases (n = 297) were significantly younger and had fewer thoracic injuries, but did not have significantly shorter TTD, compared with non-CNSI cases. However, ALC(+) CNSI cases (n = 77) were over twice as likely to have TTD < 1 hr ¿odds ratio 2.04 [0.95 CI (1.13 to 3.70)]¿. For ALC(+) isolated CNSI cases, the odds ratio for TTD < 1 hr, compared with nonisolated CNSI cases was 8.25 (0.95; CI 0.66 to 102.5). Injury Severity Score, anatomical profile, and G scores were not significantly different for ALC(+) CNSI cases, compared with ALC(-) CNSI cases, whether isolated or nonisolated. CONCLUSIONS: These data suggest that alcohol intoxication is associated with increased frequency of early death in MVC victims with CNSI, despite there being no detectable difference in anatomical injury scoring.

Regional variation of nonrural pediatric ambulance transport rates: an ecological study.

STUDY OBJECTIVE: To determine the relationship of pediatric transport rates per hundred thousand pediatric population (RATE) to socioeconomic status (SES) factors and also mortality in Emergency Medical Services (EMS) systems. DESIGN: Retrospective ecological study. SETTING: Four EMS Medical Control Authorities (MCAs) in Michigan. PARTICIPANTS: Patients (3,792), 0-19 years of age, responded to as a nonscheduled emergency response and transported to a hospital by ambulance. METHODS AND MEASUREMENTS: RATE, economic status (INCOME), private transportation status (VEHICLE), educational status (EDUC), primary care physician availability (PHYS), and EMS disease death rate (EMSDD) were determined for each MCA and analyzed using Spearman rank correlation. RESULTS: RATE between MCAs varied from 325 to 750. RATE was highest in the most urban MCA: its 0-4 RATE was fourfold larger than any other MCA. INCOME, EDUC, and VEHICLE were inversely correlated with transport rate: -1.00, -1.00, -1.00; P < 0.001. Rate was positively correlated with EMSDD: 1.00; P < 0.001. CONCLUSIONS: Substantial variation in RATE between MCAs may be primarily due to the high 0-4 transport rate in the most urban MCA. This study also suggests that higher pediatric EMS system utilization rates may be correlated to higher mortality and also to unavailability of personal transportation.

A study of preventable trauma mortality in rural Michigan.

OBJECTIVE: To determine the preventable death rate (PDR) and the frequency and types of inappropriate medical care in a large, rural region of Michigan. DESIGN: A prospective study of all deaths caused by injury during a 1-year period. METHODS: Preventability of death and appropriateness of care were determined using a structured implicit review process and expert panel. A second panel was convened to confirm the reliability of the review process. MAIN RESULTS: One hundred fifty-five injury-related deaths underwent panel review. Four deaths (2.6%) were found to be definitely preventable and 16 (10.3%) possibly preventable, for a combined preventable death rate of 12.9%. Sixty-five deaths (41.9%) occurred in the emergency department or hospital; 18 of these (27.7%) were judged to be definitely preventable or possibly preventable. Forty-three episodes of inappropriate care were identified in 27 (17.4%) of the 155 cases reviewed. These occurred primarily in the emergency department and hospital rather than during prehospital care or transfer. CONCLUSIONS: A relatively small percentage of trauma fatalities in rural Michigan could have been prevented by more appropriate or timely medical care. Efforts to improve the care of injured persons in rural Michigan should be directed primarily at the emergency department and inpatient phases of trauma system care.

EMS providers do not accurately note motor-vehicle crash patients with positive serum alcohol concentrations.

INTRODUCTION: Alcohol use is associated with many motor-vehicle crashes and may increase the severity of injury. Because alcohol use also may mask injury, prehospital emergency care providers (PHECPs) may make inaccurate assessments. To assess and triage crash victims accurately, PHECPs must identify recent alcohol use. STUDY OBJECTIVE: This study examines the accuracy of PHECPs in identifying motor-vehicle crash victims who had positive serum alcohol concentrations. DESIGN: Retrospective cohort study. POPULATION: Included in the study were motor-vehicle crash victims more than 17 years of age who were conveyed directly to a university medical center emergency department by ground ambulance (n = 372). TIME PERIOD: 15 July 1990 to 15 July 1991. METHODS: Data sources included ambulance report forms and hospital records. Variables that were abstracted included the Revised Trauma Score (RTS), the PHECPs' impression of alcohol use, and serum alcohol concentrations. Sensitivity, specificity, predictive-value positive, predictive-value negative, and 0.95 confidence intervals (0.95 CI) were calculated for the PHECPs' ability to identify patients with a serum alcohol concentration > 0. The relationship between the RTS and the impressions of alcohol use was analyzed with chi-square testing: a p-value of < 0.05 was considered statistically significant. CONCLUSION: This study suggests that PHECPs cannot accurately identify crash victims with positive serum alcohol concentrations. Selection bias and retrospective design are significant limitations of this study. Future studies should develop and evaluate methods to improve PHECPs' accuracy in assessing alcohol use in motor-vehicle crash victims.