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1.
BMC Public Health ; 21(1): 102, 2021 01 08.
Artigo em Inglês | MEDLINE | ID: mdl-33419406

RESUMO

BACKGROUND: Following the 2016 Peace Agreement with the Fuerzas Armadas Revolucionarias de Colombia (FARC), Colombia promised to reincorporate more than 13,000 guerrilla fighters into its healthcare system. Despite a subsidized healthcare insurance program and the establishment of 24 Espacios Territoriales de Capacitación y Reincorporación (ETCRs-Territorial Spaces for Training and Reintegration) to facilitate this transition, data has shown that FARC ex-combatants access care at disproportionately lower rates, and face barriers to healthcare services. METHODS: Semi-structured interviews were conducted with FARC health promoters and healthcare providers working in ETCRs to determine healthcare access barriers for FARC ex-combatants. Analysis was completed with a qualitative team-based coding method and barriers were categorized according to Julio Frenk's Domains of Healthcare Access framework. RESULTS: Among 32 participants, 25 were healthcare providers and 7 self-identified as FARC health promoters. The sample was majority female (71.9%) and worked with the FARC for an average of 12 months in hospital, health center, medical brigade, and ETCR settings. Our sample had experiences with FARC across 16 ETCRs in 13 Departments of Colombia. Participants identified a total of 141 healthcare access barriers affecting FARC ex-combatants, which affected healthcare needs, desires, seeking, initiation and continuation. Significant barriers were related to a lack of resources in rural areas, limited knowledge of the Colombian health system, the health insurance program, perceived stigma, and transition process from the FARC health system. CONCLUSIONS: FARC ex-combatants face significant healthcare access barriers, some of which are unique from other low-resource populations in Colombia. Potential solutions to these barriers included health insurance provider partnerships with health centers close to ETCRs, and training and contracting FARC health promoters to be primary healthcare providers in ETCRs. Future studies are needed to quantify the healthcare barriers affecting FARC ex-combatants, in order to implement targeted interventions to improve healthcare access.


Assuntos
Pessoal de Saúde , Acesso aos Serviços de Saúde , Cognição , Colômbia , Feminino , Humanos , Seguro Saúde , Pesquisa Qualitativa
2.
J Am Coll Emerg Physicians Open ; 1(5): 757-765, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33145516

RESUMO

Objectives: In the 2016 Peace Accord with the Fuerzas Armadas Revolucionarias de Colombia (FARC), Colombia promised to reincorporate 14,000 ex-combatants into the healthcare system. However, FARC ex-combatants have faced significant challenges in receiving healthcare, and little is known about physicians' abilities to address this population's healthcare needs. Methods: An electronic questionnaire sent to the Colombian Emergency Medicine professional society and teaching hospitals assessed physicians' knowledge, attitudes, and experiences with the FARC ex-combatant reincorporation process. Results: Among 53 participants, most were male (60.4%), and ∼25% were affected by the FARC conflict (22.6%). Overall knowledge of FARC reincorporation was low, with nearly two-thirds of participants (61.6%) scoring in the lowest category. Attitudes around ex-combatants showed low bias. Few physicians received training about reincorporation (7.5%), but 83% indicated they would like such training. Twenty-two participants (41.5%) had identified a patient as an ex-combatant in the healthcare setting. Higher knowledge scores were significantly correlated with training about reincorporation (r = 0.354, n = 53, P = 0.015), and experience identifying patients as ex-combatants (r = 0.356, n = 47, P = 0.014). Conclusion: Findings suggested high interest in training and low knowledge of the reincorporation process. Most physicians had low bias, frequent experiences with ex-combatants, and cared for these patients when they self-identify. The emergency department (ED) serves as an entrance into healthcare for this population and a potential setting for interventions to improve care delivery, especially those related to mental healthcare. Future studies could evaluate effects of care delivery following training on ex-combatant healthcare reintegration.

3.
R I Med J (2013) ; 102(7): 40-43, 2019 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-31480819

RESUMO

INTRODUCTION: Colombia represents a country in transition, from decades of devastating civil war to a post-conflict era of peace building, to the recent management of the influx of thousands of Venezuelan migrants. Brown University, along with Colombian partners, are leading the way in an international, multi-institutional consortium with the goal of emergency medicine capacitation across Colombia. Program Implementations: Through these collaborative efforts, exchange programs for residents and faculty alike have been successfully established. A baseline assessment of emergency medicine education for medical students is underway. By the end of 2019, the Harvard Humanitarian Initiative (HHI) will launch an online tool in multiple languages, including Spanish, to help medical and nursing educators conduct systematic needs assessments of the way in which conflict has impacted medical and nursing schools. CONCLUSIONS: Successful avenues for collaboration and partnership are described between Brown Emergency physicians and Colombian collaborating universities. These programs help to build capacity in Colombia and also provide education and support for residents and faculty at Brown University. Current work will see these programs grow into the future.


Assuntos
Serviços Médicos de Emergência/organização & administração , Medicina de Emergência/organização & administração , Acesso aos Serviços de Saúde/organização & administração , Hospitais Universitários/organização & administração , Médicos/organização & administração , Guerra , Colômbia/epidemiologia , Planejamento em Desastres/organização & administração , Serviços Médicos de Emergência/normas , Medicina de Emergência/normas , Acesso aos Serviços de Saúde/normas , Humanos , Cooperação Internacional , Avaliação de Processos e Resultados em Cuidados de Saúde , Avaliação de Programas e Projetos de Saúde , Refugiados , Rhode Island/epidemiologia
5.
West J Emerg Med ; 18(6): 1120-1127, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29085546

RESUMO

INTRODUCTION: Emergency medicine (EM) is in different stages of development around the world. Colombia has made significant strides in EM development in the last two decades and recognized it as a medical specialty in 2005. The country now has seven EM residency programs: three in the capital city of Bogotá, two in Medellin, one in Manizales, and one in Cali. The seven residency programs are in different stages of maturity, with the oldest founded 20 years ago and two founded in the last two years. The objective of this study was to characterize these seven residency programs. METHODS: We conducted semi-structured interviews with faculty and residents from all the existing programs in 2013-2016. Topics included program characteristics and curricula. RESULTS: Colombian EM residencies are three-year programs, with the exception of one four-year program. Programs accept 3-10 applicants yearly. Only one program has free tuition and the rest charge tuition. The number of EM faculty ranges from 2-15. EM rotation requirements range from 11-33% of total clinical time. One program does not have a pediatric rotation. The other programs require 1-2 months of pediatrics or pediatric EM. Critical care requirements range from 4-7 months. Other common rotations include anesthesia, general surgery, internal medicine, obstetrics, gynecology, orthopedics, ophthalmology, radiology, toxicology, psychiatry, neurology, cardiology, pulmonology, and trauma. All programs offer 4-6 hours of protected didactic time each week. Some programs require Advanced Cardiac Life Support, Pediatric Advanced Life Support and Advanced Trauma Life Support, with some programs providing these trainings in-house or subsidizing the cost. Most programs require one research project for graduation. Resident evaluations consist of written tests and oral exams several times per year. Point-of-care ultrasound training is provided in four of the seven programs. CONCLUSION: As emergency medicine continues to develop in Colombia, more residency programs are expected to emerge. Faculty development and sustainability of academic pursuits will be critically important. In the long term, the specialty will need to move toward certifying board exams and professional development through a national EM organization to promote standardization across programs.


Assuntos
Educação de Pós-Graduação em Medicina/normas , Medicina de Emergência/educação , Internato e Residência/normas , Desenvolvimento de Programas/normas , Colômbia , Currículo , Medicina de Emergência/normas , Humanos , Avaliação de Programas e Projetos de Saúde
6.
Artigo em Inglês | MEDLINE | ID: mdl-26582632

RESUMO

PURPOSE: Smartphone technology offers a multitude of applications (apps) that provide a wide range of functions for healthcare professionals. Medical trainees are early adopters of this technology, but how they use smartphones in clinical care remains unclear. Our objective was to further characterize smartphone use by medical trainees at two United States academic institutions, as well as their prior training in the clinical use of smartphones. METHODS: In 2014, we surveyed 347 internal medicine and emergency medicine resident physicians at the University of Utah and Brigham and Women's Hospital about their smartphone use and prior training experiences. Scores (0%-100%) were calculated to assess the frequency of their use of general features (email, text) and patient-specific apps, and the results were compared according to resident level and program using the Mann-Whitney U-test. RESULTS: A total of 184 residents responded (response rate, 53.0%). The average score for using general features, 14.4/20 (72.2%) was significantly higher than the average score for using patient-specific features and apps, 14.1/44 (33.0%, P<0.001). The average scores for the use of general features, were significantly higher for year 3-4 residents, 15.0/20 (75.1%) than year 1-2 residents, 14.1/20 (70.5%, P=0.035), and for internal medicine residents, 14.9/20 (74.6%) in comparison to emergency medicine residents, 12.9/20 (64.3%, P= 0.001). The average score reflecting the use of patient-specific apps was significantly higher for year 3-4 residents, 16.1/44 (36.5%) than for year 1-2 residents, 13.7/44 (31.1%; P=0.044). Only 21.7% of respondents had received prior training in clinical smartphone use. CONCLUSION: Residents used smartphones for general features more frequently than for patient-specific features, but patient-specific use increased with training. Few residents have received prior training in the clinical use of smartphones.

7.
CJEM ; 17(6): 685-8, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25915003

RESUMO

Given the discrepancy between men and women's equal rates of medical school matriculation and their rates of academic promotion and leadership role acquisition, the need to provide mentorship and education to women in academic medicine is becoming increasingly recognized. Numerous large-scale programs have been developed to provide support and resources for women's enrichment and retention in academic medicine. Analyses of contributory factors to the aforementioned discrepancy commonly cite insufficient mentoring and role modeling as well as challenges with organizational navigation. Since residency training has been shown to be a critical juncture for making the decision to pursue an academic career, there is a need for innovative and tailored educational and mentorship programs targeting residents. Acknowledging residents' competing demands, we designed a program to provide easily accessible mentorship and contact with role models for our trainees at the departmental and institutional levels. We believe that this is an important step towards encouraging women's pursuit of academic careers. Our model may be useful to other emergency medicine residencies looking to provide such opportunities for their women residents.


Assuntos
Escolha da Profissão , Educação de Pós-Graduação em Medicina/organização & administração , Medicina de Emergência/educação , Internato e Residência/métodos , Mentores , Faculdades de Medicina/organização & administração , Feminino , Humanos , Masculino
8.
Int J Emerg Med ; 8: 9, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25897343

RESUMO

Colombia is an upper-middle-income country with a population of 45 million people and one of the best national healthcare and medical education systems in South America. However, its widely diverse and difficult terrains hinder healthcare delivery to rural areas, creating disparities in healthcare access and outcomes between the urban and rural settings. Currently, emergency medical care is overwhelmingly provided by general practitioners without residency training, who obtain specialty consultations based on the medical/surgical condition identified. A few emergency medicine (EM) residency programs have sprouted over the last two decades in renowned academic institutions in the largest cities, producing high-quality EM specialists. With the establishment of EM as a specialty in 2005 and increasing recognition of the specialty, there has been an increasing demand for EM specialists in cities, which is only slowly being met by the current residencies. The critical challenges for EM in Colombia are both, establishing itself as a well-recognized specialty - by increasing academic production and reaching a critical mass of and unity among EM specialists - and providing the highest quality and safest emergency care to the people of Colombia - by improving capacity both in emergency departments and in the regional and national emergency response systems. Historically, the establishment of EM as a strongly organized specialty in other countries has spanned decades (e.g., the United States), and Colombia has been making significant progress in a similar trajectory.

9.
Am J Emerg Med ; 32(5): 452-6, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-24650718

RESUMO

OBJECTIVE: Neuromuscular paralysis without sedation is an avoidable medical error with negative psychologic and potentially physiologic consequences. We determine the frequency of long-acting paralysis without concurrent sedation among patients intubated in our emergency department (ED) or before arrival. METHODS: We performed a retrospective cohort study from July 2007 to August 2009. We chose this time interval because in 2006, our institution developed a multidisciplinary plan designed to improve care of intubated patients. We identified all mechanically ventilated patients using billing codes. We reviewed all records to identify use of long-acting neuromuscular blocking agents. We captured data on patient characteristics and location of intubation, using a standardized data collection form. We report bivariate risk ratios to quantify associations with lack of concurrent sedation. A priori, we defined concurrent sedation as administration of any sedative during the 60 minutes preceding and the 15 minutes after administration of the long-acting paralytic. RESULTS: Over the 26-month period of study, 292 patients received a long-acting paralytic. Of the 212 available for analysis, 39 (18%) did not receive concurrent sedation. Every decade of age increased the risk of paralysis without concurrent sedation by 1.2 (95% confidence interval [CI], 1.1-1.4). Paralysis for intubation (vs for transport or ventilation management) increased the odds of no sedation by 2.1 (95% CI, 1.2-3.7). No other covariates predicted nonsedation. CONCLUSION: Absence of concurrent sedation was common among patients receiving long-acting neuromuscular paralysis before arrival or at our ED, despite implementation of a guideline to improve practice.


Assuntos
Serviços Médicos de Emergência , Serviço Hospitalar de Emergência , Intubação Intratraqueal , Bloqueio Neuromuscular/métodos , Bloqueadores Neuromusculares/administração & dosagem , Adulto , Idoso , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Masculino , Pessoa de Meia-Idade , Respiração Artificial , Estudos Retrospectivos
10.
Int J Emerg Med ; 7(1): 7, 2014 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-24499650

RESUMO

BACKGROUND: Emergency medicine (EM) is a growing specialty in Colombia with five residency programs in the country. EM leadership is interested in incorporating point-of-care (POC) ultrasound into a standardized national EM residency curriculum. This study is a nationwide survey of Colombian EM residents designed to explore the current state of POC ultrasound use within EM residencies and examine specific barriers preventing its expansion. METHODS: We conducted a mix-methodology study of all available current EM residents in the five EM residencies in Colombia. The quantitative survey assessed previous ultrasound experience, current use of various applications, desire for further training, and perceived barriers to expanded use. Focus group discussions (FGDs) were conducted with current EM residents to gather additional qualitative insight into their practice patterns and perceived barriers to clinician-performed ultrasound. RESULTS: Sixty-nine EM residents completed the quantitative survey, a response rate of 85% of all current EM residents in Colombia; 52% of resident respondents had previously used ultrasound during their training. Of these, 58% indicated that they had performed <10 scans and 17% reported >40 scans. The most frequently used applications indicated by respondents were trauma, obstetrics, and procedures including vascular access. A quarter indicated they had previously received some ultrasound training, but almost all expressed an interest in learning more. Significant barriers included lack of trained teachers (indicated by 78% of respondents), absence of machines (57%), and limited time (41%). In FGDs, the barriers identified were inter-specialty conflicts over the control of ultrasonography, both institutionally and nationally, and program-specific curriculum decisions to include POC ultrasound. CONCLUSION: While currently limited in their access, EM residents in Colombia have a strong interest in integrating POC ultrasound into their training. Current barriers to expanded use include traditional barriers such as a lack of equipment seen in many developing countries, as well as inter-specialty conflicts typical of developed countries. Further collaboration is underway to help overcome these obstacles and integrate POC ultrasound into Colombian EM residency training.

11.
PLoS One ; 8(1): e53408, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23308216

RESUMO

BACKGROUND: HIV infection remains a major US public health concern. While HIV-infected individuals now benefit from earlier diagnosis and improved treatment options, progress is tempered by large numbers of newly diagnosed patients who are lost to follow-up prior to disease confirmation and linkage to care. METHODOLOGY: In the randomized, controlled USHER trial, we offered rapid HIV tests to patients presenting to a Boston, MA emergency department. Separate written informed consent was required for confirmatory testing. In a secondary analysis, we compared participants with reactive results who did and did not complete confirmatory testing to identify factors associated with refusal to complete the confirmation protocol. PRINCIPAL FINDINGS: Thirteen of 62 (21.0%, 95% CI (11.7%, 33.2%)) participants with reactive rapid HIV tests refused confirmation; women, younger participants, African Americans, and those with fewer HIV risks, with lower income, and without primary care doctors were more likely to refuse. We projected that up to four true HIV cases were lost at the confirmation stage. CONCLUSIONS: These findings underscore the need to better understand the factors associated with refusal to confirm reactive HIV testing and to identify interventions that will facilitate confirmatory testing and linkage to care among these populations. TRIAL REGISTRATION: ClinicalTrials.gov NCT00502944; NCT01258582.


Assuntos
Infecções por HIV/diagnóstico , Infecções por HIV/psicologia , Soropositividade para HIV/diagnóstico , Soropositividade para HIV/psicologia , HIV , Recusa de Participação/psicologia , Sorodiagnóstico da AIDS , Adolescente , Adulto , Afro-Americanos , Fatores Etários , Idoso , Boston , Escolaridade , Serviço Hospitalar de Emergência , Grupo com Ancestrais do Continente Europeu , Feminino , Imunofluorescência , Infecções por HIV/sangue , Infecções por HIV/etnologia , Soropositividade para HIV/sangue , Soropositividade para HIV/etnologia , Hispano-Americanos , Humanos , Renda , Perda de Seguimento , Masculino , Pessoa de Meia-Idade , Recusa de Participação/etnologia , Fatores Sexuais
12.
J Acquir Immune Defic Syndr ; 61(5): 588-92, 2012 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-23183149

RESUMO

BACKGROUND: Oral rapid HIV testing has been reported to have a lower sensitivity and specificity than rapid HIV testing with whole blood and has been associated with clusters of false-positive results. Patient preference for oral rapid HIV testing compared with more invasive whole blood fingerstick may influence the acceptance of rapid HIV testing. OBJECTIVE: To compare HIV test acceptance rates among patients routinely offered fingerstick compared with those routinely offered oral fluid screening in an urban hospital emergency department. METHODS: The Universal Screening for HIV Infection in the Emergency Room Phase II was a single-center, prospective, randomized controlled trial that randomized subjects to either fingerstick or oral rapid HIV screening in an urban academic emergency department. From May 5, 2009, to January 4, 2010, eligible patients aged 18-75 years were invited to participate in the trial. The primary outcome measure was HIV test acceptance rate. RESULTS: : 2012 eligible patients were approached, of whom 1651 (82%) consented to trial participation and enrolled. Among those enrolled, 830 and 821 were randomized to the fingerstick and oral fluid arms, respectively. Acceptance of rapid HIV testing was similar in both arms; 67% (553 of 830) of subjects accepted fingerstick testing compared with 69% (565 of 821) who accepted oral (P = 0.34). CONCLUSIONS: Although fingerstick rapid HIV testing is more invasive than oral fluid testing, test acceptance rates did not differ. Given the option, preference should therefore be given to fingerstick testing because of its slightly superior test characteristics. System factors such as ease of staff use, necessary Clinical Laboratory Improvement Amendments waivers, laboratory capacity, and HIV prevalence should also be considered.


Assuntos
Sorodiagnóstico da AIDS/métodos , Adulto , Serviços Médicos de Emergência , Feminino , Anticorpos Anti-HIV/análise , Anticorpos Anti-HIV/sangue , Humanos , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde , Preferência do Paciente , Estudos Prospectivos , Saliva/imunologia
14.
J Emerg Med ; 42(1): 7-14, 2012 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-19828278

RESUMO

BACKGROUND: The Centers for Disease Control and Prevention (CDC) recently published recommendations for routine, voluntary human immunodeficiency virus (HIV) testing of adults in all health care settings, including the emergency department (ED). STUDY OBJECTIVE: The objective of this study was to examine the willingness of ED providers to offer HIV testing, as well as their perceived barriers to implementation of these guidelines. METHODS: Before the establishment of a routine HIV testing program in the ED, a 21-item survey was used to assess ED providers' knowledge, attitudes, and perceived challenges to HIV testing. Six months after program initiation, the identical survey was re-administered to determine whether HIV testing program experience altered providers' perceptions. RESULTS: There were 108 of 146 (74%) providers who completed both the pre- and post-implementation surveys. Although the majority of emergency providers at 6 months were supportive of an ED-based HIV testing program (59/108 [55%]), only 38% (41/108) were willing to offer the HIV test most or all of the time. At 6 months, the most frequently cited barriers to offering a test were: inadequate time (67/108 [62%]), inadequate resources (65/108 [60%]), and concerns regarding provision of follow-up care (64/108 [59%]). CONCLUSIONS: After the implementation of a large-scale HIV testing program in an ED, the majority of emergency providers were supportive of routine HIV testing. Nevertheless, 6 months after program initiation, providers were still reluctant to offer the test due to persistent barriers. Further studies are needed to identify feasible implementation strategies that minimize barriers to routine HIV testing in the ED.


Assuntos
Atitude do Pessoal de Saúde , Serviço Hospitalar de Emergência , Infecções por HIV/diagnóstico , Sorodiagnóstico da AIDS/métodos , Sorodiagnóstico da AIDS/estatística & dados numéricos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Adulto Jovem
15.
PLoS One ; 6(11): e27701, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-22110730

RESUMO

OBJECTIVE: To estimate the prevalence of undiagnosed HIV, the prevalence of diagnosed HIV, and proportion of HIV that is undiagnosed in populations with similar demographics as the Universal Screening for HIV in the Emergency Room (USHER) Trial and the Brigham and Women's Hospital (BWH) Emergency Department (ED) in Boston, MA. We also sought to estimate these quantities within demographic and risk behavior subgroups. METHOD: We used data from the USHER Trial, which was a randomized clinical trial of HIV screening conducted in the BWH ED. Since eligible participants were HIV-free at time of enrollment, we were able to calculate the prevalence of undiagnosed HIV. We used data from the Massachusetts Department of Public Health (MA/DPH) to estimate the prevalence of diagnosed HIV since the MA/DPH records the number of persons within MA who are HIV-positive. We calculated the proportion of HIV that is undiagnosed using these estimates of the prevalence of undiagnosed and diagnosed HIV. Estimates were stratified by age, sex, race/ethnicity, history of testing, and risk behaviors. RESULTS: The overall expected prevalence of diagnosed HIV in a population similar to those presenting to the BWH ED was 0.71% (95% CI: 0.63%, 0.78%). The prevalence of undiagnosed HIV was estimated at 0.22% (95% CI: 0.10%, 0.42%) and resultant overall prevalence was 0.93%. The proportion of HIV-infection that is undiagnosed in this ED-based setting was estimated to be 23.7% (95% CI: 11.6%, 34.9%) of total HIV-infections. CONCLUSIONS: Despite different methodology, our estimate of the proportion of HIV that is undiagnosed in an ED-setting was similar to previous estimates based on national surveillance data. Universal routine testing programs in EDs should use these data to help plan their yield of HIV detection.


Assuntos
Cidades/estatística & dados numéricos , Interpretação Estatística de Dados , Serviços Médicos de Emergência/estatística & dados numéricos , Infecções por HIV/diagnóstico , Infecções por HIV/epidemiologia , Adolescente , Adulto , Idoso , Demografia , Feminino , Hospitais/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Assunção de Riscos , Adulto Jovem
16.
PLoS One ; 6(10): e25575, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-22022415

RESUMO

BACKGROUND: Routine HIV screening in emergency department (ED) settings may require dedicated personnel. We evaluated the outcomes, costs and cost-effectiveness of HIV screening when offered by either a member of the ED staff or by an HIV counselor. METHODS: We employed a mathematical model to extend data obtained from a randomized clinical trial of provider- vs. counselor-based HIV screening in the ED. We compared the downstream survival, costs, and cost-effectiveness of three HIV screening modalities: 1) no screening program; 2) an ED provider-based program; and 3) an HIV counselor-based program. Trial arm-specific data were used for test offer and acceptance rates (provider offer 36%, acceptance 75%; counselor offer 80%, acceptance 71%). Undiagnosed HIV prevalence (0.4%) and linkage to care rates (80%) were assumed to be equal between the screening modalities. Personnel costs were derived from trial-based resource utilization data. We examined the generalizability of results by conducting sensitivity analyses on offer and acceptance rates, undetected HIV prevalence, and costs. RESULTS: Estimated HIV screening costs in the provider and counselor arms averaged $8.10 and $31.00 per result received. The Provider strategy (compared to no screening) had an incremental cost-effectiveness ratio of $58,700/quality-adjusted life year (QALY) and the Counselor strategy (compared to the Provider strategy) had an incremental cost-effectiveness ratio of $64,500/QALY. Results were sensitive to the relative offer and acceptance rates by strategy and the capacity of providers to target-screen, but were robust to changes in undiagnosed HIV prevalence and programmatic costs. CONCLUSIONS: The cost-effectiveness of provider-based HIV screening in an emergency department setting compares favorably to other US screening programs. Despite its additional cost, counselor-based screening delivers just as much return on investment as provider based-screening. Investment in dedicated HIV screening personnel is justified in situations where ED staff resources may be insufficient to provide comprehensive, sustainable screening services.


Assuntos
Aconselhamento/economia , Serviço Hospitalar de Emergência/economia , Infecções por HIV/diagnóstico , Infecções por HIV/economia , Pessoal de Saúde/economia , Recursos em Saúde/estatística & dados numéricos , Sistemas Automatizados de Assistência Junto ao Leito/economia , Adulto , Terapia Antirretroviral de Alta Atividade , Ensaios Clínicos como Assunto , Análise Custo-Benefício , Feminino , Recursos em Saúde/economia , Humanos , Masculino , Programas de Rastreamento/economia , Pessoa de Meia-Idade , Modelos Biológicos , Sensibilidade e Especificidade
17.
J Natl Med Assoc ; 103(5): 439-42, 2011 May.
Artigo em Inglês | MEDLINE | ID: mdl-21809794

RESUMO

All applicants to US residency programs are required to write a personal statement. Recent reports of plagiarism and homogeneity in these freeform essays suggest the need for better guidance in this process. The authors review the historical and current role of the personal statement and provide a practical framework for writing a unique and effective personal statement, which will help both applicants and residency directors to maximize their chances of a successful match.


Assuntos
Internato e Residência , Critérios de Admissão Escolar , Redação , Escolha da Profissão , Humanos , Motivação , Plágio , Estados Unidos
18.
Ann Emerg Med ; 58(1 Suppl 1): S126-32.e1-4, 2011 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-21684391

RESUMO

OBJECTIVE: We compare rates of rapid HIV testing, test offer, and acceptance in an urban emergency department (ED) when conducted by dedicated HIV counselors versus current members of the ED staff. METHODS: The Universal Screening for HIV Infection in the Emergency Room [USHER] trial is a prospective randomized controlled trial that implemented an HIV screening program in the ED of an urban tertiary medical center. ED patients were screened and consented for trial enrollment by an USHER research assistant. Eligible subjects were randomized to rapid HIV testing (oral OraQuick) offered by a dedicated counselor (counselor arm) or by an ED provider (provider arm). In the counselor arm, counselors-without other clinical responsibilities-assumed nearly all testing-related activities (consent, counseling, delivery of test results). In the provider arm, trained ED emergency service assistants (nursing assistants) consented and tested the participant in the context of other ED-related responsibilities. In this arm, ED house officers, physician assistants, or attending physicians provided HIV test results to trial participants. Outcome measures were rates of HIV testing and test offer among individuals consenting for study participation. Among individuals offered the test, test acceptance was also measured. RESULTS: From February 2007 through July 2008, 8,187 eligible patients were approached in the ED, and 4,855 (59%) consented and were randomized to trial participation. The mean age was 37 years, 65% were women, and 42% were white. The overall testing rate favored the counselor arm (57% versus 27%; P<.001); 80% (1,959/2,446) of subjects in the counselor arm were offered an HIV test compared with 36% (861/2,409) in the provider arm (P<.001). HIV test acceptance was slightly higher in the provider arm (counselor arm 71% versus provider arm 75%; P = .025). CONCLUSION: Routine rapid HIV testing in the ED was accomplished more frequently by dedicated HIV counselors than by ED staff in the course of routine clinical work. Without dedicated staff, HIV testing in this setting may not be truly routine.


Assuntos
Serviço Hospitalar de Emergência , Infecções por HIV/diagnóstico , Adolescente , Adulto , Fatores Etários , Idoso , Boston , Aconselhamento , Feminino , Hospitais Urbanos , Humanos , Consentimento Livre e Esclarecido , Masculino , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Aceitação pelo Paciente de Cuidados de Saúde , Sistemas Automatizados de Assistência Junto ao Leito , Fatores de Risco , Adulto Jovem
19.
Ann Emerg Med ; 58(1 Suppl 1): S49-52, 2011 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-21684408

RESUMO

OBJECTIVE: Patient satisfaction with HIV screening is crucial for sustainable implementation of the Centers for Disease Control and Prevention (CDC) HIV testing recommendations. This investigation assesses patient satisfaction with rapid HIV testing in the emergency department (ED) of an urban tertiary academic medical center. METHODS: After receiving HIV test results, participants in the Universal Screening for HIV Infection in the Emergency Room (USHER) randomized controlled trial were offered a patient satisfaction survey. Questions concerned overall satisfaction with ED visit, time spent on primary medical problem, time spent on HIV testing, and test provider's ability to answer HIV-related questions. Responses were reported on a 4-point Likert scale, ranging from very dissatisfied to very satisfied (defined as optimal satisfaction). RESULTS: Of 4,860 USHER participants, 2,025 completed testing and were offered the survey: 1,616 (79.8%) completed the survey. Overall, 1,478 (91.5%) were very satisfied. Satisfaction was less than optimal for 34.5% (10 of 29) of participants with reactive results and for 7.5% (115 of 1,542) with nonreactive results. The independent factors associated with less than optimal satisfaction were reactive test result, aged 60 years or older, black race, Hispanic/Latino ethnicity, and testing by ED provider instead of HIV counselor. CONCLUSION: Most participants were very satisfied with the ED-based rapid HIV testing program. Identification of independent factors that correlate with patient satisfaction will help guide best practices as EDs implement CDC recommendations. It is critical to better understand whether patients with reactive results were negatively affected by their results or truly had concerns about the testing process.


Assuntos
Sorodiagnóstico da AIDS , Serviço Hospitalar de Emergência , Satisfação do Paciente , Sorodiagnóstico da AIDS/psicologia , Sorodiagnóstico da AIDS/normas , Centros Médicos Acadêmicos , Adulto , Fatores Etários , Idoso , Boston , Grupos de Populações Continentais , Serviço Hospitalar de Emergência/normas , Feminino , Pesquisas sobre Serviços de Saúde , Hospitais Urbanos , Humanos , Masculino , Programas de Rastreamento/psicologia , Programas de Rastreamento/normas , Pessoa de Meia-Idade
20.
Open Access Emerg Med ; 3: 21-7, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-27147848

RESUMO

PURPOSE: When emergency department (ED) overcrowding includes admitted mechanically ventilated (MV) critically-ill patients without an open intensive care unit (ICU) bed, emergency providers must deliver ICU level care in the ED. Implementing standardized hospital based clinical guidelines may help providers achieve uniform care standards for assessing and managing pain and sedation for the MV patient. OBJECTIVE: This paper is a description of a hospital performance improvement project that was implemented in the ED. The objective of this study was to measure the degree of adoption of a hospital-wide clinical guideline for the management of pain, sedation and neuromuscular blockade in MV patients into clinical practice in the ED. METHODS: A retrospective analysis was performed for all mechanically ventilated patients who were admitted from ED to an Intensive Care Unit (ICU). Patient charts were reviewed before (December 2005) and after the implementation of the guideline (June, August, and December 2006). Data was collected and analyzed for the ED visit only and no ICU data was used. The primary outcome was the degree of adoption of the guideline by emergency providers into their daily clinical practice. RESULTS: A convenience sample of 170 adult MV patients who were admitted to the ICU during the preselected time period was analyzed. There were no demographic differences between groups of patients observed during each month interval, age (P = 0.34), gender (P = 0.40), race (P = 0.14), and Hispanic ethnicity (P = 0.84). Overall, there was an increase in the provider use of propofol (P < 0.01), RASS sedation scale (P < 0.01), and a decrease in the use of a paralytic agent (P < 0.01). CONCLUSION: There was partial adoption of a guideline into their clinical practice by emergency providers in a busy urban emergency department. Across the 12-month implementation period, there was improvement in the assessment of and use of analgesia and sedation for MV patients.

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