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1.
Geriatrics (Basel) ; 6(3)2021 Aug 11.
Artigo em Inglês | MEDLINE | ID: mdl-34449655

RESUMO

BACKGROUND: This study describes long length of stay during emergency department (ED) visits and hospital admissions, barriers to discharge, and discharge solutions for geriatric patients. METHODS: We conducted a retrospective medical record review of a random sample of 150 ED patients and 150 inpatients with long length of stay (LOS) encounters. Cohorts were characterized by demographics, social determinants of health (e.g., health insurance, housing), medical comorbidities at admission, discharge care coordination, and final disposition. RESULTS: In the ED, the primary barrier to discharge was inadequate inpatient bed availability (63%). In the inpatient setting, barriers to discharge were predominantly due to a demonstrated medical requirement for continued hospitalization (55%), followed by difficulty with coordinating discharge to a skilled nursing facility or rehabilitation center (22%). DISCUSSION: Among long LOS ED patients, discharge delays were often the result of unavailable inpatient beds and services. Reducing the LOS for ED patients may require further investigation as to which hospital services are most frequently utilized by geriatric patients and structuring inpatient bed allocation to prevent extended patient boarding in the ED. Reducing long inpatient LOS may require early identification of high-risk patients and strengthening of relationships with community-based services.

2.
J Am Heart Assoc ; 10(15): e019305, 2021 08 03.
Artigo em Inglês | MEDLINE | ID: mdl-34323113

RESUMO

Background Timely emergency medical services (EMS) response, management, and transport of patients with suspected acute coronary syndrome (ACS) significantly reduce delays to emergency treatment and improve outcomes. We evaluated EMS response, scene, and transport times and adherence to proposed time benchmarks for patients with suspected ACS in North Carolina from 2011 to 2017. Methods and Results We conducted a population-based, retrospective study with the North Carolina Prehospital Medical Information System, a statewide electronic database of all EMS patient care reports. We analyzed 2011 to 2017 data on patient demographics, incident characteristics, EMS care, and county population density for EMS-suspected patients with ACS, defined as a complaint of chest pain or suspected cardiac event and documentation of myocardial ischemia on prehospital ECG or prehospital activation of the cardiac care team. Descriptive statistics for each EMS time interval were computed. Multivariable logistic regression was used to quantify relationships between meeting response and scene time benchmarks (11 and 15 minutes, respectively) and prespecified covariates. Among 4667 patients meeting eligibility criteria, median response time (8 minutes) was shorter than median scene (16 minutes) and transport (17 minutes) time. While scene times were comparable by population density, patients in rural (versus urban) counties experienced longer response and transport times. Overall, 62% of EMS encounters met the 11-minute response time benchmark and 49% met the 15-minute scene time benchmark. In adjusted regression analyses, EMS encounters of older and female patients and obtaining a 12-lead ECG and venous access were independently associated with lower adherence to the scene time benchmark. Conclusions Our statewide study identified urban-rural differences in response and transport times for suspected ACS as well as patient demographic and EMS care characteristics related to lower adherence to scene time benchmark. Strategies to reduce EMS scene times among patients with ACS need to be developed and evaluated.


Assuntos
Síndrome Coronariana Aguda/terapia , Serviços Médicos de Emergência/normas , Disparidades em Assistência à Saúde/normas , Tempo para o Tratamento , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Benchmarking/normas , Bases de Dados Factuais , Serviço Hospitalar de Emergência/normas , Feminino , Fidelidade a Diretrizes/normas , Humanos , Masculino , Pessoa de Meia-Idade , North Carolina , Guias de Prática Clínica como Assunto/normas , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Estudos Retrospectivos , Serviços de Saúde Rural/normas , Fatores de Tempo , Transporte de Pacientes/normas , Serviços Urbanos de Saúde/normas
3.
Prehosp Emerg Care ; 25(1): 8-15, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33074060

RESUMO

The COVID-19 pandemic is a worldwide historical event that will continue to affect nearly every aspect of ordinary life, including affecting our economic, political, and healthcare eco-systems. An effective pandemic response demands a coordinated and integrated response across community healthcare stakeholders, including Public Health and Emergency Management Officials. EMS systems are in a unique position and perform an essential role on the frontlines of COVID-19, including facilitating coordination of response efforts to COVID-19 within their communities while supporting public health mitigation efforts to slow the spread of the SARS-CoV-2. EMS physicians serve their communities at a unique intersection as clinical leaders, population health experts, and advocates. This paper examines and recommends crucial roles for EMS physician leaders as communities work together in pandemic response.


Assuntos
COVID-19 , COVID-19/epidemiologia , Atenção à Saúde , Serviço Hospitalar de Emergência , Humanos , Pandemias , Papel do Médico , Saúde Pública , SARS-CoV-2
4.
Prehosp Emerg Care ; 25(2): 182-190, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32176548

RESUMO

OBJECTIVES: The opioid crisis is a growing cause of mortality in the United States and may be mitigated by innovative approaches to identifying individuals at-risk of fatal opioid overdose. We examined Emergency Medical Services (EMS) utilization among a cohort of individuals who died from opioid overdose in order to identify potential opportunities for intervention. Methods: Individuals who died of unintentional opioid overdose in a large North Carolina county between 01/01/2014 and 12/31/2016 were studied in a retrospective cohort. Death records obtained from North Carolina Vital Records were linked to EMS patient care records obtained from the county EMS System in order to describe the EMS encounters of each decedent in the year preceding their death. Patient demographics and EMS encounters were assessed to identify encounter characteristics that may be targeted for intervention. Chi-square tests and odds ratios were used to evaluate and characterize the statistical significance of differences in EMS utilization. Results: Of the 218 individuals who died from unintentional opioid overdose in the study interval, 30% (n = 66) utilized EMS in the year before their death and 17% (n = 38) had at least one EMS encounter with documented drug or alcohol use (i.e. "drug-related encounter"). The mean age at death was 38 (range 19-74) years, 30% were female, 89% were White, and 8% were Black/African American. Factors associated with higher incidence of EMS utilization included age (P<.001), gender (P=.006), and race (P<.001). Decedents aged 56-65 had the highest EMS utilization (47%) and patients aged <25 and 25-35 had more drug-related EMS encounters (29% and 20%, respectively). The most common reasons for EMS utilization were "other medical" (27%), "non-traumatic pain" (20%), "traumatic injury" (16%), and "poisoning/drug ingestion" (14%). Drug or alcohol use was documented by EMS in 33% of all encounters and an opioid prescription was reported in 22% of encounters. Conclusions: Nearly one-third of individuals who died from accidental opioid overdose utilized EMS in the year before their death and nearly one-fifth had a drug-related encounter. EMS encounters may present an opportunity to identify individuals at-risk of opioid overdose and, ultimately, reduce overdose mortality.


Assuntos
Overdose de Drogas , Serviços Médicos de Emergência , Overdose de Opiáceos , Preparações Farmacêuticas , Adulto , Idoso , Analgésicos Opioides/efeitos adversos , Overdose de Drogas/tratamento farmacológico , Overdose de Drogas/prevenção & controle , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Naloxona/uso terapêutico , North Carolina/epidemiologia , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
5.
Am J Emerg Med ; 46: 550-555, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33279330

RESUMO

BACKGROUND AND OBJECTIVES: Lack of mental health resources, such as inpatient psychiatric beds, has increased frequency and duration of boarding for mental health patients presenting to U.S. emergency departments (EDs). The purpose of this study is to describe characteristics of mental health patients with an ED length of stay of one week or longer and to identify barriers to their disposition. METHODS: This study was conducted in an academic ED in which emergency psychiatric evaluations and care are provided by a Psychiatric Emergency Services (PES) team contained within the Department of Emergency Medicine. Prolonged boarding was defined as an ED length of stay of 7 days or more. Pediatric, adult, and geriatric mental health patients with prolonged ED boarding from January 1 to August 31, 2019 were included. This study includes prospective data collection of the boarding group and retrospective identification and data collection of a comparison group of non-barding patients over the same 8-month period to compare patient characteristics and outcomes for each group. RESULTS: Between January 1 and August 31, 2019, the PES team completed 2,745 new assessments of mental health patients, of whom 39 met criteria for prolonged ED boarding. The following characteristics were associated with boarding: child (8%), male (64%), having Medicaid (49%) or both Medicaid and Medicare (18%), and having either a neurodevelopmental (15%) or neurocognitive disorder (15%) with a median stay of 18 days. Barriers to discharge included being declined from all state inpatient psychiatric hospitals (69%), declined from community living environments (21%), or declined from both (10%). The most common ED non-boarding patients were: Caucasian (64%), have a diagnosis of unspecified mental disorder (including suicidal ideation) or other specified mental disorder (59%) and have private insurance (42%) with a median stay of 1 day. CONCLUSION: In this study of mental health patients with prolonged ED stays, the primary barrier to disposition was the lack of patient acceptance to inpatient psychiatric hospitals, community settings, or other housing. Early identification of potential prolonged boarding, quality treatment and care for those patients, and effective case management, may resolve the ongoing challenges of boarding within the ED.


Assuntos
Ocupação de Leitos , Serviço Hospitalar de Emergência , Hospitalização , Transtornos Mentais , Transferência de Pacientes , Adolescente , Adulto , Fatores Etários , Idoso , Moradias Assistidas , Criança , Pré-Escolar , Serviços de Emergência Psiquiátrica , Feminino , Lares para Grupos , Número de Leitos em Hospital , Hospitais Psiquiátricos , Hospitais Estaduais , Habitação , Humanos , Lactente , Masculino , Medicaid , Medicare , Pessoa de Meia-Idade , Transtornos do Humor , Transtornos Neurocognitivos , Transtornos do Neurodesenvolvimento , Alta do Paciente , Transtornos Psicóticos , Estudos Retrospectivos , Esquizofrenia , Fatores Sexuais , Transtornos Relacionados ao Uso de Substâncias , Estados Unidos , Adulto Jovem
6.
Prehosp Disaster Med ; 34(5): 497-505, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31516102

RESUMO

INTRODUCTION: In January of 2010, North Carolina (NC) USA implemented state-wide Trauma Triage Destination Plans (TTDPs) to provide standardized guidelines for Emergency Medical Services (EMS) decision making. No study exists to evaluate whether triage behavior has changed for geriatric trauma patients. HYPOTHESIS/PROBLEM: The impact of the NC TTDPs was investigated on EMS triage of geriatric trauma patients meeting physiologic criteria of serious injury, primarily based on whether these patients were transported to a trauma center. METHODS: This is a retrospective cohort study of geriatric trauma patients transported by EMS from March 1, 2009 through September 30, 2009 (pre-TTDP) and March 1, 2010 through September 30, 2010 (post-TTDP) meeting the following inclusion criteria: (1) age 50 years or older; (2) transported to a hospital by NC EMS; (3) experienced an injury; and (4) meeting one or more of the NC TTDP's physiologic criteria for trauma (n = 5,345). Data were obtained from the Prehospital Medical Information System (PreMIS). Data collected included proportions of patients transported to a trauma center categorized by specific physiologic criteria, age category, and distance from a trauma center. RESULTS: The proportion of patients transported to a trauma center pre-TTDP (24.4% [95% CI 22.7%-26.1%]; n = 604) was similar to the proportion post-TTDP (24.4% [95% CI 22.9%-26.0%]; n = 700). For patients meeting specific physiologic triage criteria, the proportions of patients transported to a trauma center were also similar pre- and post-TTDP: systolic blood pressure <90 mmHg (22.5% versus 23.5%); respiratory rate <10 or >29 (23.2% versus 22.6%); and Glascow Coma Scale (GCS) score <13 (26.0% versus 26.4%). Patients aged 80 years or older were less likely to be transported to a trauma center than younger patients in both the pre- and post-TTDP periods. CONCLUSIONS: State-wide implementation of a TTDP had no discernible effect on the proportion of patients 50 years and older transported to a trauma center. Under-triage remained common and became increasingly prevalent among the oldest adults. Research to understand the uptake of guidelines and protocols into EMS practice is critical to improving care for older adults in the prehospital environment.


Assuntos
Escala de Gravidade do Ferimento , Avaliação de Processos e Resultados em Cuidados de Saúde , Triagem/normas , Ferimentos e Lesões/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Serviços Médicos de Emergência , Feminino , Avaliação Geriátrica , Serviços de Saúde para Idosos , Humanos , Masculino , Pessoa de Meia-Idade , North Carolina , Estudos Retrospectivos , Ferimentos e Lesões/terapia
7.
South Med J ; 112(6): 331-337, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31158888

RESUMO

OBJECTIVES: Effective regionalization of acute stroke care requires assessment and coordination of limited hospital resources. We described the availability of stroke-specific hospital resources (neurology specialty physicians and neuro-intensive care unit [neuro-ICU] bed capacity) for North Carolina overall and by region and population density. We also assessed daily trends in hospital bed availability. METHODS: This statewide descriptive study was conducted with data from the State Medical Asset Resource Tracking Tool (SMARTT), a Web-based system used by North Carolina to track available medical resources within the state. The SMARTT system was queried for stroke-specific physician and bed resources at each North Carolina hospital during a 1-year period (June 2015-May 2016), including daily availability of neuro-ICU beds. We compared hospital resources by geographic region and population density (metropolitan, urban, and rural). RESULTS: Data from 108 acute care hospitals located in 75 of 100 counties in North Carolina were included in the analysis. Fifty-seven percent of hospitals had no neurology specialty physicians. Western and eastern North Carolina had the lowest prevalence of these physicians. Most hospitals (88%) had general ICUs, whereas only 17 hospitals (16%) had neuro-ICUs. Neuro-ICUs were concentrated in metropolitan areas and in central North Carolina. On average, there were 276 general ICU and 27 neuro-ICU beds available statewide each day. Daily neuro-ICU bed availability was lowest in eastern and southeastern regions and during the week compared with weekends. CONCLUSIONS: In North Carolina, stroke-specific hospital subspecialists and resources are not distributed evenly across the state. Daily bed availability, particularly in neuro-ICUs, is lacking in rural areas and noncentral regions and appears to decrease on weekdays. Regionalization of stroke care needs to consider the geographic distribution and daily variability of hospital resources.


Assuntos
Acesso aos Serviços de Saúde , Número de Leitos em Hospital/estatística & dados numéricos , Neurologistas/provisão & distribuição , Acidente Vascular Cerebral/terapia , Humanos , Unidades de Terapia Intensiva/provisão & distribuição , North Carolina/epidemiologia , Acidente Vascular Cerebral/epidemiologia
8.
Prehosp Emerg Care ; 23(2): 179-186, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30118357

RESUMO

OBJECTIVE: The objective of this study was to characterize key health indicators in Emergency Medical Services (EMS) personnel and identify areas for intervention in order to ensure a strong and capable emergency health workforce. METHODS: Participants were EMS personnel delivering patients to 4 regional tertiary care emergency departments within North Carolina (NC). After transferring patient care and agreeing to participate, height, weight, and blood pressure (BP) measurements were recorded and each participant completed a questionnaire regarding demographics, activity levels, alcohol consumption, smoking, and medical history. Data were analyzed descriptively. RESULTS: A sample of 452 EMS personnel from across NC was enrolled. The cohort was predominantly male (74.1%) and employed full-time (85.5%). The prevalence of overweight and obesity (80.3%) among EMS personnel was higher than the NC population (65.6%) and the general United States (US) population (70.8%). A previous diagnosis of high BP was reported by only 18.3% of participants, but 65.1% had elevated BP at the time of measurement. Alcohol consumption in the past 30 days among participants (55.4%) was slightly higher than state estimates (48.0%) and similar to national estimates (57.1%). However, heavy drinking (22.2%) and binge drinking (28.8%) were reported at much higher rates than state (5.6% and 15.2%, respectively) and national (6.6% and 18.3%, respectively) estimates. The prevalence of current smoking (21.5%) and quit attempts (48.8%) in the cohort was similar to state (21.8% and 55.0%, respectively) and national (21.2% and 55.7%, respectively) estimates. Likewise, the proportion of EMS providers meeting the Center for Disease Control's activity guidelines (49.6%) was similar to that found in the NC (46.8%) and the general US (48.0%) populations. CONCLUSIONS: These findings suggest a high prevalence of overweight and obesity, heavy drinking, binge drinking, and high BP among NC EMS personnel. Similar to fire service personnel, these rates are higher than the general US population. As such, they suggest areas where intervention would have the greatest positive impact on the health and performance of the EMS workforce.


Assuntos
Serviços Médicos de Emergência , Comportamentos Relacionados com a Saúde , Pessoal de Saúde/estatística & dados numéricos , Hipertensão/epidemiologia , Obesidade/epidemiologia , Adolescente , Adulto , Consumo de Bebidas Alcoólicas , Estudos Transversais , Feminino , Pessoal de Saúde/psicologia , Nível de Saúde , Humanos , Masculino , North Carolina , Prevalência , Inquéritos e Questionários , Estados Unidos , Adulto Jovem
9.
Prehosp Emerg Care ; 22(6): 773-777, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29521551

RESUMO

BACKGROUND: Accessing the emergency medical services system via 9-1-1 operators is an effective way for patients to seek urgent health care; however, technological advances and telecommunication practices inundate the 9-1-1 and emergency services infrastructure with unintentional calls that delay response efforts to legitimate medical emergencies. OBJECTIVE: To determine whether the change in university-wide dial-out prefix from "9" to "7" reduced unnecessary calls to a 9-1-1 call center. METHODS: This is a retrospective study conducted utilizing information obtained from the University of North Carolina at Chapel Hill (UNC) Department of Public Safety (DPS) call center. Call center calls received during pre-change, intervening, and post-change periods were included in the study. The cost savings, defined in time and money, resulting from the prefix change were also examined. RESULTS: A total of 33,646 calls were made during the study period (January 11, 2010 through December 31, 2012) and included in the analysis. The prefix change was found to reduce the rate of invalid calls to the call center by 319 calls per month, resulting in a 43% reduction in total calls to the call center while preserving the rate of valid calls. The largest decrease occurred in hang-up calls (a decrease of 232 calls per month), especially those originating from the university. The prefix change was found to save the UNC DPS telecommunications division approximately $798.82 per month and the police officer division approximately $3,874.95 per month. CONCLUSION: A prefix change was not only beneficial to the UNC community but it also has potentially wide-reaching effects. A reduction of invalid 9-1-1 calls translates to telecommunicators having more time available to handle true emergencies, phone lines remaining available for true emergencies, and police officers dedicating more time and effort to matters that necessitate officer assistance. Based on the call decrease seen with the prefix change, this study may be used as evidence to advocate for a change of dial-out codes beginning with "9."


Assuntos
Sistemas de Comunicação entre Serviços de Emergência , Linhas Diretas/organização & administração , Universidades , Emergências , Serviços Médicos de Emergência , Feminino , Linhas Diretas/estatística & dados numéricos , Humanos , Polícia , Estudos Retrospectivos , Telecomunicações
10.
J Am Geriatr Soc ; 66(5): 962-968, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29566428

RESUMO

OBJECTIVES: To describe statewide emergency medical service (EMS) protocols relating to identification, management, and reporting of elder abuse in the prehospital setting. DESIGN: Cross-sectional analysis. SETTING: Statewide EMS protocols in the United States. PARTICIPANTS: Publicly available statewide EMS protocols identified from published literature, http://EMSprotocols.org, and each state's public health website. MEASUREMENTS: Protocols were reviewed to determine whether elder abuse was mentioned, elder abuse was defined, potential indicators of elder abuse were listed, management of older adults experiencing abuse was described, and instructions regarding reporting were provided. EMS protocols for child abuse were reviewed in the same manner for the purpose of comparison. RESULTS: Of the 35 publicly available statewide EMS protocols, only 14 (40.0%) mention elder abuse. Of protocols that mention elder abuse, 6 (42.9%) define elder abuse, 10 (71.4%) describe indicators of elder abuse, 8 (57.1%) provide instruction regarding management, and 12 (85.7%) provide instruction regarding reporting. Almost twice as many states met each of these metrics for child abuse. CONCLUSION: Statewide EMS protocols for elder abuse vary in regard to identification, management, and reporting, with the majority of states having no content on this subject. Expansion and standardization of protocols may increase the identification of elder abuse.


Assuntos
Abuso de Idosos/diagnóstico , Serviços Médicos de Emergência/normas , Notificação de Abuso , Idoso , Estudos Transversais , Feminino , Humanos , Masculino , Estados Unidos
11.
South Med J ; 110(8): 516-522, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28771648

RESUMO

OBJECTIVES: Little is known about the personal readiness of hospital staff for disasters. As many as 30% of hospital staff say that they plan not to report for work during a large-scale disaster. We sought to understand the personal disaster preparedness for hospital staff. METHODS: Surveys were distributed to the staff of a large academic tertiary-care hospital by either a paper-based version distributed through the departmental safety coordinators or a Web-based version distributed through employee e-mail services, depending on employee familiarity with and access to computer services. Surveys assessed the demographic variables and characteristics of personal readiness for disaster. RESULTS: Of the individuals who accessed the survey, 1334 (95.9%) enrolled in it. Women made up 75% of the respondents, with a mean age of 43 years. Respondents had worked at the hospital an average of 9 years, with the majority (90%) being full-time employees. Most households (93%) reported ≤4 members, 6% supported a person with special medical needs, and 17% were headed by a single parent. A small number (24%) of respondents reported an established meeting place for reuniting households during a disaster. Many reported stockpiling a 3-day supply of food (86%) and a 3-day supply of water (51%). Eighteen percent of respondents were not aware of workplace evacuation plans. Most respondents were willing to report to work for natural disasters (eg, tornado, snowstorm; all categories >65%), but fewer respondents were willing to report during events such as an influenza epidemic (54%), a biological outbreak (41%), a chemical exposure, (40%), or a radiation exposure (39%). Multivariate analysis revealed being female, having a child in the household younger than 6 years old, and having a child in school lowered the likelihood of being willing to report to work in two or more event types, whereas pet ownership, being a clinical healthcare worker, and being familiar with the work emergency plan increased the likelihood. CONCLUSIONS: Despite being employed at the same facility for a prolonged period, employees reported being willing to report for work at a low rate in a variety of disasters. Subjects reported suboptimal personal preparedness for disaster, which may further limit the number of staff who will report for work. Hospitals should promote personal disaster preparedness for staff and explore staffing models with an understanding of reduced staff availability during disasters.


Assuntos
Atitude do Pessoal de Saúde , Planejamento em Desastres , Desastres , Recursos Humanos em Hospital , Trabalho/psicologia , Adulto , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Autorrelato
12.
Ann Emerg Med ; 70(4): 506-515.e3, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28559037

RESUMO

STUDY OBJECTIVE: The objective of this study is to characterize repeated emergency medical services (EMS) transports among older adults across a large and socioeconomically diverse region. METHODS: Using the North Carolina Prehospital Medical Information System, we analyzed the frequency of repeated EMS transports within 30 days of an index EMS transport among adults aged 65 years and older from 2010 to 2015. We used multivariable logistic regressions to determine characteristics associated with repeated EMS transport. RESULTS: During the 6-year period, EMS performed 1,711,669 transports for 689,664 unique older adults in North Carolina. Of these, 303,099 transports (17.7%) were followed by another transport of the same patient within 30 days. The key characteristics associated with an increased adjusted odds ratio of repeated transport within 30 days include transport from an institutionalized setting (odds ratio [OR] 1.42; 95% confidence interval [CI] 1.38 to 1.47), blacks compared with whites (OR 1.29; 95% CI 1.24 to 1.33), a dispatch complaint of psychiatric problems (OR 1.38; 95% CI 1.25 to 1.52), back pain (OR 1.35; 95% CI 1.26 to 1.45), breathing problems (OR 1.21; 95% CI 1.15 to 1.30), and diabetic problems (OR 1.14; 95% CI 1.06 to 1.22). Falls accounted for 15.6% of all transports and had a modest association with repeated transports (OR 1.07; 95% CI 1.00 to 1.14). CONCLUSION: More than 1 in 6 EMS transports of older adults in North Carolina are followed by a repeated transport of the same patient within 30 days. Patient characteristics and chief complaints may identify increased risk for repeated transport and suggest the potential for targeted interventions to improve outcomes and manage EMS use.


Assuntos
Serviços Médicos de Emergência , Serviço Hospitalar de Emergência/estatística & dados numéricos , Serviços de Saúde para Idosos/estatística & dados numéricos , Transporte de Pacientes/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Masculino , North Carolina/epidemiologia , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos
13.
Prehosp Emerg Care ; 21(5): 605-609, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28481669

RESUMO

OBJECTIVE: The optimal resuscitation approach during the initial treatment of hypotensive trauma patients remains unknown, but some clinical trials have observed a survival benefit from restricting fluid administration prior to definitive hemorrhage control. We sought to characterize emergency medical services (EMS) protocols for the administration of intravenous fluids in this setting. METHODS: Publicly accessible statewide EMS protocols for the treatment of hypotensive trauma patients were included and characterized by: 1) goal of fluid administration, 2) dosing strategy, 3) maximum dose, 4) type of fluid, and 5) specific protocols for head trauma, if present. RESULTS: Of the 27 states with a publicly available, statewide protocol, 21 have a numeric systolic blood pressure (SBP) target for resuscitation. Of these, 16 describe a goal of maintaining SBP ≥90 mmHg with or without additional goals, three specify a goal that is less than 90 mmHg, and two specify a goal ≥100 mHg. Dosing strategies also vary and include both standard bolus strategies (200 mL, 250 mL, 500 mL, and 1 L with repeat) as well as weight-based strategies (20 mL/kg). Nine states specify a maximum dose of 2 L without medical control. Fifteen protocols recommend the use of normal saline, 1 recommends the use of lactated Ringer's, and 11 recommend the use of either normal saline or lactated Ringer's. Nine states have distinct protocols for patients with head trauma, all of which indicate maintaining a higher SBP than for trauma patients without head trauma. CONCLUSION: State EMS protocols for fluid administration for hypotensive trauma patients vary in regard to SBP goal, fluid dose, and fluid type. Clinical trials to determine the optimal use of intravenous fluids for hypotensive trauma patients are needed to define the optimal approach.


Assuntos
Serviços Médicos de Emergência/métodos , Hidratação/métodos , Hipotensão/terapia , Ferimentos e Lesões/terapia , Pressão Sanguínea , Estudos Transversais , Humanos , Hipotensão/etiologia , Ressuscitação/métodos , Inquéritos e Questionários , Ferimentos e Lesões/complicações
14.
Prehosp Emerg Care ; 21(5): 591-604, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28422541

RESUMO

OBJECTIVE: Timely triage and appropriate destination decision making for injured patients are central challenges faced by emergency medical services (EMS) systems. In 2010, North Carolina (NC) adopted a statewide Trauma Triage and Destination Plan (TTDP) based on the CDC's Field Triage Guidelines to better address these challenges. We sought to characterize the implementation of these guidelines by quantifying their effect on multiple metrics of patient care. METHODS: We employed a retrospective pre-post study design utilizing a statewide EMS medical record database. We assessed several metrics of patient care-including changes in destination choice, appropriateness of EMS destination, transit time to first hospital, transit time to definitive care, and others-in a six-month period in the year before and after the implementation of the guidelines. RESULTS: We evaluated a total of 190,307 EMS encounters pre- (n = 93,927) and post-implementation (n = 96,380). Among all patients, there was not a significant difference in the percentage transported to a community hospital or Level I, II, or III trauma center as their first destination. Among those patients meeting TTDP guidelines for transport to a trauma center, the number transported to a Level I or II trauma center decreased 1.0% from 30.6% (n = 2,911) to 29.6% (n = 2,954) (95% CI: -0.2%, 2.2%). Those transported to a Level I trauma center decreased 0.4% from 21.2% to 20.8% in the post-period (95% CI: -0.7%, 1.5%). There were also no significant changes in EMS scene times (14.0 pre-, 14.1 post-) and transport times (12.9 pre-, 13.0 post-). While scene distance from a Level I trauma center showed a decreased likelihood of transport to that center, there was an overall post-implementation increase of 2.5% from 18.0% to 20.5% (95% CI: -3.6%, -1.3%) in transport to a Level I trauma center among patients meeting anatomic criteria across all distance ranges. CONCLUSIONS: We found that implementation of region-specific destination plans based on the Field Triage Guidelines had little effect on selected hospital destination, scene times, transport times, and other metrics of EMS decision making and effectiveness. We suspect this is due to delays in information dissemination and adoption by field providers.


Assuntos
Fidelidade a Diretrizes/estatística & dados numéricos , Assistência ao Paciente/estatística & dados numéricos , Triagem/normas , Ferimentos e Lesões/terapia , Adolescente , Adulto , Idoso , Criança , Bases de Dados Factuais , Tomada de Decisões , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , North Carolina , Avaliação de Resultados em Cuidados de Saúde , Assistência ao Paciente/métodos , Estudos Retrospectivos , Tempo para o Tratamento/estatística & dados numéricos , Transporte de Pacientes/estatística & dados numéricos , Centros de Traumatologia , Triagem/estatística & dados numéricos , Adulto Jovem
16.
J Health Commun ; 20(5): 539-45, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25807061

RESUMO

Measuring health literacy efficiently yet accurately is of interest both clinically and in research. The authors examined 6 brief health literacy measures and compared their categorization of patient health literacy levels and their comparative associations with patients' health status. The authors assessed 400 emergency department patients with the Short Test of Functional Health Literacy in Adults, the Newest Vital Sign, Single Item Literacy Screen, brief screening questions, Rapid Estimate of Adult Literacy in Medicine-Revised, and the Medical Term Recognition Test. The authors analyzed data using Spearman's correlation coefficients and ran separate logistic regressions for each instrument for patient self-reported health status. Tests differed in the proportion of patients' skills classified as adequate, but all instruments were significantly correlated; instruments targeting similar skills were more strongly correlated. Scoring poorly on any instrument was significantly associated with worse health status after adjusting for age, sex and race, with a score in the combined inadequate/marginal category on the Short Test of Functional Health Literacy in Adults carrying the largest risk (OR = 2.94, 95% CI [1.23, 7.05]). Future research will need to further elaborate instrument differences in predicting different outcomes.


Assuntos
Serviço Hospitalar de Emergência , Letramento em Saúde , Programas de Rastreamento/métodos , Adulto , Feminino , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos Testes , Sudeste dos Estados Unidos
17.
Prehosp Emerg Care ; 19(1): 53-60, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-24878396

RESUMO

Abstract Objective. Planning for time-sensitive injury may allow emergency medical services (EMS) systems to more accurately triage patients meeting accepted criteria to facilities most capable of providing life-saving treatment. In 2010, North Carolina (NC) implemented statewide Trauma Triage and Destination Plans (TTDPs) in all 100 of North Carolina's county-defined EMS systems. Each system was responsible for identifying the specific destination hospitals with appropriate resources to treat trauma patients. We sought to characterize the accuracy of their hospital designations. Methods. In this cross-sectional study, we collected TTDPs for each county-defined EMS system, including their assigned hospital capabilities (i.e., trauma center or community hospital). We conducted a survey with each EMS system to determine how their TTDP was constructed and maintained, as well as with each TTDP-designated hospital to verify their capabilities. We determined the accuracy of the EMS assigned hospital designations by comparing them to the hospital's reported capabilities. Results. The 100 NC EMS systems provided 380 designations for 112 hospitals. TTDPs were created by EMS administrators and medical directors, with only 55% of EMS systems engaging a hospital representative in the plan creation. Compared to the actual hospital capabilities, 97% of the EMS TTDP designations were correct. Twelve hospital designations were incorrect and the majority (10) overestimated hospital capabilities. Of the 100 EMS systems, 7 misclassified hospitals in their TTDP. EMS systems that did not verify their local hospitals' capabilities during TTDP development were more likely to incorrectly categorize a hospital's capabilities (p = 0.001). Conclusions. A small number of EMS systems misclassified hospitals in their TTDP, but most plans accurately reflected hospital capabilities. Misclassification occurred more often in systems that did not consult local hospitals prior to developing their TTDP. The potential of the TTDP to improve communication between EMS agencies and the facilities with which they work has not been fully realized. EMS agencies or systems should verify local hospital capabilities when engaging in destination planning efforts.

18.
Prehosp Emerg Care ; 19(2): 247-53, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25289878

RESUMO

BACKGROUND: While large-scale disasters are uncommon, our society relies on emergency personnel to be available to respond and act. Faith in their availability may lead to a false sense of security. Many emergency personnel obligate themselves to more than one agency and so may be overcommitted, leaving agencies with unfilled positions in a disaster. We sought to describe the frequency of overcommitment of emergency medical services (EMS) personnel in North Carolina. METHODS: We conducted a cross-sectional study utilizing the Credentialing Information System (CIS) of the North Carolina Office of EMS. The CIS database manages demographic and certification information for all EMS personnel in North Carolina. The state is divided into 100 EMS systems based on county boundaries. Utilizing de-identified provider data from the CIS, we collected system(s) affiliation(s) and level of certification. To calculate an overcommitment rate per system, we divided the number of personnel with more than one system affiliation by total number of system roster personnel. To compare urbanicity and certification level with overcommitment, analysis of variance and the chi-square test were used, respectively. RESULTS: North Carolina credentials 14,717 EMS providers (8,346 EMT, 1,709 EMT-intermediate (EMT-I), 4,662 EMT-paramedic (EMT-P)). Of these, 10,928 (74%) are affiliated with a single system. Of the 3,789 committed to more than one system, 3,020 (21%) were committed to two systems, 571 (4%) to three, 138 (1%) to four, and 60 (<1%) to five or more. EMT-Is and EMT-Ps were more likely to be overcommitted when compared to EMTs (37, 32, 20% respectively, p < 0.0001). Statewide, the median overcommitment rate for EMS systems was 24% (IQR 16-37%). Personnel working in systems servicing less densely populated areas were more likely to be overcommitted: 33% wilderness, 29% rural, 20% suburban and 11% urban (p < 0.0001). Additionally, 40% wilderness, 23% rural, 4% suburban, and 0% urban systems had >37% of their personnel engaged in 9-1-1 response in more than one system. CONCLUSION: Many EMS personnel have multiple EMS commitments. Disaster planners and emergency managers should consider overcommitment of emergency responders when calculating the work force on which they can rely.


Assuntos
Planejamento em Desastres , Serviços Médicos de Emergência , Auxiliares de Emergência , Sistemas de Informação , Certificação , Estudos Transversais , Humanos , North Carolina
19.
J Emerg Med ; 48(2): 230-8, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25456778

RESUMO

BACKGROUND: The collection of a complete, verified medication history is essential to patient safety. The involvement of clinical pharmacists has been shown to improve the completeness and accuracy of medication histories; however, to our knowledge, involvement of pharmacy technicians has not been studied. OBJECTIVE: Our aim was to determine whether verification of medication histories by pharmacy technicians in the emergency department (ED) would result in fewer errors in inpatient medication regimens compared to verification by the admitting physician team. METHODS: We performed a prospective cohort study of adult ED patients admitted for continuing care. In the intervention group, medication reconciliation was performed by pharmacy technicians in the ED before the creation of physician admitting orders. In the control group, pharmacy technicians conducted their history taking later, after admission. Initial admitting orders were then compared to the pharmacy technicians' medication reconciliation taken before admission (intervention group) or after admission (control group). Medication discrepancies were classified and determined to be justified or unjustified. Unjustified discrepancies were rated for harm potential. RESULTS: In our cohort of 113 intervention and 75 control subjects, the mean age was 55 years (standard deviation [SD] 16 years); 96 patients (51%) were male. In the intervention group, 566 changes to home medications were observed on admission; 352 (62%) were unjustified. Among controls, 406 changes to home medications were observed; 228 (56%) were unjustified. This difference was not statistically significant (p = 0.0586). The rate of unjustified medication changes per patient was likewise not significantly different (3.14 [SD 2.98] in interventions vs. 3.17 [SD 2.81] in controls; p = 0.9570). The rate of medical errors did not differ between study groups, nor did severity ratings of unjustified changes. CONCLUSIONS: Medication reconciliation by pharmacy technicians in the ED did not lead to a significant reduction in unjustified medication discrepancies.


Assuntos
Serviço Hospitalar de Emergência , Erros de Medicação/prevenção & controle , Reconciliação de Medicamentos/organização & administração , Serviço de Farmácia Hospitalar/organização & administração , Adulto , Idoso , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente , Estudos Prospectivos
20.
J Stroke Cerebrovasc Dis ; 23(10): 2800-2808, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25294057

RESUMO

BACKGROUND: Our goal was to determine if a statewide Emergency Medical Services (EMSs) Stroke Triage and Destination Plan (STDP), specifying bypass of hospitals unable to routinely treat stroke patients with thrombolytics (community hospitals), changed bypass frequency of those hospitals. METHODS: Using a statewide EMS database, we identified stroke patients eligible for community hospital bypass and compared bypass frequency 1-year before and after STDP implementation. RESULTS: Symptom onset time was missing for 48% of pre-STDP (n = 2385) and 29% of post-STDP (n = 1612) cases. Of the remaining cases with geocodable scene addresses, 58% (1301) in the pre-STDP group and 61% (2,078) in the post-STDP group were ineligible for bypass, because a community hospital was not the closest hospital to the stroke event location. Because of missing data records for some EMS agencies in 1 or both study periods, we included EMS agencies from only 49 of 100 North Carolina counties in our analysis. Additionally, we found conflicting hospital classifications by different EMS agencies for 35% of all hospitals (n = 38 of 108). Given these limitations, we found similar community hospital bypass rates before and after STDP implementation (64%, n = 332 of 520 vs. 63%, n = 345 of 552; P = .65). CONCLUSIONS: Missing symptom duration time and data records in our state's EMS data system, along with conflicting hospital classifications between EMS agencies limit the ability to study statewide stroke routing protocols. Bypass policies may apply to a minority of patients because a community hospital is not the closest hospital to most stroke events. Given these limitations, we found no difference in community hospital bypass rates after implementation of the STDP.


Assuntos
Área Programática de Saúde , Serviços Médicos de Emergência/organização & administração , Sistemas de Informação Geográfica , Acesso aos Serviços de Saúde/organização & administração , Hospitais Comunitários , Regionalização da Saúde/organização & administração , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Transporte de Pacientes/organização & administração , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , North Carolina , Avaliação de Programas e Projetos de Saúde , Acidente Vascular Cerebral/diagnóstico , Tempo para o Tratamento/organização & administração , Resultado do Tratamento , Triagem/organização & administração
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