Implementing real-time system interfaces to support the shared care of diabetes patients.

This paper describes a collaborative project: the Medway Integrated Care Support (MEDICS) Project, involving GP and Hospital system suppliers, an NHS Trust, General Practitioners and the NHS Information Authority. The objective of the project is to assess the Object Management Group's (OMG/CORBAMed) Clinical Observations Access Service (COAS) standard, by demonstrating its use in implementing a real-time interface between a GP system and a hospital clinical system, supporting the shared care of diabetes patient.

A statewide study of EMS oversight: medical director characteristics and involvement compared with national guidelines.

INTRODUCTION: From their inception, advanced life support (ALS) programs have had oversight by emergency medical services (EMS) medical directors. Position statements about medical direction have been published in the medical literature, initially by the American College of Emergency Physicians (ACEP). Most recently, the National Association of EMS Physicians (NAEMSP) published a position paper to serve as a guideline for the medical directors' tasks, describing qualifications and areas of involvement. OBJECTIVE: To study the baseline status of EMS oversight in Maryland as the position paper was disseminated, to view how local directors meet the published guidelines. METHODS: Twenty-two of the 23 (96%) jurisdictional EMS medical directors (JMDs) in Maryland were interviewed in face-to-face meetings. Information was collected about their qualifications and their regular involvement in activities within various EMS subsystems. RESULTS: Sixteen (73%) JMDs are members of ACEP and four (18%) are members of NAEMSP. Six (27%) received EMS medical director training. Three (14%) went through a formal application process for their positions. Activities of relatively high involvement were investigations of variance from protocols (100% of JMDs involved), runsheet review (15 [68%]), liaison duties (20 [91%]), and disaster drills (15 [68%]). Most other subsystems, including dispatch, public health, administration, system evaluation, and quality programs, showed relatively low regular involvement (0-59%). CONCLUSION: In Maryland, significant increases in active physician involvement in EMS are necessary to meet the national job description. These data provide supportive evidence of the need for further commitment by state and local agencies, as well as trained EMS physicians in national societies, to enable all JMDs to reach the goals set forth for their important roles in EMS systems.

Change the scope of practice of paramedics? An EMS/public health policy perspective.

OBJECTIVE: To analyze the potential for expanding the scope of practice of paramedics from public health, health planning, and health policy perspectives, utilizing data covering more than 42,000 emergency patients. METHODS: The authors conducted a retrospective study of 42,918 patients seen in two Baltimore emergency departments over a six-month period, 5,259 of whom were transported by emergency ambulance. The authors constructed epidemiologic profiles of in-hospital and prehospital patients, and merged ambulance data with discharge diagnoses. RESULTS: The 42,918 patients had a total of 2,118 different discharge diagnoses. The ten most frequent diagnoses of ambulance-transported patients were convulsions, injuries, asthma, congestive heart failure, chest pain, syncope and collapse, otitis media, abdominal pain, cardiac arrest, and respiratory abnormality. The ten most frequent diagnoses for all ED patients were otitis media, asthma, finger and nonspecific injuries, upper respiratory infections, chest pain, bronchitis, pharyngitis, gastroenteritis, nonspecific viral infections, and urinary tract infections. Infections accounted for 31.6% of the top 50% of diagnoses by volume, followed by injuries (24%) and cardiovascular cases (16.5%). However, 26.9% of ED patients received an assessment and diagnosis of general symptoms (no procedure). CONCLUSIONS: The high number of diagnoses and the frequency of infections as a primary complaint in this patient sample reconfirm the primacy of the physician in prioritizing patients and assigning treatment pathways. The authors suggest a methodology that may allow properly trained medics to alter some of their role as physician extenders, but suggest that system planners must first ensure that any changes not reduce the public health benefits that each EMS system already provides.

A medically wise approach to expanding the role of paramedics as physician extenders.

The authors examined a portion of the complex issue of the scope of practice of paramedics in light of the epidemiologic profile of emergency patients seen at two Baltimore hospitals. They suggest that the same approach could and should be used to help decide on the scope of work of prehospital personnel in any jurisdiction. The findings lead the authors to urge caution toward any potential changes to the work done by medics, because of the enormous breadth of presenting patient conditions. The authors suggest that the epidemiologic profile witnessed in Baltimore would require increased direct physician input on patient destination decisions for all medics who would be working under an expanded scope of functions, and the paper suggests a mechanism for accomplishing this goal. Finally, while there may be compelling economic reasons to change what medics do in the field, this article cautions health care managers to design changes, based on solid evidence, that will have a positive public health impact, and then work to evaluate the character of the impact after changes are implemented.

Differences in mortality rates among trauma patients transported by helicopter and ambulance in Maryland.

INTRODUCTION: A comprehensive state-wide emergency medical services and helicopter transport system has been developed in the State of Maryland on the principle that early definitive care improves patient outcomes. The purpose of this study was to determine if empirical data exist to support the theory that air medical transportation services provided by the Maryland State Police (MSP) Aviation Division contribute to an improved trauma patient survival rate in Maryland. METHODS: A retrospective study was conducted on the records of all patients transported by helicopter or ground ambulance and admitted to the R Adams Cowley Shock Trauma Center (STC) of the University of Maryland Medical System. Data were obtained from the Maryland Institute of Emergency Medical Services Systems (MIEMSS) Shock Trauma Clinical Registry for the period January 1988 through July 1995, covering 23,002 patients. Patients included those transported directly from the scene of injury to the STC as well as those from interfacility transfers. All patients were stratified by injury severity and compared by outcome (mortality) using Mantel-Haenszel statistics. RESULTS: During the study period, 11,379 patients were transported by ground and 11,623 were transported by MSP helicopter. The mean Injury Severity Score (ISS) for patients transported by ground was 12.7 (SD = 12.52) and the mean ISS for patients transported by air was 14.6 (SD = 13.42), p < 0.001. Among patients classified as having a high index of injury severity, the mortality rate was lower among those transported by MSP helicopter than among those transported by ambulance. The mortality rate was significantly lower for air transported patient with an ISS higher than 31. CONCLUSION: The State of Maryland has demonstrated a commitment to its citizenry and invested heavily in its public safety air medical service. This study suggests the rapid air transport of victims of traumatic events by specialized personnel in Maryland has a positive effect on the outcome of severely injured patients. Further research is necessary to clarify the causal relationships in order to more fully elucidate the value of this resource.

The efficacy of advanced life support: a review of the literature.

INTRODUCTION: Jurisdictions throughout the United States and some other parts of the world have invested substantial time and resources into creating and sustaining a prehospital advanced life support (ALS) system without knowing whether the efficacy of ALS-level care had been validated scientifically. In recent years, it has become fashionable for speakers before large audiences to declare that there is no scientific evidence for the clinical effectiveness of ALS-level care in the out-of-hospital setting. This study was undertaken to evaluate the evidence that pertains to the efficacy of ALS-level care in the current scientific literature. METHODS: An extensive review of the available literature was accomplished using computerized and manual means to identify all applicable articles from 1966 to October, 1995. Selected articles were read, abstracted, analyzed, and compiled. Each article also was categorized as presenting evidence supporting or refuting the clinical efficacy of ALS-level care, and a list was constructed that pointed to where the preponderance of the evidence lies. RESULTS: Research in this field differs widely in terms of methodological sophistication. Of the 51 articles reviewed, eight concluded that ALS-level care is not any more effective than is basic life support, seven concluded that it is effective in some applications but not for others, and the remainder demonstrated effectiveness. The strongest support for ALS-level care was in the area of responses to victims of cardiac arrest, whereas somewhat more divergent findings related to trauma or non condition-specific studies. CONCLUSIONS: While not unanimous, the predominant finding of recent research into the clinical effectiveness of advanced life support demonstrates improved effectiveness over basic life support for patients with certain pathologies. More outcomes-based research is needed.

Primary care and women physicians.

Primary care is on the minds of many politicians, insurance companies, patients, and physicians who have been involved in the tremendous changes occurring in medical care in the United States. The call for more primary care providers has been almost universal, but attracting physicians into the field has been difficult. In the first part of this article, an overview of the field will be presented, followed by an invitation encouraging more women to enter the field.

Health care personnel in disaster response. Reversible roles or territorial imperatives?

Disasters frequently demand exceptional skills from medical responders. Providers work most efficiently and effectively, however, within the roles and hierarchical structures with which they are familiar. The goal of disaster medical response planners is to assign personnel to roles that are as familiar as possible and to simultaneously enhance flexibility of response to extraordinary circumstances. We have outlined the most common disaster medical response roles and the personnel types that fit most directly as a primary provider within each role. Medics excel in field operations and field care of patients, whereas the training of nurses and physicians makes them the most flexible all-around providers, if specially trained in field emergency care, and the sole providers of definitive care. None of the providers, by virtue of their basic training, is well equipped to manage the public health consequences of disasters, but nurses and physicians should be able to easily move into the role, given appropriate special training. Some of the special courses needed to make medics, nurses, and physicians capable of serving flexible roles already exist; others need to be developed or enhanced.

International health: beyond the year 2000. Project selection. Many needs, few resources.

With the tightening of health budgets in developing countries and aid donor allocations, the question of setting priorities is again at the forefront of policy issues. The luxury of letting a free market in health projects flourish cannot be afforded. This article reviews some of the major proposals for setting such priorities set out in recent years and argues for additional criteria to be applied, as well as the essential role of a new international mechanism to bridge the gap between the world of health research and service needs in the field. With some modest leadership in this area, the 1990s could be a time of major broad-based achievements in international health.

Post-disaster malaria in Costa Rica.

INTRODUCTION: In recent years, controversy has surrounded the issue of whether infectious disease should be considered a serious potential consequence of natural disasters. This article contributes to this debate with evidence of a significant outbreak of malaria in Costa Rica's Atlantic region after the 1991 earthquake and subsequent floods. METHODS: This study is an epidemiologic investigation of the incidence of malaria for the periods of 22 months before the April 1991 Limón earthquake and for 13 months afterward. Data were obtained from the Costa Rican Ministry of Health's malaria control program. RESULTS: Some of the cantons in the region experienced increases in the incidence of malaria as high as 1,600% and 4,700% above the average monthly rate for the preearthquake period (p < or = 0.01). Causal mechanisms are postulated as relating to changes in human behavior (increased exposure to mosquitoes while sleeping outside, and a temporary pause in malaria control activities), changes in the habitat that were beneficial to mosquito breeding (landslide deforestation, river damming, and rerouting), and the floods of August 1991. CONCLUSIONS: It is recommended that there be enhanced awareness of the potential consequences of disaster-wrought environmental changes. Date of Event: 22 April 1991; Type: Earthquake, 7.4 Richter scale; LOCATION: Costa Rica; Number of deaths and casualties: 54 deaths and 505 moderate to severe injuries.

An analysis of prehospital mortality in an earthquake. Disaster Reanimatology Study Group.

INTRODUCTION: Anecdotal observations about prehospital emergency medical care in major natural and human-made disasters, such as earthquakes, have suggested that some injured victims survive the initial impact, but eventually die because of a delay in the application of life-saving medical therapy. METHODS: A multidisciplinary, retrospective structured interview methodology to investigate injury risk factors, and causes and circumstances of prehospital death after major disasters was developed. In this study, a team of United States researchers and Costa Rican health officials conducted a survey of lay survivors and health care professionals who participated in the emergency medical response to the earthquake in Costa Rica on 22 April 1991. RESULTS: Fifty-four deaths occurred prior to hospitalization (crude death rate = 0.4/1,000 population). Seventeen percent of these deaths (9/54) were of casualties who survived the initial impact but died at the scene or during transport. Twenty-two percent (2/9) were judged preventable if earlier emergency medical care had been available. Most injuries and deaths occurred in victims who were inside wooden buildings (p < .01) as opposed to other building types or were pinned by rubble from building collapse. Autopsies performed on a sample of victims showed crush injury to be the predominant cause of death. CONCLUSIONS: A substantial proportion of earthquake mortality in Costa Rica was protracted. Crush injury was the principal mechanism of injury and cause of death. The rapid institution of enhanced prehospital emergency medical services may be associated with a significant life-saving potential in these events.

Post-preparedness medical disaster response in Costa Rica.

INTRODUCTION: The 1991 earthquake in the Limón area of Costa Rica presented the opportunity to examine the effectiveness of a decade of disaster preparedness. HYPOTHESIS: Costa Rica's concentrated work in disaster preparedness would result in significantly better management of the disaster response than was evident in earlier disasters in Guatemala and Nicaragua, where disaster preparedness largely was absent. METHODS: Structured interviews with disaster responders in and outside of government, and with victims and victims' neighbors. Clinical and epidemiologic data were collected through provider agencies and the coroner's office. RESULTS: Medical aspects of the disaster response were effective and well-managed through a network of clinic-based radio communications. Nonmedical aspects showed confusion resulting from: 1) poor government understanding of the roles and responsibilities of the central disaster coordinating agency; and 2) poor extension of disaster preparedness activities to the rural area that was affected by the earthquake. CONCLUSION: To be effective, disaster preparedness activities need to include all levels of government and rural, as well as urban, populations.

Working women at risk. Results from a survey of Hispanic injury patients.

Women experience lower rates of occupational injury than do men in general, but subgroups are at increased risk. Based on the medical records of 2572 injury patients requesting treatment in a Washington, DC, emergency department during a 1991 survey of injured Hispanics, we found that whereas women in general had a low risk of occupational injury. Hispanic women did not realize this protection. All Hispanics were at increased risk of occupational injury, but the relative risk attributable to ethnicity for Hispanic women (3.83; 95% confidence interval, 2.85,5.14) was nearly twice that of the corresponding relative risk suffered by working Hispanic men (2.07; 95% confidence interval, 1.72,2.48). It was also found that whereas, overall, women had a lower risk of assault than did men, relative risks of assault based on sex were the same in the workplace.

A prospective study of giardiasis and water supplies in Colorado.

A prospective study of 484 visitors to Vail and Aspen/Snowmass, Colorado, was conducted to determine the risk of acquiring giardiasis. Of the 259 visitors to Vail, no cases of giardiasis were confirmed and only one of 12 water filtrates were positive for Giardia cysts. Of 225 visitors to Aspen/Snowmass two cases of giardiasis were confirmed and 12 of 20 water filtrates were positive for Giardia cysts. The regular occurrence of Giardia cysts in Aspen and Snowmass water was associated with lower rates of giardiasis acquisition than reported during outbreaks of waterborne giardiasis.

Delayed-impact infectious disease after a natural disaster.

Most recent studies of natural disasters have shown little increase in post-disaster infectious disease. The result has been a de-emphasis of the disease control portion of many disaster relief programs. This study demonstrates a significant increase in four out of the five diseases studied following two hurricanes in the Dominican Republic, with the major impact of the increases coming several months after the disaster. Posited reasons for the increase in infectious diseases are: (a) overcrowding of makeshift refugee centers with insufficient sanitary facilities, and (b) flood-caused water transmission of pathogens.