Knowledge and attitudes of the out-of-hospital emergency care consumers in Santo Domingo, Dominican Republic.

INTRODUCTION: Prehospital emergency services are a vital public service, and consumer access to the system is an important factor in their use. The Dominican Republic recently experienced "the epidemiological transition" leading to increased morbidity and mortality secondary to traumatic and cardiac conditions--thus, increasing the need for prompt and adequate delivery of emergency medical care. METHODS: A survey was administered to 90 subjects from diverse backgrounds, all living in Santo Domingo. Survey items included questions on emergency medical services (EMS) systems knowledge (i.e., access numbers), confidence in the system, first-aid education and prior experience with the EMS system. Chi-square was used to measure statistical significance for categorical variables and Student's t-test for continuous variables (JMP 2.0 software was used for statistical processing). RESULTS: A total of 90 subjects were surveyed. The average age of respondents was 36 +/- 12 years SD. More than one-fifth (22.2%) of respondents did not know the established universal emergency number (9-1-1), and 37.8% responded that they would access a different telephone number in case of a medical emergency. CONCLUSIONS: Important deficiencies and access-to-care concerns were interpreted from the results. An adequate understanding of the current state of prehospital care could lead to creation of policies by system administrators to further improve the delivery of emergency medical care. This study will assist system administrators in future design and policy issues.

Receiving care facility and outcome differences for victims of severe violent injuries.

OBJECTIVE: Each year millions of people die resulting from violence. Our objective was to evaluate and describe the demographic characteristics, access to trauma center care, mortality and morbidity outcomes of victims of severe violence in Pennsylvania. METHODS: This was a cross-sectional population-based observational study. ICD-9-CM diagnostic codes were utilized to define acute injuries; severe injury was defined by an Injury Severity Score (ISS) greater than 15. Descriptive statistics and confidence intervals were used to present group characteristics. For categorical variables, chi-square testing and Fisher's exact testing were used to assess associations, and the Odds Ratio was used as the measure of strength of association. For all tests statistical significance was set at the 0.05 level. RESULTS: A total of 8,977 patients with ISS > 15 were included; out of which 663 cases resulted from violence. Three hundred and forty seven (52.3%) were admitted to non-trauma center hospitals (NTC); Three hundred-and-sixteen (47.7%) to trauma center hospitals (TC). Mean length of stay and the rate of complications were significantly greater in the NTC facilities (p = 0.001 and 0.003, respectively) and a higher but statistically nonsignificant mortality increase was found in non-trauma centers (10.4% vs. 15.2%). CONCLUSION: Despite statewide EMS and trauma care systems, half of severely injured victims of violence were cared for in NTC facilities. TC hospitals showed a small but significant outcomes benefit in terms of complications and lengths of stay.

Predictive effect of out-of-hospital time in outcomes of severely injured young adult and elderly patients.

INTRODUCTION: The importance of accessing care within the first hour after injury has been a fundamental tenet of trauma system planning for 30 years. However, the scientific basis for this belief either has been missing or largely derived from case series from trauma centers. This study sought to determine the correlation between prehospital times and outcomes among severely injured elderly patients. METHODS: This is a cross-sectional, observational study. All adults (> or = 18 years of age) with acute trauma as defined by The International Classification of Diseases Ninth Edition, Clinical Modification diagnostic codes and E-codes were included. Poisonings, single system burns, and late effects of injury were excluded. Chi-square and Student's t-test were used for significance testing. To assess the predictive effects of prehospital time and outcomes, three independent logistic regression models were constructed for both young and elderly groups, with hospital length of stay, mortality, and complications as individual dependent variables. Statistical significance was set at the 0.05 level. RESULTS: Of 41,041 cases, 37,276 were > or = 18 years of age. Of the 1,866 with an Injury Severity Score (ISS) > 15, 1,205 were young and 661 elderly. Logistic regression results showed that prehospital time correlated significantly with hospital length of stay (p = 0.001) and complications (p = 0.016), but not with mortality (p = 0.264) among young patients, whereas in the elderly group pre-hospital time had no significant predictive effect for length of stay, complications, or mortality (p = 0.512, p = 0.512, and p = 0.954 respectively). CONCLUSION: This population-based study has demonstrated that prehospital time correlates with length of stay and complications in young patients. In elderly patients, prehospital time failed to show correlation with any outcomes measured.

Hypersensitivity reactions and deaths associated with intravenous iron preparations.

BACKGROUND: Parenteral iron therapy is an accepted adjunctive management of anaemia in kidney disease. Newer agents may have fewer severe hypersensitivity adverse events (AE) compared with iron dextrans (ID). The rate of type 1 AE to iron sucrose (IS) and sodium ferric gluconate (SFG) relative to ID is unclear. We used the US Food and Drug Administration's Freedom of Information (FOI) surveillance database to compare the type 1 AE profiles for the three intravenous iron preparations available in the United States. METHODS: We tabulated reports received by the FOI database between January 1997 and September 2002, and calculated 100 mg dose equivalents for the treated population for each agent. We developed four clinical categories describing hypersensitivity AE (anaphylaxis, anaphylactoid reaction, urticaria and angioedema) and an algorithm describing anaphylaxis, for specific analyses. RESULTS: All-event reporting rates were 29.2, 10.5 and 4.2 reports/million 100 mg dose equivalents, while all-fatal-event reporting rates were 1.4, 0.6 and 0.0 reports/million 100 mg dose equivalents for ID, SFG and IS, respectively. ID had the highest reporting rates in all four clinical categories and the anaphylaxis algorithm. SFG had intermediate reporting rates for urticaria, anaphylactoid reaction and the anaphylaxis algorithm, and a zero reporting rate for the anaphylaxis clinical category. IS had either the lowest or a zero reporting rate in all clinical categories/algorithm. CONCLUSIONS: These findings confirm a higher risk for AE, especially serious type 1 reactions, with ID therapy than with newer intravenous iron products and also suggest that IS carries the lowest risk for hypersensitivity reactions.

Design of a questionnaire to measure trust in an emergency department.

OBJECTIVE: To develop a valid and reliable questionnaire for measuring patient trust in an emergency department (ED) that can be administered by phone, direct interview, or mail. METHODS: This was a survey conducted at a Level 1 urban trauma center with an annual census of 52,000 visits. Literature review, focus group discussions, and direct patient interviews identified potential items for pilot surveys. Fifteen ED nurses, residents, and faculty scored the items on a 1-10 scale, rephrasing or removing ambiguous items to ensure face and content validity. A telephone survey with responses recorded on a five-point Likert scale was conducted. Reliability and internal consistency of items were tested using SPSS software. Factor analyses were performed using principal components analysis and Varimax rotation with Eigen values set at 1.0. RESULTS: A total of 383 patients seen in the ED were surveyed. Using two pilot surveys, 18 of 42 potential items were extracted among five factors identified as important to the development of trust. Internal consistency for the final 18 items was calculated, and a Cronbach's alpha of 0.88 was obtained for all items. Test-retest reliability was calculated by telephoning 38 patients twice, two weeks apart, and correlation coefficients of >0.748 were obtained for all items. CONCLUSIONS: This questionnaire can be used for telephone or direct interview to survey patients' trust in EDs.

System compliance with out-of-hospital trauma triage criteria.

BACKGROUND: Emergency Medical Services (EMS) providers are the initial link to a trauma care system. Previous studies have demonstrated poor compliance with trauma triage by EMS personnel. We sought to determine the proportion of adult EMS cases within a large state meeting Trauma Triage Criteria (TTC) who are ultimately cared for in trauma centers. METHODS: Merged EMS and hospital discharge records for 1996 were examined. All adult acute trauma cases were included. Single-system burns and late effects of injury were excluded. RESULTS: Nine thousand one hundred seventy-four adult cases had at least one TTC, and 60.1% of these patients were transported to a non-trauma center (NTC) and 74.6% of cases with an Injury Severity Score > 15 and one TTC were taken to trauma centers. Analyzing two large urban counties, 58.2% and 27.0% of all TTC cases were still taken to NTC hospitals. CONCLUSION: A significant proportion of seriously injured patients meeting TTC were transported by EMS personnel to NTCs.

Effectiveness of a Glasgow Coma Scale instructional video for EMS providers.

INTRODUCTION: The Glasgow Coma Scale (GCS) is the standard measure used to quantify the level of consciousness of patients who have sustained head injuries. Rapid and accurate GCS scoring is essential. OBJECTIVE: To evaluate the effectiveness of a GCS teaching video shown to prehospital emergency medical services (EMS) providers. METHODS: Participants and setting--United States, Mid-Atlantic region EMS providers. Intervention--Each participant scored all of the three components of the GCS for each of four scenarios provided before and after viewing a video-tape recording containing four scenarios. Design--Before-and-after single (Phase I) and parallel Cohort (Phase II). Analysis--Proportions of correct scores were compared using chi-square, and relative risk was calculated to measure the strength of the association. RESULTS: 75 participants were included in Phase I. In Phase II, 46 participants participated in a parallel cohort design: 20 used GCS reference cards and 26 did not use the cards. Before observing the instructional video, only 14.7% score all of the scenarios correctly, where as after viewing the video, 64.0% scored the scenarios results were observed after viewing the video for those who used the GCS cards (p = 0.001; RR = 2.0; 95% CI = 1.29 to 3.10) than for those not using the cards (p < 0.0001; RR = 10.0; 95% CI = 2.60 to 38.50). CONCLUSIONS: Post-video viewing scores were better than those observed before the video presentation. Ongoing evaluations include analysis of long-term skill retention and scoring accuracy in the clinical environment.