Individual and household influences on food security and dietary diversity in seven Dominican batey communities.

BACKGROUND: To identify individual and household characteristics associated with food security and dietary diversity in seven Haitian-Dominican bateyes. METHODS: A cross-sectional sample of 667 households were surveyed. Novel household food security scores were calculated from components of the Household Food Insecurity Assessment Scale, while the Food and Agricultural Organization's Household Dietary Diversity Score was utilized to calculate individual dietary diversity scores. Multivariable analyses were performed using ordinal logistic regression models to estimate the association between these scores and the covariate variables. Secondary dietary diversity analyses were performed after removing non-nutritious food groups. RESULTS: Food security was significantly associated with being above the poverty line (OR 3.14, 95% CI 1.92 to 5.14), living in a rural batey (OR 1.44, 95% CI 1.02 to 2.03), receiving gifts and/or donations (OR 1.76, 95% CI 1.03 to 3.00) and having a salaried job (i.e., not being paid hourly; OR 1.67, 95% CI 1.05 to 2.64). Dietary diversity was significantly associated with living in a semi-urban batey (OR 1.70, 95% CI 1.26 to 2.30), living with a partner (OR 1.47, 95% CI 1.08 to 2.00), growing at least some of one's own food (OR 1.62, 95% CI 1.17 to 2.23), and receiving gifts and/or donations (OR 1.72, 95% CI 1.08 to 2.73). CONCLUSIONS: Food insecurity and low dietary diversity are highly prevalent in Haitian-Dominican bateyes. The inclusion of sweets and non-milk beverages in dietary diversity calculations appear to skew scores towards higher levels of diversity, despite limited nutritional gains.

Public Health Rationale for Investments in Emergency Medicine in Developing Countries - Ghana as a Case Study.

BACKGROUND: Ghana is a developing country that has strategically invested in expanding emergency care services as a means of improving national health outcomes. OBJECTIVES: Here we present Ghana as a case study for investing in emergency care to achieve public health benefits that fuel for national development. DISCUSSION: Ghana's health leadership has affirmed emergency care as a necessary adjunct to its preexisting primary health care model. Historically, developing countries prioritize primary care efforts and outpatient clinic-based health care models. Ghana has added emergency medicine infrastructure to its health care system in an effort to address the ongoing shift in disease epidemiology as the population urbanizes, mobilizes, and ages. Ghana's investments include prehospital care, personnel training, health care resource provision, communication improvements, transportation services, and new health facilities. This is in addition to re-educating frontline health care providers and developing infrastructure for specialist training. Change was fueled by public support, partnerships between international organizations and domestic stakeholders, and several individual champions. CONCLUSION: Emergency medicine as a horizontal component of low- to middle-income countries' health systems may fuel national health and economic development. Ghana's experience may serve as a model.

Epidemiology and mapping of serious and fatal road traffic injuries in Guyana: results from a cross-sectional study.

OBJECTIVE: To describe the epidemiology of Guyana's road traffic injuries and perform the first geocoding of road traffic injuries in this setting. METHODS: This was a registry-based retrospective cross-sectional study investigating collisions resulting in serious and fatal injuries. Police reports from two police divisions were used to identify victim, second party (ie, non-victim) and collision characteristics of all serious and fatal collisions between January 2012 and June 2015. Collisions with available location data were geocoded using Geographic Information Systems. Distributions of characteristics were compared for urban and rural areas. Multivariable logistic regression was used to assess variables associated with fatal collisions. RESULTS: The study included 751 collisions, resulting in 1002 seriously or fatally injured victims. Fatally injured victims tended to be older, male and either pedestrians or cyclists. Fatal collisions tended to take place in rural areas, occur on weekends and involve speeding. Fifty-three per cent of fatalities occurred due to non-motorised road users being struck by motorised road users, and the most common fatal collision type was between pedestrians and motor vehicles (35%). The distribution of collisions was similar for urban (43.8%) and rural (56.2%) areas. Fatal collisions were more likely to occur in rural settings. CONCLUSIONS: Road traffic injuries pose a considerable public health burden in Guyana. These results suggest a pattern of high mortality in rural collisions and a disproportionate burden of injuries on vulnerable road users. The spatial distribution of collisions should be considered in order to target interventions and improve road traffic safety.

Acute Coronary Syndrome Screening and Diagnostic Practice Variation.

BACKGROUND: In the absence of the existing acute coronary syndrome (ACS) guidelines directing the clinical practice implementation of emergency department (ED) screening and diagnosis, there is variable screening and diagnostic clinical practice across ED facilities. This practice diversity may be warranted. Understanding the variability may identify opportunities for more consistent practice. METHODS: This is a cross-sectional clinical practice epidemiology study with the ED as the unit of analysis characterizing variability in the ACS evaluation across 62 diverse EDs. We explored three domains of screening and diagnostic practice: 1) variability in criteria used by EDs to identify patients for an early electrocardiogram (ECG) to diagnose ST-elevation myocardial infarction (STEMI), 2) nonuniform troponin biomarker and formalized pre-troponin risk stratification use for the diagnosis of non-ST-elevation myocardial infarction (NSTEMI), and 3) variation in the use of noninvasive testing (NIVT) to identify obstructive coronary artery disease or detect inducible ischemia. RESULTS: We found that 85% of EDs utilize a formal triage protocol to screen patients for an early ECG to diagnose STEMI. Of these, 17% use chest pain as the sole criteria. For the diagnosis of NSTEMI, 58% use intervals ≥4 hours for a second troponin and 34% routinely risk stratify before troponin testing. For the diagnosis of noninfarction ischemia, the median percentage of patients who have NIVT performed during their ED visit is 5%. The median percentage of patients referred for NIVT in hospital (observation or admission) is 61%. Coronary CT angiography is used in 66% of EDs. Exercise treadmill testing is the most frequently reported first-line NIVT (42%). CONCLUSION: Our results suggest highly variable ACS screening and clinical practice.

Performance of Emergency Department Screening Criteria for an Early ECG to Identify ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Timely diagnosis of ST-segment elevation myocardial infarction (STEMI) in the emergency department (ED) is made solely by ECG. Obtaining this test within 10 minutes of ED arrival is critical to achieving the best outcomes. We investigated variability in the timely identification of STEMI across institutions and whether performance variation was associated with the ED characteristics, the comprehensiveness of screening criteria, and the STEMI screening processes. METHODS AND RESULTS: We examined STEMI screening performance in 7 EDs, with the missed case rate (MCR) as our primary end point. The MCR is the proportion of primarily screened ED patients diagnosed with STEMI who did not receive an ECG within 15 minutes of ED arrival. STEMI was defined by hospital discharge diagnosis. Relationships between the MCR and ED characteristics, screening criteria, and STEMI screening processes were assessed, along with differences in door-to-ECG times for captured versus missed patients. The overall MCR for all 7 EDs was 12.8%. The lowest and highest MCRs were 3.4% and 32.6%, respectively. The mean difference in door-to-ECG times for captured and missed patients was 31 minutes, with a range of 14 to 80 minutes of additional myocardial ischemia time for missed cases. The prevalence of primarily screened ED STEMIs was 0.09%. EDs with the greatest informedness (sensitivity+specificity-1) demonstrated superior performance across all other screening measures. CONCLUSIONS: The 29.2% difference in MCRs between the highest and lowest performing EDs demonstrates room for improving timely STEMI identification among primarily screened ED patients. The MCR and informedness can be used to compare screening across EDs and to understand variable performance.

Extravasation Risk Using Ultrasound-guided Peripheral Intravenous Catheters for Computed Tomography Contrast Administration.

OBJECTIVE: Ultrasound-guided intravenous catheter (USGIV) insertion is increasingly being used for administration of intravenous (IV) contrast for computed tomography (CT) scans. The goal of this investigation was to evaluate the risk of contrast extravasation among patients receiving contrast through USGIV catheters. METHODS: A retrospective observational study of adult patients who underwent a contrast-enhanced CT scan at a tertiary care emergency department during a recent 64-month period was conducted. The unadjusted prevalence of contrast extravasation was compared between patients with an USGIV and those with a standard peripheral IV inserted without ultrasound. Then, a two-stage sampling design was used to select a subset of the population for a multivariable logistic regression model evaluating USGIVs as a risk factor for extravasation while adjusting for potential confounders. RESULTS: In total, 40,143 patients underwent a contrasted CT scan, including 364 (0.9%) who had contrast administered through an USGIV. Unadjusted prevalence of extravasation was 3.6% for contrast administration through USGIVs and 0.3% for standard IVs (relative risk = 13.9, 95% confidence interval [CI] = 7.9 to 24.6). After potential confounders were adjusted for, CT contrast administered through USGIVs was associated with extravasation (adjusted odds ratio = 8.6, 95% CI = 4.6 to 16.2). No patients required surgical management for contrast extravasation; one patient in the standard IV group was admitted for observation due to extravasation. CONCLUSIONS: Patients who received contrast for a CT scan through an USGIV had a higher risk of extravasation than those who received contrast through a standard peripheral IV. Clinicians should consider this extravasation risk when weighing the risks and benefits of a contrast-enhanced CT scan in a patient with USGIV vascular access.

Implementing Data Definition Consistency for Emergency Department Operations Benchmarking and Research.

OBJECTIVES: The objective was to obtain a commitment to adopt a common set of definitions for emergency department (ED) demographic, clinical process, and performance metrics among the ED Benchmarking Alliance (EDBA), ED Operations Study Group (EDOSG), and Academy of Academic Administrators of Emergency Medicine (AAAEM) by 2017. METHODS: A retrospective cross-sectional analysis of available data from three ED operations benchmarking organizations supported a negotiation to use a set of common metrics with identical definitions. During a 1.5-day meeting-structured according to social change theories of information exchange, self-interest, and interdependence-common definitions were identified and negotiated using the EDBA's published definitions as a start for discussion. Methods of process analysis theory were used in the 8 weeks following the meeting to achieve official consensus on definitions. These two lists were submitted to the organizations' leadership for implementation approval. RESULTS: A total of 374 unique measures were identified, of which 57 (15%) were shared by at least two organizations. Fourteen (4%) were common to all three organizations. In addition to agreement on definitions for the 14 measures used by all three organizations, agreement was reached on universal definitions for 17 of the 57 measures shared by at least two organizations. The negotiation outcome was a list of 31 measures with universal definitions to be adopted by each organization by 2017. CONCLUSION: The use of negotiation, social change, and process analysis theories achieved the adoption of universal definitions among the EDBA, EDOSG, and AAAEM. This will impact performance benchmarking for nearly half of US EDs. It initiates a formal commitment to utilize standardized metrics, and it transitions consistency in reporting ED operations metrics from consensus to implementation. This work advances our ability to more accurately characterize variation in ED care delivery models, resource utilization, and performance. In addition, it permits future aggregation of these three data sets, thus facilitating the creation of more robust ED operations research data sets unified by a universal language. Negotiation, social change, and process analysis principles can be used to advance the adoption of additional definitions.