Evaluation of repatriation parameters: does medical history matter?

BACKGROUND: Aeromedical repatriation of patients is an expanding service due to the growing number of travelers worldwide. Of these repatriated patients, a small number require specialized transportation due to severe medical complications. We evaluated the medical in-flight records of Dutch patients with severe disease or polytrauma who were repatriated by air from 1998 to 2002 via one of the largest Dutch alarm centers. We questioned how this Dutch population of repatriated patients is demographically distributed and whether this population is a priori at high risk for acute medical complications that need specialized medical attention. RESULTS: Seventy-seven of 115 repatriated patients were 50 years and older, of which most were male (73%). Fifty patients had no significant medical history, whereas the remaining 65 patients suffered from comorbidities such as cardiovascular disease or cancer. In patients aged 18 to 49 years, one third of all patients were repatriated due to traumatic fractures. In the older age category, the main reasons for repatriation were cardiopulmonary incidents. There was an equal distribution in the primary medical reason for repatriation as defined by need for trauma/neurological support and ventilation or circulatory support. Of note, 82% of the 65 patients who traveled with a chronic disease condition were repatriated due to worsening of this particular condition. CONCLUSIONS: The present study shows that an aeromedical repatriation service is frequently employed by travelers with a history of chronic disease who develop medical complications. The growing number of repatriated elderly patients and/or patients with preexisting comorbidities requires development of secure pretravel risk assessment and adaptation of the medical service level in foreign countries.

Cost-effectiveness of the SEN-concept: Specialized Emergency Nurses (SEN) treating ankle/foot injuries.

BACKGROUND: Emergency Departments (EDs) are confronted with progressive overcrowding. As a consequence, the workload for ED physicians increases and waiting times go up with the risk of unnecessary complications and patient dissatisfaction. To cope with these problems, Specialized Emergency Nurses (SENs), regular ED-nurses receiving a short, injury-specific course, were trained to assess and treat minor injuries according to a specific protocol. METHODS: An economic evaluation was conducted alongside a randomized controlled trial comparing House Officers (HOs) and SENs in their assessment of ankle and foot injuries. Cost prices were established for all parts of healthcare utilization involved. Total costs of health care utilization were computed per patient in both groups. Cost-effectiveness was investigated by comparing the difference in total cost between groups with the difference in sensitivity and specificity between groups in diagnosing fractures and severe sprains. Finally, cost-effectiveness ratios were calculated and presented on a cost-effectiveness plane. RESULTS: No significant differences were seen between treatment groups for any of the health care resources assessed. However, the waiting times for both first assessment by a treatment officer and time spent waiting between hearing the diagnosis and final treatment were significantly longer in the HO group. There was no statistically significant difference in costs between groups. The total costs were euro 186 (SD euro 623) for patients in the SEN group and euro 153 (SD euro 529) for patients in the HO group. The difference in total costs was euro 33 (95% CI: - euro 84 to euro 155). The incremental cost-effectiveness ratio was euro 27 for a reduction of one missed diagnosis and euro 18 for a reduction of one false negative. CONCLUSION: Considering the benefits of the SEN-concept in terms of decreased workload for the ED physicians, increased patient satisfaction and decreased waiting times, SENs appear to be a useful solution to the problem of ED crowding.

Maximum potential preventive effect of hip protectors.

OBJECTIVES: To estimate the maximum potential preventive effect of hip protectors in older persons living in the community or homes for the elderly. DESIGN: Observational cohort study. SETTING: Emergency departments in the Netherlands. PARTICIPANTS: Hip fracture patients aged 70 and older who visited the emergency departments of five hospitals in the Netherlands (n=520). MEASUREMENTS: Using the risk score of the Dutch Guidelines for Osteoporosis, how many patients had a high risk for fractures was retrospectively assessed. In addition, the circumstances of the hip fracture were assessed (n=299). Four factors were specified that might influence the maximum potential preventive effect of hip protectors: (1) hip fracture occurred in persons having a low risk, (2) hip fracture was not the consequence of a fall, (3) hip fracture occurred during circumstances that preclude the use of hip protectors, and (4) hip fracture occurred during the night. RESULTS: When providing hip protectors to women at high risk of fractures, 48.2% of all hip fractures could have been prevented. CONCLUSION: Many hip fractures occur in persons with a low risk for hip fracture or under circumstances that preclude the use of hip protectors. It was estimated that the maximum potential preventive effect of hip protectors is approximately 50% in older women living in the community or homes for the elderly. The actual preventive effect will be lower and depends on the acceptance and effectiveness of hip protectors and adherence to wearing them.

Specialized emergency nurses treating ankle and foot injuries: a randomized controlled trial.

OBJECTIVE: To cope with emergency departments (EDs) being progressively overcrowded, the concept of specialized emergency nurses (SENs) was conceived. In this study, the ability of SENs to treat ankle/foot injuries was assessed. METHODS: Regular emergency nurses were trained in a 2-day session that addressed all aspects of ankle/foot injuries. A randomized controlled trial was set up in which the diagnostic accuracy of SENs was compared with that of house officers (HOs). Secondary outcome parameter was patient satisfaction measured by a standardized questionnaire. RESULTS: In total, 512 consecutive patients were included. The sensitivity of SENs was 0.94 (95% confidence interval [CI], 0.78-0.99) compared with 0.78 (95% CI, 0.57-0.91) of HOs. Specificity was 0.94 (95% CI, 0.90-0.97) for SENs compared with 0.95 (95% CI, 0.91-0.98) for HOs. The delivered care by SENs was found to be significantly better and the median waiting time at the ED was significantly reduced (21 minutes for SENs vs 32 minutes for HOs). CONCLUSIONS: Specialized emergency nurses are capable of assessing and treating ankle/foot injuries accurately with excellent patient satisfaction and with a reduction of waiting times. Other injury-specific courses are now developed for this approach.

Diagnostic accuracy of lower extremity X-ray interpretation by 'specialized' emergency nurses.

OBJECTIVES: In the quest for a cost-effective and quality-preserving solution to manage crowding in the emergency department, the possibility of deploying regular emergency nurses for the treatment of acute ankle injuries was investigated. The aim of this study is to compare the diagnostic accuracy of emergency nurses with that of senior house officers in interpreting ankle and foot radiographs. METHODS: A prospective study comparing the assessment of 60 radiographs (30 feet and 30 ankles) by 16 emergency nurses before and after an educational session was performed. Each subset of 30 radiographs contained 12 fractures, hand-picked by a radiologist to represent everyday traumatology in the emergency department. The control group consisted of eight senior house officers representing everyday expertise. The outcome of the diagnostic assessment, represented as the pooled sensitivity and specificity for both groups, was compared using Z-statistics. RESULTS: Before the training session, the specialized emergency nurse group showed a sensitivity of 0.87 (confidence interval 0.83-0.91) compared with 0.93 (confidence interval 0.88-0.96) for the control group (P = 0.05). The specificity of specialized emergency nurses was 0.87 (confidence interval 0.81-0.92) compared with 0.93 (confidence interval 0.89-0.95) for the senior house officers (P < 0.05). After the training session, specialized emergency nurse diagnostic parameters did not differ significantly from the control group, displaying a sensitivity of 0.89 (confidence interval 0.86-0.92) and specificity of 0.92 (confidence interval 0.87-0.95). CONCLUSION: Before the training session, the specialized emergency nurse group showed a significantly lower accuracy than the SHO group. After training, however, the diagnostic accuracy did not differ significantly between groups. Therefore, we conclude that emergency nurses are able to accurately interpret foot and ankle radiographs after a short educational session.

Diagnostic accuracy and reproducibility in the interpretation of Ottawa ankle and foot rules by specialized emergency nurses.

OBJECTIVES: The ED is often confronted with long waiting periods. Because of the progressive shortage in general practitioners, further growth is expected in the number of patients visiting the ED without consulting a general practitioner first. These patients mainly present with minor injuries suitable for a standardized diagnostic protocol. The question was raised whether these injuries can be treated by trained ED nurses (specialized emergency nurses [SENs]). The aim of this study was to evaluate the diagnostic accuracy and reproducibility of SENs in assessing ankle sprains by applying the Ottawa Ankle Rules (OAR) and Ottawa Foot Rules (OFR). METHODS: In a prospective study, all ankle sprains presented in the ED from April to July 2004 were assessed by both a SEN and a junior doctor (house officer [HO]) randomized for first observer. Before the study, SENs were trained in applying OAR and OFR. In all patients, radiography was performed (gold standard). The diagnostic accuracy for the application of OAR and OFR was calculated for both groups and was compared using z statistics. Furthermore, from the paired results, reproducibility was calculated using kappa statistics. RESULTS: In total, 106 injuries were assessed in pairs, of which 14 were ultimately found to concern acute fractures (prevalence, 13%). The sensitivity for the SEN group was 0.93 (95% confidence interval [CI], 0.64-1.00) compared with 0.93 (95% CI, 0.64-1.00) for the HO group (no significance [ns]). The specificity of the nurses was 0.49 (95% CI, 0.38-0.60) compared with 0.39 (95% CI, 0.29-0.50) for the doctors (ns). The positive predictive value for the SEN group was 0.22 (95% CI, 0.13-0.35) compared with 0.19 (95% CI, 0.11-0.31) for the HO group (ns). The negative predictive value for the nurses was 0.98 (95% CI, 0.87-1.00) compared with 0.97 (95% CI, 0.84-1.00) for the doctors (ns). The interobserver agreement for the OAR and OFR subsets was kappa = 0.38 for the lateral malleolus; kappa = 0.30, medial malleolus; kappa = 0.50, navicular; kappa = 0.45, metatarsal V base; and kappa = 0.43, weight-bearing. The overall interobserver agreement for the OAR was kappa = 0.41 and kappa = 0.77 for the OFR. CONCLUSION: Specialized emergency nurses are able to assess ankle and foot injuries in an accurate manner with regard to the detection of acute fractures after a short, inexpensive course.