Mortality among seriously injured patients treated in remote rural trauma centers before and after implementation of a statewide trauma system.

BACKGROUND: Injury mortality in rural regions remains high with little evidence that trauma system implementation has benefited rural populations. OBJECTIVE: To evaluate risk-adjusted mortality in remote regions of Oregon before and after implementation of a statewide trauma system. RESEARCH DESIGN: A retrospective cohort study assessing injury mortality through 30 days after hospital discharge. SETTING: Nine rural Oregon hospitals serving counties with populations <18 persons per square mile. SUBJECTS: Severely injured patients presenting to four level-3 and five level-4 trauma hospitals 3 years before and 3 years after trauma system implementation. MEASURES: Interhospital transfer, hospital death, and demise within 30 days following hospital discharge. RESULTS: A total of 940 patients were analyzed. After trauma system implementation, patients presenting to level-4 hospitals were more likely transferred to level-2 facilities (P <0.001). Interhospital transfer times from level-3 hospitals lengthened significantly after system implementation (P <0.001). Overall mortality rates were higher in the postsystem period (8.3%) than the presystem period (6.7%), but not significantly. Controlling for covariates, no additional benefit to risk-adjusted mortality was associated with trauma system implementation. Additional deaths, occurring after trauma system implementation, included head-injured patients transferred from rural hospitals to nonlevel-1 trauma center hospitals. CONCLUSIONS: Increased injury survival after Oregon trauma system implementation, demonstrated in urban and statewide analyses, was not confirmed in remote regions of the state. Efforts to improve trauma systems in rural areas should focus on the processes of care for head-injured patients transferred to higher designation trauma centers.

A randomized controlled trial to assess decay in acquired knowledge among paramedics completing a pediatric resuscitation course.

BACKGROUND: Critical pediatric illness or injury occurs infrequently in out-of-hospital settings, making it difficult for paramedics to maintain physical assessment, treatment, and procedure skills. OBJECTIVES: To document the ability of paramedics to retain clinical knowledge over a one-year interval after completing a pediatric resuscitation course and to determine whether clinical experience or retesting improves retention. METHODS: This was a randomized controlled study assessing retention of knowledge in pediatric resuscitation soon after, six months after, and 12 months following completion of a pediatric advanced life support course. Forty-three paramedics participated in pre- and post-pediatric resuscitation course testing and were randomly assigned to one of four groups. Group 1 received a knowledge examination (KE) and mock resuscitation scenarios (MR) at six months. Group 2 received only the KE at six months. Group 3 received the MR only at six months. Group 4 received no intermediate testing. All groups were reassessed at 12 months. RESULTS: Pediatric clinical knowledge (as measured by KE) rose sharply immediately after the course but returned to baseline levels within six months. There was no difference between the groups in knowledge scores at 12 months, despite the interventions at six months. CONCLUSIONS: Although intensive out-of-hospital pediatric education enhances knowledge, that knowledge rapidly decays. Emergency medical services programs need to find novel ways to increase retention and ensure paramedic readiness.

Suicidal patients in the ED: ethical issues.

Emergency physicians frequently are expected to evaluate and develop treatment plans for potentially suicidal patients. The struggle to prevent someone from self-injury while respecting their personal autonomy is frequently present in the ED, as physicians must decide whether to intervene with a patient who does not seek treatment. The implications of this struggle are discussed in the article.

Trauma system impact on admission site: a comparison of two states.

OBJECTIVE: To introduce a measure assessing statewide hospital admission patterns for trauma and evaluate its utility in identifying significant admission redistributions in neighboring states as a function of trauma system implementation. METHODS: A retrospective claims database analysis was performed of hospitalized trauma patients in Washington and Oregon. The site of hospitalization and diagnostic information were used to determine an admission rate difference for each hospital: the rate of index patient admissions minus the rate of non-index patient admissions. Mean admission rate differences for Level II and III versus other hospitals in each state were compared as a function of time. RESULTS: A bias in favor of admitting more serious injuries to Level II and III hospitals was seen with trauma system implementation in both states, but it was more pronounced in the Oregon trauma system. CONCLUSION: Assessment of admission rate differences is a helpful method of characterizing the evolution of statewide trauma systems.

Second-generation antihistamines: a comparative review.

Second-generation histamine H1 receptor antagonists (antihistamines) have been developed to reduce or eliminate the sedation and anticholinergic adverse effects that occur with older H1 receptor antagonists. This article evaluates second-generation antihistamines, including acrivastine, astemizole, azelastine, cetirizine, ebastine, fexofenadine, ketotifen, loratadine, mizolastine and terfenadine, for significant features that affect choice. In addition to their primary mechanism of antagonising histamine at the H1 receptor, these agents may act on other mediators of the allergic reaction. However, the clinical significance of activity beyond that mediated by histamine H1 receptor antagonism has yet to be demonstrated. Most of the agents reviewed are metabolised by the liver to active metabolites that play a significant role in their effect. Conditions that result in accumulation of astemizole, ebastine and terfenadine may prolong the QT interval and result in torsade de pointes. The remaining agents reviewed do not appear to have this risk. For allergic rhinitis, all agents are effective and the choice should be based on other factors. For urticaria, cetirizine and mizolastine demonstrate superior suppression of wheal and flare at the dosages recommended by the manufacturer. For atopic dermatitis, as adjunctive therapy to reduce pruritus, cetirizine, ketotifen and loratadine demonstrate efficacy. Although current evidence does not suggest a primary role for these agents in the management of asthma, it does support their use for asthmatic patients when there is coexisting allergic rhinitis, dermatitis or urticaria.

Oregon emergency medical technicians' attitudes toward physician-assisted suicide.

OBJECTIVES: To determine Oregon intermediate and advanced emergency medical technicians' (EMTs') attitudes toward physician-assisted suicide (PAS) and factors associated with those attitudes. METHODS: An anonymous survey was sent to a random sample of 498 EMTs registered in Oregon. RESULTS: Surveys were delivered to 498 EMTs and 343 completed surveys were returned, for a response rate of 69%. The mean age of the respondents was 37.5 years (+/-8.73) and 79% were male. 232 (68%) agreed that PAS should be legal, 263 (77%) agreed that terminally ill people have a right to decide to commit suicide, while 57 (17%) thought not attempting resuscitation would be immoral. 251 (73%) reported seeing attempted suicide in terminally ill patients at least once, with 117 (34%) experiencing such calls >5 times. Only 22 (6%) stated that they would be unable to work in a system that directed them to withhold resuscitation after a PAS attempt, and 277 (81%) agreed that treatment protocols should direct EMTs to withhold resuscitation. 105 (31%) thought EMTs should participate in the decision to withhold resuscitation. 206 (60%) thought the law should allow lethal injection for terminally ill patients. 201 (59%) agreed there were circumstances under which they might personally consider PAS. If PAS were legal, EMTs stated they would withhold treatment from a terminally ill patient following attempted suicide in the following circumstances: based on standing orders, 78%; with on-line medical direction, 67%; after speaking with the primary physician, 53%; if the patient had decision-making capacity, 45%; with written documentation from the patient's physician, 68%; and never, 6%. CONCLUSIONS: A majority of Oregon EMTs responding to this survey expressed support for PAS, think treatment protocols should direct paramedics to withhold resuscitation in such cases, and would feel comfortable withholding resuscitation given appropriate protocols. Nearly 3 out of 4 Oregon EMTs report seeing at least 1 terminally ill patient who had attempted suicide.

Elimination of over-the-counter medication coverage in the Oregon Medicaid population: the impact on program costs and drug use.

OBJECTIVES: To reduce program costs, the Oregon Medicaid program eliminated reimbursement for over-the-counter (OTC) medications. Considering that physicians might substitute more expensive prescription-only products for eliminated OTC therapy, this investigation evaluates the policy's impact on medication costs. METHODS: This retrospective investigation examines pharmacy claims for adult Medicaid eligible recipients between March 1992 and February 1994 using an interrupted time-series analysis. The policy's impact on program costs and on the number of submitted claims was evaluated separately for prescription-only and total prescribing in nine therapeutic categories. RESULTS: In the preintervention period, OTC products comprised 36% (213,516 of 592,672) of drug claims and 9% ($1.36 million of $14.58 million) of medication costs in the nine therapeutic categories. Decreased program costs were noted in five categories and no significant changes were found in four others; overall, medication costs decreased from $7.86 to $7.39 per eligible recipient per month. A significant increase in prescription-only prescribing was noted in the hematinics category, but the net effect on total costs demonstrated a significant decrease. CONCLUSIONS: The OTC elimination policy was successful in reducing program drug costs with limited evidence for substitution of prescription-only products. Further study is needed to determine the impact on patients who regularly received OTC medications and to evaluate secondary effects on outpatient visits, hospitalization, and clinical outcomes.

Adequacy of hospital discharge status as a measure of outcome among injured patients.

CONTEXT: Crude mortality rates at the time of hospital discharge are commonly used to assess the quality of care provided to patients hospitalized following trauma. OBJECTIVES: To evaluate the adequacy of hospital death rates as an outcome measure following trauma and to determine the influence of noninjury illness as a cause of hospital death and the frequency of postdischarge death. DESIGN: Retrospective cohort analyses using hospital discharge data for injured patients cross-linked to death certificate data that provided 1 year of follow-up for all patients discharged alive. PATIENTS: A total of 90048 injured patients admitted to all acute care hospitals in the state of Washington from 1991 through 1993 and discharged with at least 1 diagnosis coded in the International Classification of Diseases, Ninth Revision, Clinical Modification to indicate trauma. MAIN OUTCOME MEASURES: Death in the hospital and death within 30 days of hospital discharge. RESULTS: Among 1912 injured patients with in-hospital deaths, 825 death certificates (43%) listed a noninjury cause of death. The overall mortality rate at hospital discharge was 21.2 per 100000 hospitalized injured patients, and was 12.1 per 100000 for trauma deaths and 9.1 per 100000 for those designated as nontrauma deaths. Patients with trauma-related death designations were younger (mean age, 51.5 years vs 77.9 years), had shorter lengths of stay (median stay, 2 days vs 5 days), and sustained more severe injures (P<.001). Including the 1273 deaths that occurred within 30 days of hospital discharge increased rates for trauma-designated deaths to 14.1 per 100000 and increased rates for nontrauma-designated deaths to 21.3 per 100000. CONCLUSIONS: Hospital discharge death rates are incomplete measures of death frequency for injured patients. Designation of the cause of death, especially among older, hospitalized, injured patients often reflects preexisting medical conditions. Adequate assessment of mortality following trauma requires measurement of the frequency of death following hospital discharge.

Rural hospital transfer patterns before and after implementation of a statewide trauma system. OHSU Rural Trauma Research Group.

OBJECTIVE: To evaluate trauma transfer practices in rural Oregon before and after implementation of a statewide trauma system. METHODS: A pre- vs post-system implementation (historical control) analysis of trauma transfer practices was performed using a sample of rural ED trauma patients from 4 Level-3 and 5 Level-4 trauma hospitals. Medical records of patients with specific index injury diagnoses in 4 anatomic regions (head, chest, liver/ spleen, and femur/open-tibia) were reviewed for a 3-year period before statewide trauma system implementation and 3 years after hospital trauma designation. RESULTS: Of 1,057 patients entered into the database, 532 were evaluated during the pre-system period and 525 were evaluated during the post-system period. Overall, 47% had head injuries, 34% had chest injuries, 23% had femur/open-tibia injuries, and 12% had spleen/liver injuries. There were 142 (13%) patients with an injury in > 1 index area. After trauma system implementation, there was a significant increase in the proportion of ED trauma patients transferred from Level-4 trauma hospitals (32% vs 68%, p < 0.001), with a corresponding decrease in the number of hospital admissions to these facilities (63% to 29%, p < 0.001). Significant increases in the proportion transferred from Level-4 trauma hospital EDs were noted for all index injury categories (p < 0.001). Trauma patients presenting to Level-4 EDs were significantly more likely to be transferred to Level-2 facilities (66% vs 82%, p = 0.030), while patients at Level-3 facilities were significantly more likely to be transferred to Level-1 centers (2% vs 14%, p = 0.002) following trauma system implementation. Multiple logistic regression modeling indicated that implementation of the statewide trauma system was an independent predictor of rural trauma patient transfer from Level-4 hospitals, while transfers from Level-3 facilities were dependent on type of injury. CONCLUSION: Implementation of the Oregon statewide trauma system was associated with a redistribution of rural trauma patients to trauma hospitals with greater therapeutic resources.

Impact of a statewide trauma system on rural emergency department patient assessment documentation. OHSU Rural Trauma Research Group.

OBJECTIVE: To determine the association of rural ED patient assessment documentation with state trauma system implementation, hospital trauma categorization level (i.e., Level-3 vs Level-4), injury diagnosis, and patient demographics. METHODS: A pre- vs post-system implementation (historical control) analysis of trauma documentation was performed using a sample of rural ED trauma patients from 4 Level-3 and 5 Level-4 trauma hospitals. The medical records of patients with specific index diagnoses in 4 anatomic regions (head, chest, liver/spleen, and femur/open-tibia) were reviewed for 3-year periods before statewide trauma system implementation and after hospital categorization. Vital sign, % inspired O2, and O2 saturation determinations were identified relative to the first and the last vital signs documented on the ED record. If not documented in the medical chart within 5 minutes of the first or last ED vital sign assessment, these measurements were considered missing. Separately, neurologic documentation (initial and final) also was sought for patients meeting criteria for an index head injury. RESULTS: Of 1,057 patients entered into the database, 532 were evaluated during the pre-system period and 525 were evaluated during the post-system period. Overall, 47% had a head injury, 34% had a chest injury, 23% had a femur/open-tibia injury, and 12% had a spleen/liver injury. There were 142 (13%) patients with an injury in > 1 index area. Except for initial systolic blood pressure, documentation of all other initial and final patient vital signs increased significantly (p < 0.05). Documentation of the Glasgow Coma Scale score (initial and final; p = 0.0001) and a final pupil examination on head-injured patients (p = 0.025) also increased. The effects of hospital level, injury diagnosis, and patient demographics on documentation rate were minimal. CONCLUSION: The study found overall improved ED documentation of trauma patient status in association with implementation of a statewide trauma system. This improvement in documentation suggests an enhanced process of care with trauma system participation.

Telemark skiing injuries: a three-year study.

Telemark skiing is an increasingly popular wilderness activity. Little is known, however, about the injuries incurred during modern telemark skiing. To determine the incidence and types of these injuries we carried out a prospective analysis of injured telemarkers over three ski seasons from November 1994 through May 1997 at the Mount Hood Meadows ski area medical clinic in Oregon. Injured telemark skiers presenting to the clinic were asked to fill out a one-page survey, and a diagnosis was provided by the clinic physician or nurse. During the 1995-1996 and 1996-1997 ski seasons, skiers were counted at the ski lifts to determine the proportion of telemark skiers, alpine skiers, and snowboarders using the lifts. Using these proportions and the total ticket sales for the year, the number of downhill skiers, snowboarders, and telemarkers over the season were estimated, and injury rates were calculated. During the three ski seasons, 33 injuries were identified in 28 injured telemarkers. Of the study participants, 75% (21) were male. The average age was 33.1 years. Self-described intermediate and advanced telemarkers accounted for 74% of the injured. In 96% of the injuries, the skier was performing a telemark turn. Powder snow or heavy, wet snow conditions were reported most often. Lower-extremity injuries were most common, accounting for 42.5% (14) of the total. Seven of the lower-extremity injuries were ankle injuries, and four were knee injuries. Upper-extremity injuries comprised 24.2% (8) and head and facial injuries 21.2% (7) of the total. The least number of injuries occurred in the spine, 12.1% (4). Release plates were used by 8 of 28 skiers and only released in two instances. Telemark skiers comprised 0.9% of skiers counted at the lifts during the 1995-1996 season and 1.8% in 1996-1997. Injury rates/1000 skier days in 1995-1996 were 3.3 (95% CI: 3.27, 3.35) for downhill skiers, 4.1 (95% CI: 3.32, 5.22) for telemark skiers, and 6.8 (95% CI: 6.54, 7.00) for snowboarders. Injury rates/1000 skier days in 1996-1997 were 3.1 (95% CI: 3.05, 3.15) for downhill skiers, 1.7 (95% CI: 1.44, 2.11) for telemark skiers, and 5.6 (95% CI: 5.39, 5.78) for snowboarders. We conclude that telemark skiers comprise only a small proportion of skiers at a lift-served area. Lower-extremity injuries were most common, followed by upper-extremity and head and facial injuries. Injury rates for telemarkers are comparable to those for alpine skiers.

Oregon emergency physicians' experiences with, attitudes toward, and concerns about physician-assisted suicide.

OBJECTIVE: To determine emergency physicians' (EPs') attitudes toward physician-assisted suicide (PAS), factors associated with those attitudes, current experiences with attempted suicides in terminally ill persons, and concerns about the impact of legalizing PAS on emergency medicine practice. METHODS: A cross-sectional, anonymous mailed survey was taken of EPs in the state of Oregon. RESULTS: Of 356 eligible physicians, 248 (70%) returned the survey. Of the respondents, 69% indicated that PAS should be legal, 65% considered PAS consistent with the physician's role, and 19% believed that it is immoral. The respondents were concerned that patients might feel pressure if they perceived themselves to be either a care burden on others (82%) or a financial stress to others (69%). Only 37% indicated that the Oregon initiative has enough safeguards to protect vulnerable persons. Support for legalization was not associated with gender, age, or practice location. Respondents with no religious affiliation were most supportive of PAS (p < 0.001), and Catholic respondents were least suppportive (p = 0.03). A majority (58%) had treated at least 1 terminally ill patient after an apparent overdose. Most respondents (97%) indicated at least 1 circumstance for which they would sometimes be willing to let a terminally ill patient die without resuscitation after PAS if the Oregon initiative becomes law: if verified with an advance directive from the patient (81%), with documentation in writing from the physician (73%), after speaking to the primary physician (64%), if a competent patient verbally confirmed intent (60%), or if the family verbally confirmed intent (52%). CONCLUSIONS: Although the majority of Oregon EPs favor the concept of legalization of PAS, most have concerns that safeguards in the Oregon initiative are inadequate to protect vulnerable patients. These physicians would consider not resuscitating terminally ill patients who have attempted suicide under the law's provisions, only in the setting of documentation of the patient's intent.

Community-wide emergency department visits by patients suspected of drug-seeking behavior.

OBJECTIVE: To measure community-wide ED use by patients at high risk for drug-seeking behavior. METHODS: A retrospective, observational study was performed to analyze a cohort of university hospital ED patients seen January 1 to June 30, 1990, for specific pain-related diagnoses (i.e., ureteral colic, toothache, back pain, abdominal pain, or headache) and either independently identified on at least one other local hospital's "patient alert" list or having a drug-related death during 1990. Patients with terminal illnesses were excluded. The frequency of ED (and affiliated urgent care clinic) visits and hospital admissions were determined for January 1 to December 31, 1990, at seven local hospitals. Detailed, supplemental chart review was performed for visits to three of these hospitals from 1990 to 1992. RESULTS: Thirty patients were identified as being at risk for drug-seeking behavior (mean age: 34.3 years; range: 21-55 years; 50% males). We identified 379 visits for this cohort (86% ED visits, 9.8% urgent care visits, 4.7% hospital admissions), for an average of 12.6 visits (range: 2-33) per patient per year. On average, each patient visited 4.1 (range: 1-7) different hospitals and used 2.2 (range: 1-6) different aliases. Two patients died of drug overdose. Supplemental chart review revealed 28 episodes (among 17 different patients) in which a patient was told that he or she "would receive no further 'narcotics'" from that facility; these patients subsequently received controlled substances from another hospital in 93% of these instances and from the same facility in 71%. CONCLUSIONS: Patients identified as being at high risk for drug-seeking behavior have high community-wide ED visit rates. Improving communication between and within hospitals may help identify patients who could benefit from more consistent community-wide care and appropriate treatment for addiction.

Applying the trauma triage rule to blunt trauma patients.

OBJECTIVE: To determine the accuracy of the Baxt Trauma Triage Rule (TTR: systolic blood pressure < 85 mm Hg; Glasgow Coma Scale-motor score < 5; or penetrating trauma to head, neck, or trunk) for prediction of major trauma in an independent data set of blunt trauma patients. METHODS: Retrospective evaluation of the TTR in a cohort of patients identified by Oregon Trauma System entry criteria. Accuracy for prediction of "major trauma" victims was measured using resource-based definitions of major trauma. Participants included 626 adult, blunt trauma patients at a level-I trauma center serving a metropolitan center of more than one million people. RESULTS: Of 524 patients with sufficient registry data to apply the TTR, 95 (18%) and 63 (12%) patients met the criteria for major trauma suggested by Baxt et al. and Emerman et al., respectively. Using the Baxt definition of major trauma, the TTR had a sensitivity of 74% (95% CI: 0.65-0.83) and a specificity of 84% (95% CI: 0.81-0.88). There were 25 significant false-negative results, including 12 patients requiring urgent laparotomy and four patients requiring emergency airway procedures. Using the Emerman definition of major trauma, sensitivity improved modestly to 76% (95% CI: 0.65-0.87) and specificity decreased slightly to 80% (95% CI: 0.77-0.84). CONCLUSIONS: In this blunt trauma population, the Baxt TTR failed to identify a significant number of severely injured patients. Slight alterations in the definition of "major trauma" can significantly affect the performance characteristics of triage instruments.

Manufacturers' distribution of drug samples to a family medicine clinic.

The distribution of drug product samples by pharmaceutical companies to a family medicine clinic was studied. Data on all deliveries of drug samples to the clinic site of a university-affiliated family medicine residency program from November 1992 through December 1993 were collected. In addition, the 11 faculty family physicians were surveyed about their experiences with the deliveries of samples. Forty-three manufacturers delivered samples of 331 drugs during the 14-month study period. There were 366 visits by the drug company representatives, who made 1117 separate deliveries. The total value of the samples, based on the average whole-sale price, was $240,782. Twenty-nine percent of the drugs were nonformulary, and only 49% were stocked by the pharmacy. The physicians surveyed indicated that they were either usually or always asked to sign for samples they did not in fact request, that they usually did not know what was recorded on the receipts for samples that they signed, and that they seldom verified what was actually delivered. Pharmaceutical manufactures delivered large quantities of drug samples during the study period, and many of the drugs were nonformulary or not stocked by the pharmacy. The physicians indicated that they were not well informed about delivered samples for which they signed receipts.

Possible interactions with terfenadine or astemizole.

Concurrent use of terfenadine or astemizole with erythromycin or ketoconazole can prolong the QT interval and produce potentially fatal ventricular arrhythmias. We examine the frequency and patterns of concurrent prescribing and suggest methods to reduce the incidence of serious drug interactions. By retrospectively reviewing Oregon Medicaid prescription claims data over 22 months, we determined the frequency of concurrent prescribing of terfenadine or astemizole with macrolide antibiotics or ketoconazole. From 1991 to 1992, terfenadine use increased by 29%, with a seasonal peak in June of each year. Terfenadine was one of the most prescribed medications from March through July 1992. During the 22 months reviewed, there were 122 episodes of concurrent use of terfenadine or astemizole with macrolide antibiotics or ketoconazole. Most of these episodes (94%) involved terfenadine. The frequency of concurrent use increased more than threefold from 1991 to 1992. Although patients received prescriptions from different physicians in 48% of these episodes, they used different pharmacies only 3% of the time. We demonstrate that terfenadine use is extensive and increasing, thus increasing the possibility of serious interactions, and many physicians may remain unaware of this potential. Effective prospective screening by pharmacists could dramatically reduce the incidence of concurrent prescribing. Physicians must be aware of the potential for these drug interactions, avoid prescribing these medications concurrently, and consider these interactions in the evaluation of syncope and cardiac arrhythmias.