Planning recommendations for international emergency medicine and out-of-hospital care system development.

OBJECTIVES: To present suggestions on planning for development of emergency medicine (EM) and out-of-hospital care in countries that are in an early phase of this process, and to provide basic background information for planners not already familiar with EM. METHODS: The techniques and programs used by the authors and others in assisting in EM development in other countries to date are described. CONCLUSIONS: Some aspects of EM system development have applicability to most countries, but other aspects must be decided by planners based on country-specific factors. Because of the very recent initiation of many EM system development efforts in other countries, to the authors' knowledge there have not yet been extensive evaluative reports of the efficacy of these efforts. Further studies are needed on the relative effectiveness and cost-benefit of different EM development efforts.

Managed care organization authorization denials: lack of patient knowledge and timely alternative ambulatory care.

STUDY OBJECTIVE: To assess patient knowledge of managed care organization (MCO) regulations, availability of alternative ambulatory care, and patient outcome after MCO insurance authorization denial for an emergency department visit. METHODS: A medical screening examination and a follow-up structured interview were conducted with patients denied authorization for ED visits. The study was conducted at a large urban hospital with 36,000 annual ED visits and 40% MCO patients. RESULTS: During a 7-month period, 151 patients did not receive MCO authorization for ED care. The interview response rate was 75% (104/138) with 13 patients excluded. Eighty-three percent (86/104) of respondents came to the ED because they believed their problem was an emergency. Four percent (4/104) of the respondents had been instructed to go to the ED but were later denied authorization, whereas 85.6% (89/104) did not know that the MCO could deny payment. Only 37% (38/104) of the respondents reported having received instruction on the MCO preauthorization process, whereas of the 19% who contacted their MCO as instructed, all resulted in scheduling difficulties. Although 57% (59/104) received follow-up within 24 hours, 11% (11/104) of the respondents had a subsequent return visit to the ED with a subsequent admission rate of 4% (4/104). CONCLUSION: Few patients are aware of the need for MCO preauthorization for ED care, and almost half do not receive alternative care within 24 hours. A significant number of patients (11%) returned to the ED with an admission rate of 4%.

Feasibility of an emergency department-based tuberculosis counseling and screening program.

OBJECTIVE: To assess the feasibility and effectiveness of an ED-based tuberculosis (TB) screening program. METHODS: A TB screening program of adult ED patients was conducted at a university hospital ED with 46,000 annual visits that serves a poor urban community. Patients were screened on weekdays during business hours. ED patients were counseled about the disease and the screening procedure and, after consent, purified protein derivative (PPD) tests were placed. Patients returned in 48-72 hours for reaction reading and post-test counseling. PPD-positive patients received a physical examination, chest x-ray, and HIV testing and were referred to a city TB clinic for possible treatment. RESULTS: Overall, 873 patients were counseled, 630 were eligible for screening, and 374 (59.4%) consented to PPD testing. Of the 203 (54.1%) who returned, 32 (15.8%) were PPD-positive. No active case was detected, but 26 patients were referred to the health department. Eighteen kept their appointments and all 13 who were started on therapy completed treatment. Targeted screening of groups aged 55 years or more, nonwhite groups, and those with other high-risk factors would detect 84% of PPD-positive cases while testing only 48% of eligible patients. CONCLUSION: An ED-based TB screening program is feasible and can identify many patients requiring treatment. Targeted screening of high-risk groups could reduce the program cost, but would miss some cases.

Proposed fellowship training program in international emergency medicine.

Interest in international emergency medicine (EM) has grown steadily over the last ten years. This growth has been fueled by increased demand for emergency services abroad and the proliferation of emergency physicians (EPs) working in international relief and development. As a response, several academic EM programs have developed international EM fellowships for the purpose of providing formal training to EPs interested in international health. Although there have been preliminary articles describing fellowship curricula, to the authors' knowledge no recommendations have been proposed by national consensus that suggest emphasis or required components of a fellowship program. Therefore, a group of EPs interested in fellowship training convened for the purpose of developing goals and objectives for a postgraduate training program in international EM. To that end, this article proposes guidelines for a fellowship training program for international EM.

Disease surveillance in the ED: factors leading to the underreporting of gonorrhea.

Emergency departments (EDs) are potentially important surveillance sites. This study assessed reporting completeness for gonorrhea by hospital and gender and explored reasons for underreporting. A retrospective review was conducted of ED charts from three hospitals for 2 months. Potential gonorrhea cases were identified by history, physical examination, testing, treatment, and diagnostic practices. Cases were divided into those tested only, those treated with or without testing, and those with positive tests. Reporting completeness was assessed for each. Of 936 cases included, 29.0% were tested without treatment and 71% received treatment. One third of treated patients were not tested, and none of these were reported. Two EDs reported cases themselves and reported 75.9% of confirmed cases. There were significant differences in testing and reporting between hospitals and genders. Underreporting of suspected and confirmed gonorrhea cases was common from these EDs. A major cause was physicians treating without testing for confirmation.

Guidelines for evaluation of international emergency medicine assistance and development projects.

Interest in the development of the specialty of emergency medicine and of emergency health care systems has greatly increased worldwide in the last few years. The guidelines in this article were developed in an effort to assist others in design and evaluation of all types of emergency medicine projects.

The development of international emergency medicine: a role for U.S. emergency physicians and organizations. SAEM International Interest Group.

There is a rapidly growing interest in emergency medicine (EM) and emergency out-of-hospital care throughout the world. In most countries, the specialty of EM is either nonexistent or in an early stage of development. Many countries have recognized the need for, and value of, establishing a quality emergency health care system and are striving to create the specialty. These systems do not have to be high tech and expense but can focus on providing appropriate emergency training to physicians and other health care workers. Rather than repeatedly "reinventing the wheel" with the start of each new emergency care system, the preexisting knowledge base of EM can be shared with these countries. Since the United States has an advanced emergency health care system and the longest history of recognizing EM as a distinct medical specialty, lessons learned in the United States may benefit other countries. In order to provide appropriate advice to countries in the early phase of emergency health care development, careful assessment of national resources, governmental structure, population demographics, culture, and health care needs is necessary. This paper lists specific recommendations for EM organizations and physicians seeking to assist the development of the specialty of EM internationally.

Pediatric injuries presenting to an emergency department in a developing country.

PURPOSE: To describe the causes and outcomes of pediatric injuries using the emergency departments (ED) as a surveillance site. METHOD: Prospective, 14-day surveys of all injuries were conducted in the EDs of the two national trauma referral hospitals of Trinidad and Tobago. Data on patient demographics, type, cause, and outcome of injuries were collected. The chi 2 test for significance was used for categorical variables. RESULTS: Pediatric patients (< 20 years) accounted for 41.5% (714/1722) of injury visits. Of these, 62.6% were male and 17.4% were < four years old, 26.2% four to nine years, 31.1% 10 to 14 years, and 25.4% were 15 to 19 years old. Three patients (0.4%) died, 68.6% were discharged, and 31.0% admitted. Intentional injuries accounted for 13.9% of injuries. Of the intentional injuries, the assailant was significantly more likely to be known than not (P < 0.01). The most common causes of all injuries were: falls, 44.4%; blunt objects, 12.3%; sharp objects, 11.8%; motor vehicle (including pedestrians), 7.4%; poison, 3.6%; and burns, 1.7%. Injuries occurring in the home accounted for 46.2%; in school, 25.5%; sports/recreation, 11.1%; and at work, 4.5%. The most common injuries were: lacerations, 30.8%, contusions/abrasions, 26.7%, fractures, 18.8%; and sprains/dislocations, 9.4%. CONCLUSION: Pediatric injuries are a significant cause of morbidity and mortality in this country, accounting for almost one third of injured patients. Because of the low frequency of pediatric injury deaths, ED surveillance may be a more effective means of identifying high risk groups and activities for injuries. Data from EDs may be useful in other developing countries to develop injury prevention programs.

Pediatric injuries presenting to an emergency department in a developing country

PURPOSE: To describe the causes and outcomes of pediatric injuries using the emergency departments (ED) as a surveillance site. METHOD: Prospective, 14-days surveys of all injuries were conducted in the EDs of the two national trauma referral hospitals of Trinidad and Tobago. Data on patient demographics, type, cause, and outcome of injuries were collected. The chi 2 test for significance was was used for categorical variables. RESULTS: Pediatric patients (< 20 years) accounted for 41.5 percent (714/1722) of injury visits. Of these, 62.6 percent were male and 17.4 percent were < four years old, 26.2 percent four to nine years, 31.1 percent 10 to 14 years, and 25.4 percent were 15 to 19 years old. Three patients (0.4 percent) died, 68.6 percent were discharged, and 31.0 percent admitted. Intentional injuries accounted for 13.9 percent of injuries. Of the intentional injuries, the assailant was significantly more likely to be known than not (P < 0.01). The most common causes of all injuries were: falls, 44.4 percent; blunt objects, 12.3 percent sharp objects, 11.8 percent; motor vehicle (including pedestrians), 7.4 percent; poison, 3.6 percent and burns 1.7 percent. Injuries occurring in the home accounted for 46.2 percent in school, 25.5 percent; sports/recreation, 11.1 percent and at work, 4.5 percent. The contusion/abrasions, 26.7 percent fractures, 18.8 percent; and sprains/dislocations, 9.4 percent. CONCLUSION: Pediatric injuries are significant cause of morbidity and mortality in this country, accounting for almost one third of injured patients. Because of the low frequency of pediatric injury deaths, ED surveillance may be a more effective means of identifying high risk groups and activities for injuries. Data from the EDs may be useful in other developing countries to develop injury prevention programs.(AU)

Effect of rotational patient assignment on emergency department length of stay.

The study evaluated the impact of rotational assignment of emergency department (ED) patients to residents on patient's length of stay (LOS) and resident satisfaction. The study was conducted in a university, inner-city, adult ED. Prior to the intervention, residents saw patients at their own rate as patient charts were placed into a common rack waiting to be seen. The intervention involved directly assigning patients with medical emergencies in sequential rotation to residents. Patients with surgical conditions were seen under the old self-paced system for comparison. A retrospective chart review of LOS of all ED visits for a period of 2 wks before, 6 wks after, and 1 yr after the intervention was conducted. ED administration and staffing during the study were unchanged. Comparisons excluded critical cases and nonurgent cases triaged away. A postintervention survey of physician satisfaction was conducted. During the study period, demographic characteristics of medical and surgical patients did not differ significantly between the time periods. The average total ED LOS for moderately ill medical patients decreased significantly from 7.11 to 5.86 h at 6 wks and remained significantly improved 1 yr later at 6.21 h. During the same periods, the average total LOS increased significantly for the surgical patients. Residents reported that the new system was more fair and did not affect teaching quality. The rotational assignment of patients to resident physicians led to significantly less ED LOS while improving resident satisfaction without affecting education.

Epidemiology and practice of emergency medicine in a developing country.

STUDY OBJECTIVE: To analyze the emergency medicine system in a developing country and identify areas of need and potential collaboration. DESIGN: Convenience sample surveys of all emergency visits over a 2-week period, hospital admission and health department statistics, and interviews with government officials, health providers, and EMS managers. SETTING: Port of Spain General Hospital, Trinidad and Tobago. RESULTS: The ED has more than 100,000 visits per year. No records are kept. No physician in this study had emergency medicine training; only one had completed any residency. The survey included 3,710 patients: 40.5% were admitted, and .3% died. Injuries accounted for 41.6% of all visits, asthma 7.8%. The mean time elapsed before a patient was seen was .5 hour; mean time to discharge, 1.9 hours. In only 9% of patients were laboratory tests performed. Prehospital providers had limited equipment and training. CONCLUSION: The ED and prehospital systems provide high-volume and often high-acuteness care. Barriers to improved care include limited specialized training and lack of medical records.

A role for the private sector in poliomyelitis surveillance?

In order to identify all cases of acute flaccid paralysis as quickly as possible, most countries need to include private health providers in their poliomyelitis surveillance systems. Ways of achieving this are considered below.

Local area monitoring (LAM).

Routine surveillance of the incidence of vaccine-preventable diseases has not proved sensitive enough to demonstrate the impact of the Expanded Programme on Immunization (EPI) in many countries. In order to document progress since the start of the EPI in 1979, data are needed for several years prior to that. In most developing countries these can be found only in major cities or large hospitals. Therefore a system of sentinel surveillance, the Local Area Monitoring Project (LAM), is being set up in selected institutions in the major cities of the developing world. The goal is to include the major city of each of the 25 largest developing countries, with a total population of 115 million. These 25 countries together account for 85% of all births in the developing world. In some cases the city was selected because it had an excellent municipal reporting system. For example, the Istanbul Health Office collects data from 169 hospitals, primary health centres, maternal and child health clinics and other institutions, and provides compiled municipal figures within six weeks. The trend of measles cases seen at the Children's Hospital exactly matches the trend for the city as a whole, indicating that for measles, at least, the Children's Hospital is an excellent sentinel site representative of the whole city. Manila has a hospital to which all cases of infectious disease are routinely referred, which is also a good sentinel site. In Rangoon it has been necessary to survey four hospitals, and in Jakarta seven, to cover all the target diseases.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: Routine surveillance of the incidence of vaccine-preventable diseases has not proved sensitive enough to demonstrate the impact of the Expanded Program on Immunization (EPI) in many countries. In order to document progress since the start of the EPI in 1979, data are needed for several years prior to that. In most developing countries these can be found only in major cities or large hospitals. Therefore a system of sentinel surveillance, the Local Area Monitoring Project (LAM), is being set up in selected institutions in the major cities of the developing world. The primary goal of the LAM project is to provide disease-incidence data of sufficient quality to evaluate more fully the global impact of the EPI on the 6 target diseases--diptheria, pertusis, tetanus, poliomyelitis, measles, and tuberculosis. The goal is to include the major city of each of the 25 largest developing countries, with a total population of 115 million. These 25 countries together account for 85% of all births in the developing world. The program and coverage information is used to assess the impact of individual EPI programs on disease trends. Preliminary analysis of the 12 cities with the best data suggests that the impact of the EPI on the incidence of the target diseases has been greater than previously shown by the routine system. The LAM information is useful for global and regional analysis of program impact, but for the countries themselves its utility may be even greater. It is hoped that the project will help to improve a country's surveillance system by encouraging the use of sentinel reporting as a means of supplementing routine data. The information on the impact of the EPI may further increase political and public support for a program.