Garnet E. Cummings

Health promotion and disease prevention in the emergency department: a feasibility study.

BACKGROUND Health promotion and disease prevention have been increasingly recognized as activities that may be within the scope of emergency medicine. The purpose of this feasibility study was to identify health risks and offer immediate interventions to adult patients who have drug and/or alcohol problems, incomplete immunization, are overdue for a Pap (Papanicolaou) smear, and/or are smokers. METHODS The study took place in a busy tertiary Emergency Department (ED) serving an inner-city population with a significant proportion of patients who are homeless, substance abusers, working poor, and/or recent immigrants. A convenience sample of patients completed a computer-based health-risk survey. Trained health promotion nurses offered appropriate interventions to patients following review and discussion of their self-reported data. Interventions included counseling for problem drinking, substance abuse, and smoking cessation, screening for cervical cancer, and immunization. RESULTS From October 20, 2000 to June 30, 2003, we enrolled 2366 patients. One thousand and eleven subjects (43%) reported substance abuse and 1095 (46%) were smokers. Of the 158 smokers contacted in follow-up, 19 (12%) had quit, 63 (40%) had reduced the number of cigarettes/day and 76 (48%) reported no change. Of 1248 women surveyed, 307 (25%) were overdue for a Pap smear and 54 (18%) received this intervention. Forty-four percent of subjects were overdue for at least one immunization and of those, 414 (40%) were immunized in the ED. CONCLUSION At-risk patients can be identified using a computer-based screening tool, and appropriate interventions can be given to a proportion of these patients in a busy inner city ED without increasing wait time.

SCENE DISPOSITION AND MODE OF TRANSPORT FOLLOWING RURAL TRAUMA: A PROSPECTIVE COHORT STUDY COMPARING PATIENT COSTS

This prospective cohort study was performed from 1994 to 1996 to compare the impact of scene disposition on prehospital and hospital costs incurred by rural trauma patients transported to a trauma center by helicopter or ground ambulance. The study included all rural adult injury victims who arrived at the tertiary trauma center by ambulance within 24 h of injury. Inclusion criteria consisted of inpatient admission or death in the emergency department, and any traumatic injury except burns. Data collected included mortality, mode of transport, Injury Severity Score (ISS), and costs from impact to discharge or death. Of 105 study patients, 52 initially went to a rural hospital, while 53 went directly to the trauma center. There was no significant difference in survival in the two groups. The ISS was significantly higher for patients taken directly to the trauma center from the scene. The ISS of trauma patients transported from the rural hospital was highest for patients sent by ground transport. The prehospital transport costs were significantly more for patients transported to a rural hospital first. The costs incurred at the trauma center were highest for those patients transported directly from the scene. Many severely injured patients were initially transported to a rural hospital rather than directly to the trauma center. At both the scene and rural hospital, consistent use of triage criteria appeared to be lacking in determining the severity of injury, appropriate destination, and mode of transport for trauma patients. Since no significant difference in prehospital helicopter and ground transport costs was demonstrated, the decision on mode of transport should be in the best interest of patient care.

Older Persons’ Transitions in Care (OPTIC): a study protocol

BackgroundChanges in health status, triggered by events such as infections, falls, and geriatric syndromes, are common among nursing home (NH) residents and necessitate transitions between NHs and Emergency Departments (EDs). During transitions, residents frequently experience care that is delayed, unnecessary, not evidence-based, potentially unsafe, and fragmented. Furthermore, a high proportion of residents and their family caregivers report substantial unmet needs during transitions. This study is part of a program of research whose overall aim is to improve quality of care for frail older adults who reside in NHs. The purpose of this study is to identify successful transitions from multiple perspectives and to identify organizational and individual factors related to transition success, in order to inform improvements in care for frail elderly NH residents during transitions to and from acute care. Specific objectives are to:1. define successful and unsuccessful elements of transitions from multiple perspectives;2. develop and test a practical tool to assess transition success;3. assess transition processes in a discrete set of transfers in two study sites over a one year period;4. assess the influence of organizational factors in key practice locations, e.g., NHs, emergency medical services (EMS), and EDs, on transition success; and5. identify opportunities for evidence-informed management and quality improvement decisions related to the management of NH – ED transitions.Methods/DesignThis is a mixed-methods observational study incorporating an integrated knowledge translation (IKT) approach. It uses data from multiple levels (facility, care unit, individual) and sources (healthcare providers, residents, health records, and administrative databases).DiscussionKey to study success is operationalizing the IKT approach by using a partnership model in which the OPTIC governance structure provides for team decision-makers and researchers to participate equally in developing study goals, design, data collection, analysis and implications of findings. As preliminary and ongoing study findings are developed, their implications for practice and policy in study settings will be discussed by the research team and shared with study site administrators and staff. The study is designed to investigate the complexities of transitions and to enhance the potential for successful and sustained improvement of these transitions.

Designing a curriculum in disaster medicine for Canadian medical schools

Purpose: To design an outcome‐based curriculum in disaster medicine for undergraduate, fellowship and postgraduate level students in Canadian medical schools. Methods: Based on the results of a systematic review of peer‐reviewed journals indexed in Medline, Healthstar, ERIC, or EMBASE for courses taught in medical schools in disaster medicine, a survey of Canadian medical schools, review of reference texts, articles provided in the European Master in Disaster Medicine and content from the Disaster Medicine On‐Line Course, the authors proposed an outcome‐based disaster medicine curriculum. Results: The Canadian Medical Survey demonstrated strong consensus among all of the respondents for the undergraduate curriculum in disaster medicine. The top five topics recommended in order were: pandemic, EMS (emergency medical service) and disasters, disaster management, natural disasters and hospital disaster planning. For the fellowship curriculum in disaster medicine, there was consensus within groups and divergen...

Health promoting attitudes and behaviors of emergency physicians: exploring gender differences.

PURPOSE The purpose of this paper is to report on gender differences in emergency physicians with respect to their attitudes, knowledge, and practices concerning health promotion and disease prevention. DESIGN/METHODOLOGY/APPROACH A mail survey of 325 male and 97 female Canadian emergency physicians. FINDINGS Results suggest female emergency physicians report having greater knowledge of health promotion topics, spend more time with each of their patients in the emergency setting, and engage in more health promotion counseling in the emergency setting than do their male counterparts. ORIGINALITY/VALUE The paper argues that in the future, educating and socializing emergency physicians, both male and female, in the practice of health promotion will enhance the potential of the emergency department to be a more effective resource for their community.

Disaster medicine education for physicians: a systematic review

Introduction: Events such as September 11, 2001, the 2005 tsunami in southeast Asia, and hurricane Katrina in the United States have emphasized the necessity for disaster medicine education in medical schools internationally. Society expects that physicians will be capable of planning for and managing the consequences to mankind of natural and man‐made disasters. Objective: The purpose of this systematic review was to examine articles related to disaster medicine in indexed peer‐reviewed journals, describing courses for medical students, physicians and medical military, before and after September 11, 2001. Method: This was a systematic review, from 1985 to 2006, in the English language, of four bibliographic databases (ERIC, MEDLINE, Embase, and Healthstar). Methodological quality assessment of courses described in the included articles was completed using the Learning Outcomes Inventory (LOI), which was developed to assess four key components for managing medical education: course objectives, course cont...

Disaster medicine education in Canadian medical schools before and after September 11,2001

OBJECTIVE To describe disaster medicine (DM) education in 16 Canadian medical schools before and after September 11, 2001 (9/11). METHODS Email invitations and reminders to complete an Internet-based survey were sent to 48 undergraduate and fellowship representatives. RESULTS A total of 24 responses were received from 15 of the 16 Canadian medical schools in operation at the time of the study, representing 10 undergraduate and 14 fellowship programs. Prior to 9/11, 22 programs at 9 schools taught DM compared with 14 programs post 9/11, a reduction of 37%. Six schools reported no DM teaching before 9/11; 7 reported no DM instruction after that date. Respondents from 12 schools felt that DM should be taught at the undergraduate level, and 9 of the 12 felt it should be included as core content. Respondents from all 15 responding schools felt that DM should be included as core content at the fellowship level. Twenty-two respondents (92%) indicated a belief that the public expects physicians to be prepared to deal with the consequences of disasters. The most frequently taught topics were emergency medical services and disasters, disaster management, hospital disaster planning, and bioterrorism. CONCLUSION Despite support for DM instruction and increases in terrorism and global disasters, 46% of the responding medical schools do not teach this topic and there has been a downward trend in this regard since 9/11.

The feasibility and effectiveness of emergency department based hypertension screening: A systematic review

Purpose: Hypertension is a highly prevalent risk factor for cardiovascular disease, and its early identification and management results in reductions in morbidity and mortality. Our objectives were to: (1) determine the extent to which the emergency department (ED) has been used to screen patients for undiagnosed hypertension; (2) estimate the incidence of undiagnosed hypertension in the ED population; (3) identify and describe the programs for ED hypertension screening; and (4) determine the feasibility of ED‐based hypertension screening programs and the requirements for further study. Data sources: An online search of databases (i.e., OVID Search, CINAHL, Scopus, Web of Science), unpublished sources (i.e., ProQuest Dissertation & Theses and Papers First), and grey literature (i.e., OpenSIGLE and the New York Academy of Grey Literature) was conducted. A manual search of the reference lists of relevant studies was also completed. Conclusion: Hypertension screening in the ED is feasible. Individuals with elevated blood pressure (BP) in the ED should be referred for follow‐up. Further study is needed to develop an ED screening tool that is predictive of persistently elevated BP in undiagnosed individuals. Implications for practice: Nurse practitioners in the ED should identify patients with elevated BP, provide hypertension education, and ensure appropriate intervention and referral.

Concussion diagnoses among adults presenting to three Canadian emergency departments: Missed opportunities

Objectives: Patients with concussion commonly present to the emergency department (ED) for assessment. Misdiagnosis of concussion has been documented in children and likely impacts treatment and discharge instructions. This study aimed to examine diagnosis of concussion in a general adult population. Methods: Patients >17 years old presenting meeting the World Health Organizations definition of concussion were recruited in one academic (Hospital 1) and two community (Hospitals 2 and 3) EDs in a Canadian city. A physician questionnaire and patient interviews documented recommendations given by emergency physicians. Bi‐variable comparisons are reported using chi‐square tests, t‐tests or Mann‐Whitney tests, as appropriate. Multivariate analyses were performed using logistic regression methods. Results: Overall, the study enrolled 250 patients. The median age was 35 (IQR: 23 to 49) and 52% were female. A variety of concussion causes were documented. Forty‐one (16%) patients were not diagnosed with a concussion despite meeting criteria. Concussion diagnosis was less likely with a longer ED length of stay (OR = 0.71; 95% CI: 0.60 to 0.83), presenting to the non‐academic centers (Hospital 2: OR = 0.21, 95% CI: 0.08 to 0.58; Hospital 3: OR = 0.07, 95% CI: 0.02 to 0.24), or involvement in a motor vehicle collision (OR = 0.11; 95% CI: 0.03 to 0.46). Conclusion: One in six patients with concussion signs and symptoms were misdiagnosed in the ED. Misdiagnosis was related to injury mechanism, length of stay, and enrolment site. Closer examination of institutional factors is needed to identify effective strategies to promote accurate diagnosis of concussion.