James A. Feldman

Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access ☆

OBJECTIVESnWe determined the survival and complications of ultrasonography-guided peripheral intravenous (IV) catheters in emergency department (ED) patients with difficult peripheral access.nnnMETHODSnThis was a prospective, observational study conducted in an academic hospital from April to July of 2007. We included consecutive adult ED patients with difficult access who had ultrasonography-guided peripheral IVs placed. Operators completed data sheets and researchers examined admitted patients daily to assess outcomes. The primary outcome was IV survival >96 hours. As a secondary outcome, we recorded IV complications, including central line placement. We used descriptive statistics, univariate survival analysis with Kaplan Meier, and log-rank tests for data analysis.nnnRESULTSnSeventy-five patients were enrolled. The average age was 52 years. Fifty-three percent were male, 21% obese, and 13% had a history of injection drug use. The overall IV survival rate was 56% (95% confidence interval, 44%-67%) with a median survival of 26 hours (interquartile range [IQR], 8-61). Forty-seven percent of IVs failed within 24 hours, most commonly due to infiltration. Although 47 (63%) operators reported that a central line would have been required if peripheral access was unobtainable, only 5 (7%; 95% confidence interval, 2%-15%) patients underwent central venous catheterization. Only 1 central line was placed as a result of ultrasonography-guided IV failure. We observed no infectious or thrombotic complications.nnnCONCLUSIONnDespite a high premature failure rate, ultrasonography-guided peripheral IVs appear to be an effective alternative to central line placement in ED patients with difficult access.

The Impact of Footwear and Packweight on Injury and Illness Among Long-Distance Hikers

Abstract Objective.—To determine the prevalence and predictors of injury and illness among long-distance hikers. Methods.—This was a cross-sectional study of long-distance hikers (>500 miles [805 km]) along the Appalachian Trail and Pacific Crest Trails between August and October of 2006. An 8-page survey instrument was made available to hikers at a designated station near the northern terminus of the respective trails. The survey questions were yes/no or multiple choice. Independent variables included packweight, footwear, and type and frequency of water purification. χ2 tests to compare categorical data and the Cochran-Armitage test for trend were used (P < .05 significant). We used logistic regression to compare the variables concurrently, and significance was determined using likelihood ratio tests. Profile likelihood confidence intervals for the odds ratios are reported. Results.—Of the 128 hikers completing surveys that met inclusion criteria, the mean age was 33 years (range u200a=u200a 18–65 years), 94% walked >1500 miles (2400 km), and 70% were male. Using univariate analysis, trends were noted in the proportion of hikers reporting paresthesias and increasing packweight (35% with 10–20 pound [4.5–9 kg] packs, 50% with 21–30 pound [9.5–13.5 kg] packs, and 69% with >31 pound [14 kg] packs [P < .002]), as well as in the proportion of hikers reporting paresthesias and increasing footwear rigidity (29% sandals, 36% running shoes, 42% hiking shoes, and 68% hiking boots [P < .001]). In multivariate analysis compared to sandals, the odds ratio of suffering from paresthesias with running shoes was 1.57 (95% CI 0.3, 12.2), hiking shoes 1.73 (95% CI 0.3, 13.9), and hiking boots 3.9 (95% CI 0.7, 32.1) (P u200a=u200a .16). Compared to 10 to 20 pound (4.5–9 kg) packs, the odds ratios of suffering from paresthesias with 21 to 30 pound (9.5–13.5 kg) packs was 1.5 (95% CI 0.6, 3.9), and for >31 pounds (14 kg) was 2.2 (CI 0.7, 7.1) (P u200a=u200a .03). Adjusting for footwear and pack weight, only pack weight was significantly associated with paresthesias. Packweight and footwear were not significantly associated with other musculoskeletal injuries, such as joint sprains or chronic pain, and muscle injuries. Conclusions.—There is an association between packweight and the prevalence of paresthesias among long-distance hikers. The association between type of footwear and the prevalence of paresthesias is significant when analyzed independently, but loses its significance when the variables are examined together. This suggests that there is confounding between footwear and packweight.

Barriers to Primary Care: Perceptions of Older Adults Utilizing the ED for Nonurgent Visits

This purpose of this mixed methods study was to understand access to primary care among older adults who present to an inner city emergency department (ED) for nonurgent care. Questionnaires (N = 62) included demographic, illness characteristics, and health care utilization. Qualitative interviews (N = 20) were conducted. Data was analyzed using descriptive statistics, and qualitative methodology. More than half of the participants were female (60%), African American (57%) and pain was the presenting symptoms among 48% of the participants. Nearly all participants reported barriers to primary care; difficulty with phone systems and staff, and lack of available appointments resulting in an ED visit. Older adults face barriers accessing primary care and as a result, can turn to the ED for their primary care needs. Interventions to improve access for vulnerable older adults might have benefits not only for patient outcomes but also for health policy issues related to cost effective care and overcrowded EDs.

Anonymous self-evaluation of performance by ethics board members: a pilot study.

Evaluating the effectiveness of a Reserch Ethics Committee or Institutional Review Board (IRB) continues to be a difficult task. There are limited data that examine the perceptions of members of IRBs about their own performance or methods that would allow comparison among IRB panels at a single institution or between institutions. We piloted an anonymous survey instrument that examined members attitudes about the efficiency, procedures and outcomes of IRB meetings and developed a process for presentation and discussion of these results with panel members. This quality improvement process was initially completed with one panel, and then replicated with two other IRB panels at one institution. This allowed comparison of perceived IRB performance across panels at a single institution. Further research is required to determine the association between IRB members perception of performance and other measures of IRB effectiveness and to examine the perceived performance of IRBs by other research stakeholders.