Lance E. Rodewald

Patient-Specific Reminder Letters and Pediatric Well-Child-Care Show Rates

The objective of this study was to determine whether patient-specific letters, which describe the content of an upcoming well-child appointment, improve the show rate of well-child appointments better than postcard reminders. In this prospective clinical trial conducted at a pediatric continuity clinic in a teaching hospital, 288 newborns were randomized to a letter, postcard, or control group. For every well-child appointment, families were sent either a letter pertaining to the particular well-child appointment or a postcard; the control group received no reminders. There were no differences in demographics among the groups. The show rates between the letter and postcard groups were not different, but were significantly higher than the show rate for the control group (75.0%, 73.7%, and 67.5%, respectively; P <.05) . A cost comparison between the use of postcards versus not using postcards revealed a benefit in the former. We concluded postcard reminders are effective in improving show rates for well-child-care visits, and that patient-specific letters have no additional benefit above that of postcard reminders.

Stabilization of Rural Multiple-Trauma Patients at Level III Emergency Departments Before Transfer to a Level I Regional Trauma Center

STUDY OBJECTIVE To determine whether triage and stabilization of severely injured rural trauma victims in outlying Level III emergency departments before transfer to Level I trauma centers results in outcomes similar to national normative data. DESIGN Retrospective review of trauma transfers and deaths during a 4-year period. SETTING Two Level III EDs in rural, upstate New York and an urban Level I regional trauma center. PARTICIPANTS Fifty multiple-trauma victims with a Trauma Triage Score (T-RTS) of < or = 11 or less. Forty-three patients were stabilized before transfer, and 7 died in the rural Level III ED. RESULTS There were 45 blunt injuries and 5 penetrating injuries. Mean patient age was 34 years (range, 9 months to 97 years). The Revised Trauma Score (RTS) on admission to the Level III ED was calculated for each patient (median score, 5.97; interquartile range (IQR), 4.09 to 6.90), as was the ultimate Injury Severity Score (ISS) (median score, 23; IQR, 13 to 29). With TRISS methodology, probabilities of survival (Ps) and death (Pd) were calculated. Results were compared with the Major Trauma Outcome Study (MTOS) by use of current coefficients derived from Walker-Duncan regression analysis of MTOS data. The predicted number of deaths was 13.5, whereas the actual number was 12, Z statistic, -.710. There were two unexpected survivors and three unexpected deaths. The 43 patients who were stabilized and transferred had a median RTS of 5.97 (IQR, 4.30 to 6.90) and an ISS of 18 (IQR, 12 to 25). The median interval in the Level III ED before transfer was 1 hour 43 minutes (IQR, 1 hour 11 minutes to 2 hours 40 minutes). There were two unexpected survivors (Ps = .32, Ps = .49) and 1 unexpected death (Ps = .52). The predicted number of deaths was 8.1, whereas the actual number was 5. The 7 patients who died in the rural Level III ED had a median RTS of 4.41 (IQR, 2.98 to 4.71) and a median ISS of 50 (IQR, 44 to 65). The median interval in the Level III ED before death was 42 minutes (IQR, 41 minutes to 1 hour 20 minutes). There were 2 unexpected deaths (Ps = .66, Ps = .55). The predicted number of deaths was 5.4 whereas the actual number was 7. CONCLUSION Triage and stabilization of severely injured rural trauma victims at Level III EDs before Level I transfer provide outcomes similar to national results. Unexpected death of severely injured trauma victims remains a problem in rural Level III EDs.

The Use of Structured, Complaint-Specific Patient Encounter Forms in the Emergency Department

STUDY OBJECTIVE To assess the effect of preprinted, structured, complaint-specific patient encounter forms on documentation, use of testing, and treatment compared with free-text record keeping. DESIGN Nonrandomized case-control trial. SETTING University-affiliated, tertiary referral hospital emergency department. METHODS The records of all patients with lacerations, pharyngitis, asthma, or isolated closed-head injury during an eight-month period were reviewed. INTERVENTION Use of structured complaint-specific patient encounter forms versus traditional free-text record keeping. MAIN OUTCOME MEASURE The null hypothesis was that there would be no differences in documentation, test use, or practice when the structured forms were used compared with free-text record keeping. RESULTS Differences in documentation that favored the use of the structured forms for all four problems studied were seen consistently. Not only was documentation improved, but test use also was affected in a way that decreased use. In addition, in certain areas (eg, treatment of pharyngitis), clinical practice also was changed. CONCLUSION Structured, problem-specific ED records improve documentation and affect both resource use and clinical practice. These forms may be useful for improving communication and reimbursement as well as for medicolegal documentation. They provide a method for standardized quality assurance review and clinical data abstraction. Finally, they provide a method for active dissemination of clinical standards.

Deuterium oxide as a tracer for measurement of compliance in pediatric clinical drug trials

We tested the hypothesis that a deuterium oxide (D2O) tracer could discriminate among patterns of clinically significant, imperfect compliance during drug trials. A model was developed to predict deuterium concentration during multiple dose regimens. After developing a regression equation to predict one of the model parameters for children, we selected healthy children (N = 20) at random to receive one of five 10-day D2O regimens. Five urine samples were obtained from each child during 15 days and analyzed for deuterium level by mass spectrometry. Each childs height, weight, age, and the first four urinary deuterium levels were used to estimate the amount and timing of deuterium administration. These estimates were compared with the five regimens to determine the closest match between estimate and regimen. The closest matching regimen was the regimen actually administered to 19 (95%) of the 20 children. Two of these children had D2O administration estimates that could be confused with another regimen. The correlation between the models predicted levels and the measured levels of all urine samples was 0.96. We conclude that a D2O tracer shows excellent promise as a quantitative method of assessing compliance with liquid medications under specified conditions.

A field survey of the emergency preparedness of wilderness hikers

The objective was to describe the health, first aid needs, supplies, and knowledge of wilderness hikers. A cross sectional survey was designed using a structured interview and carried out in Yosemite National Park; July 1991. The subjects were overnight hikers ( n = 301) representing 146 groups, spending a minimum of one night at one of nine sites. The average age was 34 years (range 12–84); 63% were male and 37% were female. Of the subjects, 11% had no previous experience and 40% had been on more than ten trips. Over 96% self reported being in excellent or good health; only 10% were smokers. 50% had pre-existing medical conditions requiring additional preparedness; 10% had insect allergies, 6% had asthma. The most common medical problems encountered were insect bites (82%), minor cuts (24%), blisters (24%) and sunburn (22%). Acute mountain sickness (AMS) (6%) and asthma attacks (3%) were the most common serious problems. 6% shortened their current trip due to first aid reasons. Most groups (141 = 99%) had some first aid equipment. On average, groups carried only 48% of the recommended categories of first aid supplies appropriate for their trip duration. The amount of first aid equipment was significantly associated with the maximal score per group on a generalized first aid knowledge test (p

Potential misuse of ipecac.

STUDY OBJECTIVE To evaluate the use of ipecac by health care professionals. DESIGN A descriptive case series based on a one-year review of all calls to a poison center. SETTING A university hospital-affiliated regional poison center. INTERVENTIONS The use of ipecac was judged appropriate or inappropriate based on the consensus of three professionals associated with the poison center using predetermined contraindications. MEASUREMENTS AND MAIN RESULTS In 20% of cases in which ipecac was used, its use was inappropriate. The most common inappropriate situation was that too much time had elapsed from the time of ingestion. Among adults the most common contraindication was the ingestion of a substance known to cause altered mental status. Among children, the most common contraindication was the ingestion of a nontoxic substance or amount of substance. The poison center recommended ipecac inappropriately less often than emergency departments and usually in children ingesting a nontoxic substance. EDs recommended ipecac inappropriately with a broader range of contraindications and more often in adults. CONCLUSION Ipecac has potentially adverse consequences and should not be used reflexively. Providers of emergency care should be educated about possible contraindications to its use.

The school-based immunization survey: an inexpensive tool for measuring vaccine coverage.

A school-based immunization survey was conducted among the 36 Rochester, NY, elementary schools (n = 5584 children) to determine (1) the vaccination rates at 2 years of age by type of primary care provider and (2) the accuracy of school immunization records (by comparing them with medical charts for children attending hospital-based clinics). These rates varied by provider type from 58% to 86% and were all below the national goal of 90%. In comparison with medical chart review, the school data had error rates of 15%; however, these errors occurred in both directions and were thus unbiased. School-based surveys include children who lack connections to the primary care system. With minimal effort these surveys can help identify populations in need of intervention.

Compliance with antibiotic therapy: A comparison of deuterium oxide tracer, urine bioassay, bottle weights, and parental reports*

OBJECTIVE To compare three traditional measures of compliance with antibiotic therapy (parent report diary, preregimen and postregimen bottle-weight difference, and urine bioassay for antibiotic activity), with a deuterium oxide tracer measure of compliance. METHODS Clinical trial in which all four compliance measures were used for subjects participating in a comparison of the efficacy of azithromycin and penicillin in treating group A beta-hemolytic streptococcal infection. Subjects were 41 children, aged 3 to 15 years (average age, 7.9 years), in a suburban pediatric private practice, who had positive rapid streptococcal antigen test results. RESULTS Of the 41 subjects, 20 children were randomly assigned to receive azithromycin and 21 to receive penicillin. Compliance was uniformly high by all four measures. Parent diaries indicated that all doses were administered. Urine bioassays were obtained for 40 subjects, and all showed antibiotic activity. Differences in bottle weights were obtained for 27 subjects and showed that 142% of the prescribed medication was missing from the bottles at the end of the regimen. The deuterium oxide measure was obtained for 40 subjects and showed that 107% of the prescribed azithromycin and 92% of the prescribed penicillin were ingested. The correlation coefficient between measured and expected deuterium enrichment was 0.89. There was no significant correlation between the bottle-weight measure and the deuterium oxide tracer. CONCLUSIONS The bottle-weight measure overestimates compliance; the deuterium oxide tracer is feasible for use in an office setting and produces a high correlation between the expected urinary enrichment and the measured enrichment. Increased use of this quantitative and direct measure would improve the accuracy of compliance measurement in trials of pediatric liquid medications.

The arrival of the ED-based POISINDEX : perceived impact on poison control center use

The purpose of this study was to determine the prevalence of emergency department-based POISINDEX (Micromedex Inc, Denver, CO) and assess its perceived impact on use of poison control centers. Survey methodology was used. A written questionnaire was distributed to all emergency departments (EDs) in the state of New York. ED directors or their designee (n = 239) were surveyed regarding the presence of POISINDEX in their ED and their perceptions of its impact on ED use of poison control centers. Completed questionnaires were returned from 180 of 239 (75%) EDs. Of the returned questionnaires, 42 of 180 (23%) have their own POISINDEX. In 32 of 42 (76%) of these EDs that have their own POISINDEX, it was perceived that ED-based POISINDEX decreased poison control center use. Use of ED-based POISINDEX may decrease ED use of poison control centers.