Lynne Fullerton

Repeated ambulance use by patients with acute alcohol intoxication, seizure disorder, and respiratory illness☆

Three chronic conditions were examined--acute alcohol intoxication, seizure disorder, and respiratory illness--to quantify the extent of repetitive emergency medical services (EMS) use in a defined population. Urban EMS system ambulance data from 1992 to 1994 were analyzed for the three designated conditions with respect to transports by condition and individual patient. Analysis by chi2 was used for comparing proportions. Analysis of variance after square root transformation was used to evaluate differences among means. The total number of transports analyzed was 15,541: 7,488 for acute alcohol intoxication, 4,670 for respiratory illness, and 3,383 for seizure disorder. These transports involved 8,692 patients who were transported at least once for one of the three designated conditions. The mean number of transports for alcohol was 1.96 (95% confidence intervals [CI]: 1.92, 2.01), seizure 1.32 (95% CI: 1.27, 1.36), and respiratory 1.18 (95% CI: 1.15, 1.21). Of 369 patients transported five or more times during the study period, 260 (70.5%) were for alcohol, 56 (15.2%) for seizure, and 53 (14.4%) for respiratory complaints. This group comprised only 4.3% of patients, but 28.4% of all transports. Acute alcohol intoxication resulted in more repetitive ambulance transports than either seizure disorder or respiratory illness. A small number of patients were responsible for a large number of transports. Focused intervention for patients with high ambulance transport deserves further study.

Farm-related injury mortality in New Mexico, 1980-91

To compare the epidemiology of farm with non-farm occupational injury deaths, we reviewed state medical examiner data for all occupational injury deaths in New Mexico from 1980 to 1991. We identified 53 farm-related injury deaths for a rate of 21.3 per 100,000 worker-years. Farm workers were four times more likely than non-farm workers to die from occupational injury. American Indians had the highest farm injury death rate. Farm decedents were older than non-farm decedents (t498 = 6.29, p < 0.0001). Half of the farm decedents were 50 years of age or older; one-third were 60 years of age or older. Crush injuries accounted for half of all farm injury deaths including 18 of 23 motor vehicle deaths, half of these involving a tractor rollover. One in six farm injury deaths were from electrocution: one in five involved alcohol. Our study indicates that New Mexico has high farm-related injury mortality related to tractor use, alcohol intoxication, farm animals, and exposure to electricity. American Indians and older males are especially susceptible to these factors.

Occupational Injury Mortality in New Mexico

STUDY OBJECTIVE To examine specific risks for occupational injury deaths in New Mexico. DESIGN Retrospective review of state medical investigator reports from 1980 through 1991 with regard to industry, agent of death, gender, ethnicity, location, and alcohol and other drug involvement. PARTICIPANTS New Mexico residents who were fatally injured while on the job. RESULTS We identified 613 deaths: 87.1% unintentional, 10.6% homicides, and 2.3% suicides. Industries with the most fatalities were construction (11.8%), oil/gas (10.6%), and farming (8.6%). The primary agents of death were motor vehicles (41.7%), firearms (10.1%), and falling objects (10.0%). Almost all (95.6%) of the decedents were male. However, females were overrepresented among homicide deaths (P < .0001). Most unintentional injuries occurred in rural areas (69.1%), whereas most homicides (73.4%) and suicides (71.4%) occurred in urban areas. Drug or alcohol use was evident in 19.4% of cases. CONCLUSION New Mexico has a high rate of occupational injury death, which appears to be associated with rural location and use of motor vehicles and alcohol.

Does ambulance response time influence patient condition among patients with specific medical and trauma emergencies

Objectives The relation between patient outcome and ambulance response times is unknown. We sought to measure the influence of shorter response times on patient outcomes. The objective of the study was to determine whether ambulance response time makes a difference in the outcomes of emergency medical services (EMS) patients with specific traumatic and medical emergencies. Methods This study was conducted in a metropolitan EMS system serving a population of 800,000, including urban and rural areas. Cases were included if the private EMS service was the first medical provider on scene, the case was priority 1, and the patients were 13 years old and older. A 14-month time period was used for the data evaluation. Four diagnoses were examined: motor vehicle crash injuries, penetrating trauma, difficulty breathing, and chest pain complaints. Data collected included ambulance response times, initial vital signs, and the number of vital signs out of range. Cases seen at the single major trauma center were selected for evaluation of hospital outcome. Correlation coefficients were used to evaluate interactions between independent and outcome variables. Results Of the 2164 cases we reviewed, the EMS service responded significantly faster to trauma complaints at 4.5 minutes (n = 254) than medical complaints at 5.9 minutes (n = 1910). In the trauma center sample of 559 cases, response time was not related to hospital days (P = 0.5), admissions (P = 0.7), intensive care unit admissions (P = 0.4), or deaths (P= 0.3). Conclusions This study showed that in cases seen at a major trauma center, longer response times were not associated with worse outcomes for the diagnostic groups tested.

Rural‐Urban Disparities in School Nursing: Implications for Continuing Education and Rural School Health

PURPOSE Little is known about the professional and educational challenges experienced by rural school nurses. We conducted this study to describe disparities between the urban and rural professional school nurse workforce in New Mexico and to identify how best to meet the continuing education needs of New Mexicos rural school nurse workforce. METHODS We analyzed state data from a 2009 New Mexico Department of Health school nurse workforce survey (71.7% response rate). We included all survey respondents who indicated working as a school nurse in a public school setting in any grade K-12 and who identified their county of employment (N = 311). FINDINGS Rural school nurses were twice as likely as metropolitan nurses to provide clinical services to multiple school campuses (67.3% compared to 30.1%, P < .0001). They were less likely to hold a nursing degree at the baccalaureate level or higher (62.7% compared to 82.3%, P = .0002). Rural school nurses were less likely than metropolitan nurses to have received recent continuing education on anaphylaxis (P < .0001), asthma (P = .027), body mass index (BMI)/healthy weight (P = .0002), diabetes (P < .0001), lesbian, gay, bisexual and transgender (LGBT) health (P = .0004), and suicide risk identification and prevention (P = .015). Online courses and telehealth were identified by rural school nurses as among the preferred means for receiving continuing education. CONCLUSIONS Our findings support the provision of online courses and telehealth content to address urban-rural disparities in school nursing education and support rural school health.

Outcome of Trauma Patients Immobilized by Emergency Department Staff, but Not by Emergency Medical Services Providers: A Quality Assurance Initiative

Abstract Background. Prehospital selective cervical spine immobilization (CSI) is a relatively new concept. In our emergency medical services (EMS) system, protocols for selective CSI are widely used; yet, some patients who are brought to the hospital without CSI undergo secondary immobilization and cervical spine imaging in the emergency department (ED). Immobilization in the ED, after a decision not to immobilize by EMS, suggests that either the prehospital assessment is not trusted or the patient has developed new symptoms over time. We undertook a quality assurance initiative to evaluate whether trauma patients brought to the ED without CSI, who then underwent secondary CSI and imaging in the ED, had injuries that were initially missed by EMS selective CSI protocol. Methods. This was a 36-month retrospective data analysis of blunt trauma patients transported directly from the field to the University of New Mexico Hospital level I trauma center by Albuquerque Ambulance Service (AAS) between March 2009 and February 2012. Inclusion criteria were age 18 years and older, transported by AAS without CSI, and cervical spinal imaging done in the ED. Patients were excluded if they were being transported between facilities, were prisoners, and/or refused CSI. A positive finding was defined as any acute abnormality identified by the attending radiologist on the final imaging report. Results. The study included 101 patients who met inclusion criteria. There were no significant missed injuries. Ninety-four of the 101 patients received cervical spinal CT imaging at an estimated cost of

The Environmental Health/Home Safety Education Project: A Successful and Practical U.S.-Mexico Border Initiative

1,570 per scan, not including physician charges. The remaining patients had plain film radiographic imaging. No patients had magnetic resonance imaging. Conclusions. In this retrospective quality assurance initiative, none of 101 patients who underwent secondary CSI and imaging in the ED had a missed acute cervical injury. No patients had any adverse effects or required treatment, yet these patients incurred substantial costs and increased radiation exposure. While our results suggest hospital personnel should have confidence in prehospital decisions regarding CSI, continued surveillance and a large-scale, prospective study are needed to confirm our findings.

Ondansetron Oral Dissolving Tablets are Superior to Normal Saline Alone for Prehospital Nausea

The Environmental Health/Home Safety Education Project (Proyecto de Salud Ambiental y Seguridad en el Hogar) has been developed in response to a wide array of severe and often preventable environmental health issues occurring in and around homes on the U.S.—Mexico border. Utilizing well-trained community members, called promotoras , homes are visited and assessed for potential environmental hazards, including home fire and food safety issues. Data analyzed from project years 2002 to 2005 shows a significant impact in knowledge levels and initial behavior change among targeted participants as it relates to fire and food safety issues. Since the initiation of the project in 1999, hundreds of participants have improved their quality of life by making their homes safer. The project has proven to be sustainable, replicable, flexible, and attractive to funders.

Poster 043. Ability of a Priority Dispatch System to Respond Appropriately to Victims of Cardiac Arrest

Abstract Background. Antiemetics have been shown to be effective in multiple hospital settings, but few studies have been done in the prehospital environment. Objectives. Our hypotheses were 1) that the amount of normal saline administered during an emergency medical services (EMS) transport was not related to a change in nausea and vomiting and 2) that the addition of the ondansetron orally disintegrating tablet (ODT) would decrease the degree of nausea. Methods. This was a pre–post study of two cohorts of consecutive patients with nausea in the prehospital setting. During phase 1 of the study, our local EMS agency adopted a protocol form to complete whenever a patient with nausea and/or vomiting was assessed and transported to one of the area hospitals. Patients were asked to rate their nausea on a visual analog scale (VAS) and a Likert scale, and saline administration and active vomiting were documented. During phase 2, our EMS system adopted the use of ondansetron ODT for nausea and continued to complete the same forms. The nausea forms completed by EMS during phase 1 (saline only) and phase 2 (ondansetron ODT) were evaluated and compared. For both phases, the primary outcome measures were the change in VAS nausea rating (0 = no nausea, 100 = most nausea imaginable) from beginning to end of the transport and the results on the Likert scale completed at the end of the transport. Relationships were considered significant if p < 0.01. Results. Data were collected from 274 transports in phase 1 and 372 transports in phase 2. The average patient age was 50 ± 12 years. In phase 1 of the study, 178 of 274 patients (65%) received normal saline (mean volume ± standard deviation = 265 ± 192 mL). There was no significant correlation between the VAS change and the amount of fluid administration in either phase of the study. Conversely, during phase 2, patients receiving ondansetron ODT showed significant improvement in both measures of nausea. The difference in nausea improvement between phase 1 and phase 2 was significant (difference in VAS change: 24.6; 95% confidence interval 20.9, 28.3). Conclusion. There was no improvement in patient nausea related to quantity of saline alone during an EMS transport. The addition of ondansetron ODT resulted in a significant improvement in degree of nausea.

Assessing EMS scope of practice for utility and risk: the New Mexico EMS Interventions Assessment Project, Phase One results.

Purpose: To evaluate die accuracy of die Emergency Medical Priority Dispatch System (EMPDS) with respect to response level for cardiac arrest cases, and to compare response times for delta versus other response levels. The study setting was an urban ALS system that adopted a priority dispatch system 2.5 years ago. The sensitivity of the EMPDS has not been evaluated with regard to cardiac arrest cases since its implementation. We hypothesized that 99% of cardiac arrest cases would receive the highest level of response. Methods: We retrospectively reviewed 1994 emergency medical services (EMS) atraumatic cardiac arrest incident reports. We compared response time to response level using a subsample of 230 cases for which complete data were available. We used ANOVA and chi-square tests in our analyses. Results: Of 284 cardiac arrest cases, 258 (90.8%) were classified as delta, 17 (6.0%) as charlie, eight (2.8%) as bravo, and one (0.4%) as alpha. More cases were misclassified as charlie or lower than expected ( p p = 0.25). Conclusion: The EMPDS has high sensitivity in identifying and responding to cardiac arrest calls. The highest priority calls had, on average, approximately one minute faster response times than the lower priority calls. This reflects the importance of accuracy in this system, particularly with regard to conditions, such as cardiac arrest where response time is highly correlated with survival. The results of this study support the use of the EMPDS, and indicate the need for more specific analyses of the causes and consequences of misclassification of cardiac arrest cases.