Mary Ann Gregor

Emergency Medical Services Outcomes Project I (EMSOP I): Prioritizing Conditions for Outcomes Research☆☆☆★★★

Over the past several years, out-of-hospital EMS have come under increased scrutiny regarding the value of the range of EMS as currently provided. We used frequency data and expert opinion to rank-order EMS conditions for children and adults based on their potential value for the study of effectiveness of EMS care. Relief of discomfort was the outcome parameter EMS professionals identified as having the most potential impact for the majority of children and adults in the top quartile conditions. Future work from this project will identify appropriate severity and outcome measures that can be used to study these priority conditions. The results from the first year of this project will assist those interested in EMS outcomes research to focus their efforts. Furthermore, the results suggest that nonmortality out-come measures, such as relief of discomfort, may be important parameters in determining EMS effectiveness.

A study of preventable trauma mortality in rural Michigan.

OBJECTIVE To determine the preventable death rate (PDR) and the frequency and types of inappropriate medical care in a large, rural region of Michigan. DESIGN A prospective study of all deaths caused by injury during a 1-year period. METHODS Preventability of death and appropriateness of care were determined using a structured implicit review process and expert panel. A second panel was convened to confirm the reliability of the review process. MAIN RESULTS One hundred fifty-five injury-related deaths underwent panel review. Four deaths (2.6%) were found to be definitely preventable and 16 (10.3%) possibly preventable, for a combined preventable death rate of 12.9%. Sixty-five deaths (41.9%) occurred in the emergency department or hospital; 18 of these (27.7%) were judged to be definitely preventable or possibly preventable. Forty-three episodes of inappropriate care were identified in 27 (17.4%) of the 155 cases reviewed. These occurred primarily in the emergency department and hospital rather than during prehospital care or transfer. CONCLUSIONS A relatively small percentage of trauma fatalities in rural Michigan could have been prevented by more appropriate or timely medical care. Efforts to improve the care of injured persons in rural Michigan should be directed primarily at the emergency department and inpatient phases of trauma system care.

Adolescent injury in the emergency department: Opportunity for alcohol interventions?

STUDY OBJECTIVE Alcohol, the most commonly used substance among adolescents, is frequently associated with injury. Little is known regarding the drinking characteristics of injured adolescents. Such data are critical for developing emergency department interventions to decrease alcohol-related injury among adolescents. We sought to describe the drinking characteristics of injured adolescents and to describe the relationship of injury severity and mechanisms with drinking characteristics. METHODS This study was a prospective cohort study performed in a university hospital (sampled May 1, 1995, to July 15, 1995) and a large urban teaching hospital (sampled May 1, 1996, to August 1, 1996). The participants were aged 12 to 20 years, presenting within 6 hours of an injury. We performed a saliva alcohol test and self-administered questionnaire. Age, sex, E-code, injury severity score (ISS), and ED disposition were recorded. An alcohol frequency/quantity index was calculated. Descriptive statistics and 95% confidence intervals were calculated. RESULTS Two hundred sixty-three patients with a mean age of 17 years and a mean ISS of 2.1 (SD 3.5) were recruited. One hundred fifty-two (50%) were males, and 33 (13%) were admitted. Ten (4%) patients had a positive saliva alcohol test response. On average, within the last year, these adolescents had 1.7 adverse alcohol consequences. Sixty percent drank in unsupervised settings, and 36% reported drinking 5 or more drinks in a row. CONCLUSION Alcohol use/misuse is a substantial problem among injured adolescents regardless of severity or mechanism of injury. ED physicians should consider screening/intervention or primary prevention of alcohol problems for all injured adolescents.

The accuracy of medical records and police reports in determining motor vehicle crash characteristics

OBJECTIVE To determine the accuracy of police, emergency department, and ambulance records in describing motor vehicle crash (MVC) characteristics when compared with a crash investigation report (CIR). METHODS This study was a retrospective record review. Sixty-three motor vehicle crash (MVC) patients transported to a university hospital emergency department via ambulance and also reported in a crash investigation record (CIR) during the period January 1993 to December 1995 comprised the study population. The crash characteristics analyzed were occupant position (OP), restraint use (RU), air bag deployment (AD), type of impact (TI), ejection (EJ), and external cause-of-injury code (EC). The accuracies of the police report (PR), the emergency department record (EDR), and the ambulance report (AR) for each patient were compared with the CIR by computing percent agreement, with 95% confidence intervals (95% CIs) for each variable and for each data source. RESULTS Overall average agreement was 92.9% for PR, 89.7% for EDR, and 80.7% for AR. The overall average agreement for each variable was 98.9% for EJ, 92.1% for AD, 91.5% for OP, 90.5% for EC, 77.2% for RU, and 76.2% for TI. For all but one variable (RU), 95% CIs overlapped between data sources. CONCLUSIONS The accuracy of data sources used to determine crash characteristics varies. Using a CIR as the standard, the PR was the most accurate. Inaccuracies occurred most frequently for RU and TI. Researchers and clinicians need to be aware of these inaccuracies.

Caregiver adherence to follow-up after an emergency department visit for common pediatric illnesses: Impact on future ED use

Background:Access to primary care is often a problem for children living in urban areas and the rate of emergency department (ED) use can be high. For acute childhood illnesses, primary care follow-up is often recommended to prevent subsequent ED visits. Methods:We conducted an observational study of 455 children with common childhood illnesses, between 6 weeks and 8 years of age, presenting to 1 of 3 EDs, and discharged to the community. ED physicians recommended that the child visit their primary care physician within 1 to 4 days of discharge (ie, “short-term” follow-up). Caregivers were surveyed during the ED index visit and after discharge to assess primary care follow-up adherence. We collected data on child and caregiver characteristics, type and severity of illness at the ED index visit, and ED return visits in the 2-month period after the ED index visit. Results:A total of 45.3% of caregivers adhered to short-term primary care follow-up. Short-term follow-up adherence was associated with greater ED use for the same illness over the subsequent 2 months (odds ratio = 2.97; 95% confidence interval, 1.31–6.72). Subsequent ED use was greatest for children with short-term primary care follow-up and: (1) prior ED use, (2) single caregivers, (3) mild severity illnesses at the ED index visit, or (4) younger children. ED use after the initial visit did not vary by type of illness or site. Conclusions:There was no evidence that primary care follow-up soon after an ED visit was associated with a lower rate of subsequent ED use for common pediatric illnesses.

Rates of at-risk drinking among patients presenting to the emergency department with occupational and nonoccupational injury

OBJECTIVES To compare the characteristics and rates of at-risk drinking among patients presenting to the emergency department (ED) with occupational and nonoccupational injury. METHODS Cross-sectional survey of injured patients presenting to a university hospital ED. Injured patients were prospectively identified, and consenting patients completed a survey including questions regarding quantity/frequency of alcohol use, TWEAK, CAGE, and work-relatedness of injury. Major trauma and motor-vehicle collisions were excluded. Demographic and injury information was obtained from the medical record. Patients with a TWEAK score > or =3, CAGE score > or =2, or who exceeded NIAAA quantity/frequency guidelines were defined as at-risk drinkers. Analysis utilized the Student t-test for continuous variables, and frequency and chi-square analysis for categorical variables. RESULTS Among 3,476 enrolled patients, 766 (22%) had work injuries and 2,710 (78%) had nonwork injuries. Patients with work injuries were as likely as patients with nonwork injuries to be at-risk drinkers; 35% of patients with an occupational injury and 36% of those with a nonoccupational injury were at-risk drinkers (odds ratio = 0.96). CONCLUSIONS Patients presenting to the ED with an occupational injury have rates of at-risk drinking similar to other injury patients, and may be an important group in which to target brief alcohol interventions.

Derivation and validation of criteria for determining the appropriateness of nonemergency ambulance transports

OBJECTIVE Nonemergency ambulance transports (NETs) represent a substantial proportion of all ambulance transports. Recently, the medical necessity of a substantial number of NETs has been questioned. The purpose of the study was threefold: 1) to formulate criteria for NET using a multidisciplinary panel; 2) to develop a structured implicit review instrument (SIRI) for the evaluation of NET from the criteria formulated; and 3) to evaluate the reliability and validity of the SIRI. Previously, a validated instrument has not been available to assess NET appropriateness. METHODS Using a modified Delphi process and scale development techniques, a panel of ten multidisciplinary health care professionals determined criteria for NET and developed a SIRI consisting of two dimensions: 1) ambulation status and 2) medical care requirements. A convenience sample of 50 cases (occurring January through May 1996) were retrospectively reviewed by individual panel members and two panels, and categorized as either: 1) definitely appropriate NET; 2) possibly appropriate NET; 3) patient did not require ambulance transport; 4) patient required emergency transport; and 5) indeterminate. Reliability of the SIRI was assessed using percent agreement among individual panels and weighted kappa for the two panels. Interitem consistency of the SIRI was measured by Cronbachs alpha. Criterion validity was assessed by comparing percent agreements between the SIRI and Medicare reimbursement guidelines. RESULTS Percent agreement among individual panel members was 62%. Percent agreement among the two panels was 74%, with a kappa of 0.43. Cronbachs alpha for individual panel member item response ranged from 0.647 to 0.960. Percent agreement with Medicare reimbursement guidelines was 92%. CONCLUSION Consensus criteria and an associated SIRI were developed for determining the appropriateness of NETs. Further research is needed to build on the validity and reliability of this instrument.

46. The Accuracy of Medical Records and Police Reports in Determining Motor Vehicle Crash Characteristics

Objective : To determine the accuracy of ambulance (AR), emergency department (EDR) and police (PR) records in describing motor vehicle crash (MVC) characteristics when compared to a standard - an in-depth motor vehicle crash investigation record (CIR). Methods : Fifty-six MVC patients transported to a suburban, university hospital emergency department via ambulance and included in a crash investigation were identified. The time period was January 1993 through December 1995. Data sources were the AR, EDR, PR and CIR. The CIR was abstracted to a standard form. The other data sources were abstracted to a standard form using a retrospective, blinded review. Variables included occupant position, restraint use, air bag deployment, type of impact, ejection, and external cause of injury code. Accuracy was measured by determining percent agreement and Kappa for each data source compared to the CIR. Results : Forty-six cases (82%) had one or more episodes of discordance. The mean percent agreement for the sources studied was AR 0.813, EDR 0.893 and PR 0.932. Mean values for Kappa were AR 0.712, EDR 0.831 and PR 0.885. Among variables, restraint use was determined with the least accuracy with means for percent agreement and Kappa of 0.792 and 0.674, respectively. For the AR, discordance was due to missing information almost 50% of the time.