Mary D. Gunnels

Attitudes of emergency department patients and visitors regarding emergency exception from informed consent in resuscitation research, community consultation, and public notification

OBJECTIVE To assess public views on emergency exception to informed consent in resuscitation research, public awareness of such studies, and effective methods of community consultation and public notification. METHODS A face-to-face survey was conducted in two academic Level I trauma center emergency departments (EDs) in Oregon and Minnesota from June through August 2001. RESULTS Five hundred thirty people completed the survey, with an 82% response rate. The mean age of the respondents was 41 years (range 18-95) with a standard deviation of 14.5; 46% were female and 64% white. Most (88%) believed that research subjects should be informed prior to being enrolled, while 49% believed enrolling patients without prior consent in an emergency situation would be acceptable and 70% (369) would not object to be entered into such a study without providing prospective informed consent. Informing and consulting the community as a substitute for patient consent in emergency research was thought to be reasonable by 45% of the respondents. Most respondents would prefer to be informed about a study using emergency exception from informed consent by radio and television media (42%). Two hundred fifty-eight respondents (49%) stated they would attend a community meeting; the less educated were more likely to attend than those with college degrees (OR = 0.53; 95% CI = 0.33 to 0.85, p = 0.008). However, only 5% knew of ongoing studies in their community using emergency exception from informed consent. CONCLUSIONS Most respondents disagreed with foregoing prospective informed consent for research participation even in emergency situations; however, many would be willing to participate in studies using emergency exception from informed consent. Most respondents would not attend community meetings, and would prefer to rely upon the media for information. Very few were aware of emergency exception from informed consent studies in their community. This suggests that current methods of community notification may not be effective.

The Public Access Defibrillation (PAD) trial: study design and rationale.

The PAD Trial is a prospective, multicenter, randomized clinical study testing whether volunteer, non-medical responders can improve survival from out-of-hospital cardiac arrest (OOH-CA) by using automated external defibrillators (AEDs). These lay volunteers, who have no traditional responsibility to respond to a medical emergency as part of their primary job description, will form part of a comprehensive, integrated community approach to the treatment of OOH-CA. The study is being conducted at 24 field centers in the United States and Canada. Approximately 1000 community units (e.g. apartment or office buildings, gated communities, sports facilities, senior centers, shopping malls, etc.) were randomized to treatment by trained laypersons who will provide either cardiopulmonary resuscitation (CPR) alone or CPR plus use of an AED, while awaiting arrival of the communitys emergency medical services responders. The primary endpoint is the number of OOH-CA victims who survive to hospital discharge. Secondary endpoints include neurological status, health-related quality of life (HRQL), cost, and cost-effectiveness. Data collection will last approximately 15 months and is expected to be completed in September 2003.

ATLS practices and survival at rural level III trauma hospitals, 1995-1999.

Objective: To determine whether Advanced Trauma Life Support (ATLS) practices characterizing initial resuscitation and interfacility transfer at rural trauma hospitals are associated with risk-adjusted survival. Methods: Retrospective, observational analysis of rural injured patient survival. Process-of-care variables were associated with TRISS (trauma and injury severity score)-derived Z-statistics (95% confidence intervals) for high-risk population subsets (defined below). Inclusion criteria: all patients ≥12 years of age entered into a statewide trauma system, January 1, 1995, to December 31, 1999, and initially presenting to Level III trauma centers (N = 4,961). Exclusion criteria: pronounced dead on arrival (n = 26), directly admitted to hospital (n = 3), and unknown disposition at first hospital (n = 2). Process variables include: intubation in emergency department (ED) given Glasgow Coma Scale (GCS) score < 9 [ INTUB ], administration of blood products in ED given systolic blood pressure (SBP) < 90 mm Hg [ BLOOD ], trauma surgeon presence within 5 minutes of patient arrival given GCS < 9 mm Hg or SBP < 90 mm Hg [ UNSTABLE-TS ], trauma surgeon presence within 5 minutes of patient arrival given injury severity score (ISS) > 15 [ ISS-TS ], transfer to higher level of care given ISS > 20 and no hypotension [ TRAN ], transfer to higher level of care given GCS < 9 [ TRAN-GCS ]. Results: For the high-risk subpopulations, the following Z-scores (with and without an intervention) were found: Conclusions: Some ATLS interventions ( BLOOD , TRAN , and TRAN-GCS ) are associated with improved survival for selected high-risk subgroups in these 21 rural Level III trauma hospitals.

ACCURACYOF ARRHYTHMIARECOGNITIONIN PARAMEDICTREATMENTOF PAROXYSMALSUPRAVENTRICULARTACHYCARDIA: A TEN-YEAR REVIEW

Objectives. To examine trends in paramedic rhythm misidentification rates in the use of adenosine for presumed paroxysmal supraventricular tachycardia (PSVT) over a ten-year period, and to determine variables associated with rhythm misidentification. Methods. The authors conducted a retrospective analysis of all cases in which paramedics treated presumed PSVT with adenosine from 1993 to 2002. Rhythm strips were categorized as narrow or wide-complex and regular or irregular. Appropriate use of adenosine was defined as narrow-complex regular tachycardia with no visible P waves and rate greater than 140 beats/min. Results. The authors studied 224 patients with a mean age of 60 years (range, 15–94 years); 157 (70%) were female and predominantly white. The majority (54%) of patients had initial heart rates of 161–200 beats/min. Forty-nine percent of the patients had a previous history of PSVT. Inappropriate use of adenosine occurred in 45 (20%) cases. Misidentification rates per year ranged from 9% to 31% with the lowest rate occurring after a targeted education program on tachydysrhythmias. An initial heart rate of <160 beats/min (χ2 = 14.81, p < 0.001) and absence of a medical history of either fast heart rate or palpitations (χ2 = 11.35, p = 0.001) were associated with inappropriate use of adenosine. Conclusion. Paramedics in this emergency medical services system are more likely to use adenosine appropriately for patients with initial heart rates of >160 beats/min and a history of rapid heart rate or palpitations. Further studies are required to identify factors associated with rhythm interpretation errors in the prehospital setting as well as to evaluate error reduction strategies.