Morgan Valley

Availability and Quality of Computed Tomography and Magnetic Resonance Imaging Equipment in U.S. Emergency Departments

OBJECTIVES The objective was to determine the availability and quality of computed tomography (CT) and magnetic resonance imaging (MRI) equipment in U.S. emergency departments (EDs). The authors hypothesized that smaller, rural EDs have less availability and lower-quality equipment. METHODS This was a random selection of 262 (5%) U.S. EDs from the 2005 National Emergency Department Inventories (NEDI)-USA (http://www.emnet-usa.org/). The authors telephoned radiology technicians about the presence of CT and MRI equipment, availability for ED imaging, and number of slices for the available CT scanners. The analysis was stratified by site characteristics. RESULTS The authors collected data from 260 institutions (99% response). In this random sample of EDs, the median annual patient visit volume was 19,872 (interquartile range = 6,788 to 35,757), 28% (95% confidence interval [CI] = 22% to 33%) were rural, and 27% (95% CI = 21% to 32%) participated in the Critical Access Hospital program. CT scanners were present in 249 (96%) institutions, and of these, 235 (94%) had 24/7 access for ED patients. CT scanner resolution varied: 28% had 1-4 slice, 33% had 5-16 slice, and 39% had a more than 16 slice. On-site MRI was available for 171 (66%) institutions, and mobile MRI for 53 (20%). Smaller, rural, and critical access hospitals had lower CT and MRI availability and less access to higher-resolution CT scanners. CONCLUSIONS Although access to CT imaging was high (>90%), CT resolution and access to MRI were variable. Based on observed differences, the availability and quality of imaging equipment may vary by ED size and location.

The Challenge of CT and MRI Imaging of Obese Individuals Who Present to the Emergency Department: A National Survey

The objective of this study was to estimate the availability of large weight capacity computed tomography (CT) and magnetic resonance imaging (MRI) equipment in US hospitals with emergency departments (EDs) and to evaluate animal facilities as alternate sources of imaging. We conducted a telephone survey of radiology technicians from a random sample of all the US hospitals with EDs (n = 262) and all 136 primary hospitals of academic EDs, 145 zoos, and 28 veterinary schools. We measured the prevalence of large weight capacity (>450 lb) CT and MRI, stratified by hospital characteristics. Response rates were 94–100% across samples. Nationally, 10% (95% confidence interval, 7–15) of hospitals with EDs had large weight capacity CT and 8% (95% confidence interval, 5–13) had large weight capacity MRI. In academic hospitals, access to large capacity equipment was better for CT (28%), but similar for MRI (10%) (P < 0.001 and 0.51, respectively). Few rural (5%) and critical‐access hospitals (3%) had large capacity CT. In addition, 34% of trauma centers, 23% of stroke centers, and 21% of bariatric surgery centers of excellence had large capacity CT. Only two zoos (1%) had CT scanners; both would not image human patients. Among veterinary schools, 16 (57%) had large weight capacity CT equipment, but only 4 (14%) would consider imaging human patients. Further, 23 (82%) veterinary schools reported policies that specifically prohibited imaging humans. For patients who weigh >450 lb, access to emergent CT and MRI is limited, even at academic and bariatric surgery centers. Animal facilities are not a viable alternative for diagnostic imaging of human patients.

Emergency Department Patient Volume and Troponin Laboratory Turnaround Time

OBJECTIVES Increases in emergency department (ED) visits may place a substantial burden on both the ED and hospital-based laboratories. Studies have identified laboratory turnaround time (TAT) as a barrier to patient process times and lengths of stay. Prolonged laboratory study results may also result in delayed recognition of critically ill patients and initiation of appropriate therapies. The objective of this study was to determine how ED patient volume itself is associated with laboratory TAT. METHODS This was a retrospective cohort review of patients at five academic, tertiary care EDs in the United States. Data were collected on all adult patients seen in each ED with troponin laboratory testing during the months of January, April, July, and October 2007. Primary predictor variables were two ED patient volume measures at the time the troponin test was ordered: 1) number of all patients in the ED/number of beds (occupancy) and 2) number of admitted patients waiting for beds/beds (boarder occupancy). The outcome variable was troponin turnaround time (TTAT). Adjusted covariates included patient characteristics, triage severity, season (month of the laboratory test), and site. Multivariable adjusted quantile regression was carried out to assess the association of ED volume measures with TTAT. RESULTS At total of 9,492 troponin tests were reviewed. Median TTAT for this cohort was 107 minutes (interquartile range [IQR] = 73-148 minutes). Median occupancy for this cohort was 1.05 patients (IQR = 0.78-1.38 patients) and median boarder occupancy was 0.21 (IQR = 0.11-0.32). Adjusted quantile regression demonstrated a significant association between increased ED patient volume and longer times to TTAT. For every 100% increase in census, or number of boarders over the number of ED beds, respectively, there was a 12 (95% confidence interval [CI] = 9 to 14) or 33 (95% CI = 24 to 42)-minute increase in TTAT. CONCLUSIONS Increased ED patient volume is associated with longer hospital laboratory processing times. Prolonged laboratory TAT may delay recognition of conditions in the acutely ill, potentially affecting clinician decision-making and the initiation of timely treatment. Use of laboratory TAT as a patient throughput measure and the study of factors associated with its prolonging should be further investigated.

Elevated Suicide Rates at High Altitude: Sociodemographic and Health Issues May Be to Blame.

Suicide rates are higher at high altitudes; some hypothesize that hypoxia is the cause. We examined 8,871 suicides recorded in 2006 in 15 states by the National Violent Death Reporting System, with the victims home county altitude determined from the National Elevation Dataset through FIPS code matching. We grouped cases by altitude (low<1000m; middle=1000-1999m; high≥2000m). Of reported suicides, 5% were at high and 83% at low altitude, but unadjusted suicide rates per 100,000 population were higher at high (17.7) than at low (5.7) altitude. High and low altitude victims differed with respect to race, ethnicity, rural residence, intoxication, depressed mood preceding the suicide, firearm use and recent financial, job, legal, or interpersonal problems. Even after multivariate adjustment, there were significant differences in personal, mental health, and suicide characteristics among altitude groups. Compared to low altitude victims, high altitude victims had higher odds of having family or friends report of a depressed mood preceding the suicide (OR 1.78; 95%CI:1.46-2.17) and having a crisis within 2weeks before death (OR 2.00; 95%CI:1.63-1.46). Suicide victims at high and low altitudes differ significantly by multiple demographic, psychiatric, and suicide characteristics; these factors, rather than hypoxia or altitude itself, may explain increased suicide rates at high altitude.

Ski patrollers: Reluctant role models for helmet use

Ski helmets reduce the risk of traumatic brain injury (TBI), but usage rates are low. Ski patrollers could serve as role models for helmet use, but little is known about their practices and beliefs. A written survey was distributed to ski patrollers attending continuing education conferences. The questions addressed included helmet use rates, prior TBI experiences, perceptions of helmet risks and benefits and willingness to serve as safety role models for the public. To assess predictors of helmet use, odds ratios (OR) were calculated, after adjusting for skiing experience. Ninety-three ski patrollers participated and the main outcome was self-reported helmet use of 100% while patrolling. Helmet use was 23% (95% CI 15–32%). Common reasons for non-use included impaired hearing (35%) and discomfort (29%). Most patrollers believed helmets prevent injuries (90%; 95% CI 84–96%) and that they are safety role models (92%; 95% CI 86–98%). However, many believed helmets encourage recklessness (39%; 95% CI 29–49%) and increase injury risks (16%; 95% CI 7–25%). Three factors predicted 100% helmet use: perceived protection from exposure (OR = 9.68; 95% CI 3.14–29.82) or cold (OR = 5.68; 95% CI 1.27–25.42); and belief that role modelling is an advantage of helmets (OR = 4.06; 95% CI 1.29–12.83). Patrollers who believed helmets encourage recklessness were eight times less likely to wear helmets (OR = 0.13; 95% CI 0.03–0.58). Ski patrollers know helmets reduce serious injury and believe they are role models for the public, but most do not wear helmets regularly. To increase helmet use, manufacturers should address hearing- and comfort-related factors. Education programmes should address the belief that helmets encourage recklessness and stress role modelling as a professional responsibility.

Is all pain is treated equally? A multicenter evaluation of acute pain care by age

Summary Older patients receive less analgesics than younger patients, yet had greater reductions in acute pain scores. These differences may be driven by type of pain. ABSTRACT Pain is highly prevalent in health care settings; however, disparities continue to exist in pain care treatment. Few studies have investigated if differences exist based on patient‐related characteristics associated with aging. The objective of this study was to determine if there are differences in acute pain care for older vs younger patients. This was a multicenter, retrospective, cross‐sectional observation study of 5 emergency departments across the United States evaluating the 2 most commonly presenting pain conditions for older adults, abdominal and fracture pain. Multivariable adjusted hierarchical modeling was completed. A total of 6,948 visits were reviewed. Older (≥65 years) and oldest (≥85 years) were less likely to receive analgesics compared to younger patients (<65 years), yet older patients had greater reductions in final pain scores. When evaluating pain treatment and final pain scores, differences appeared to be based on type of pain. Older patients with abdominal pain were less likely to receive pain medications, while older patients with fracture were more likely to receive analgesics and opioids compared to younger patients. Differences in pain care for older patients appear to be driven by the type of presenting pain.

Suicides in urban and rural counties in the United States, 2006-2008

BACKGROUND Suicide rates are higher in rural areas. It has been hypothesized that inadequate access to care may play a role, but studies examining individual decedent characteristics are lacking. AIMS We sought to characterize the demographic, socioeconomic, and mental health features of individual suicide decedents by urban-rural residence status. METHOD We analyzed suicides in 16 states using 2006-2008 data from the National Violent Death Reporting System and examined associations between decedent residence type and suicide variables with separate logistic regressions adjusted for age, sex, race, and ethnicity. RESULTS Of 17,504 analyzed suicides, 78% were in urban, 15% in rural adjacent, and 8% in rural nonadjacent locations. Rural decedents were less likely than urban decedents to have a mental health diagnosis or mental health care, although the prevalence of depressed moods appeared similar. Most suicides were by firearm, and rural decedents were more likely than urban decedents to have used a firearm. CONCLUSION Rural decedents were less likely to be receiving mental health care and more likely to use firearms to commit suicide. A better understanding of geographic patterns of suicide may aid prevention efforts.

Occupation and suicide: Colorado, 2004–2006

BACKGROUND Occupation has been identified as a risk factor for suicide. Changes in work environments over time suggest occupations at high risk of suicide may also change. Therefore, periodic examination of suicide by occupation is warranted. The purpose of this article is to describe suicide rates by occupation, sex, and means used in Colorado for the period 2004-2006. METHODS To provide information useful in designing suicide prevention programs, the methods used in suicide across occupational groups also are examined. Data from the Colorado Violent Death Reporting System (COVDRS) were obtained for suicides that occurred between 2004 and 2006. Denominators to calculate rates by age, sex, and race used are from the 2000 US Census of the Population data. RESULTS Men had higher suicide rates than women in all occupation categories except computers and mathematics. Among men, those in farming, fishing, and forestry (475.6 per 100,000) had the highest age-adjusted suicide rates. Among women, workers with the highest suicide rates were in construction and extraction (134.3 per 100,000). The examination of lethal means showed that workers in farming, fishing, and forestry had higher rates of suicide by firearms (50.18 per 100,000) compared with other workers. Healthcare practitioners and technicians had the highest rate of suicide by poisoning (14.25 per 100,000). Workers involved in construction and extraction (26.43 per 100,000) had higher rates of suicide by hanging, suffocation, or strangling. CONCLUSIONS Significant differences in means of suicide were seen by occupation, which could guide future suicide prevention interventions that may decrease work-related suicide risks.

Student perspectives on the diversity climate at a U.S. medical school: the need for a broader definition of diversity

BackgroundMedical schools frequently experience challenges related to diversity and inclusiveness. The authors conducted this study to assess, from a student body’s perspective, the climate at one medical school with respect to diversity, inclusiveness and cross-cultural understanding.MethodsIn 2008 students in the doctor of medicine (MD), physical therapy (PT) and physician assistant programs at a public medical school were asked to complete a diversity climate survey consisting of 24 Likert-scale, short-answer and open-ended questions. Questions were designed to measure student experiences and attitudes in three domains: the general diversity environment and culture; witnessed negative speech or behaviors; and diversity and the learning environment. Students were also asked to comment on the effectiveness of strategies aimed at promoting diversity, including diversity and sensitivity training, pipeline programs, student scholarships and other interventions. Survey responses were summarized using proportions and 95 percent confidence intervals (95% CI), as well as inductive content analysis.ResultsOf 852 eligible students, 261 (31%) participated in the survey. Most participants agreed that the school of medicine (SOM) campus is friendly (90%, 95% CI 86 to 93) and welcoming to minority groups (82%, 95% CI 77 to 86). Ninety percent (95% CI 86 to 93) found educational value in a diverse faculty and student body. However, only 37 percent (95% CI 30 to 42) believed the medical school is diverse. Many survey participants reported they have witnessed other students or residents make disparaging remarks or exhibit offensive behaviors toward minority groups, most often targeting persons with strong religious beliefs (43%, 95% CI 37 to 49), low socioeconomic status (35%, 95% CI 28 to 40), non-English speakers (34%, 95% CI 28 to 40), women (30%, 95% CI 25 to 36), racial or ethnic minorities (28%, 95% CI 23 to 34), or gay, lesbian, bisexual or transgendered (GLBT) individuals (25%, 95% CI 20 to30). Students witnessed similar disparaging or offensive behavior by faculty members toward persons with strong religious beliefs (18%, 95% CI 14 to 24), persons of low socioeconomic status (12%, 95% CI 9 to 17), non-English speakers (10%, 95% CI 6 to 14), women (18%, 95% CI 14 to 24), racial or ethnic minorities (12%, 95% CI 8 to 16) and GLBT individuals (7%, 95% CI 4 to 11). Students’ open-ended comments reinforced the finding that persons holding strong religious beliefs or conservative values were the most common targets of disparaging or offensive behavior.ConclusionsThese data suggest that medical students believe that diversity and a climate of inclusiveness and respect are important to a medical school’s educational and clinical care missions. However, according to these students, the institution must embrace a broader definition of diversity, such that all minority groups are valued, including individuals with conservative viewpoints or strong religious beliefs, the poor and uninsured, GLBT individuals, women and non-English speakers.

Older Adult Opinions About Driving Cessation: A Role for Advanced Driving Directives

Objectives: To describe older adults’ opinions about driving cessation and driver retesting. Methods: Older adult (≥ 65 years) patients visiting the emergency department or geriatric clinic at a university hospital completed a confidential survey regarding attitudes toward driving tests and restrictions. Results: The response rate was 50% (N = 169). The median age was 75 years (range, 65-98); 53% were women. Most reported driving at least occasionally (78%; 95% confidence interval [95% CI], 72-84). Twelve percent (95% CI, 7-18) reported a crash in the prior year; most (84%; 95% CI, 78-90) reported at least 1 medical diagnosis possibly linked to increased crash risk. Most participants (74%; 95% CI, 67-81) supported mandatory, age-based driver retesting but thought family (73%; 95% CI, 68-81) or physicians (60%; 95% CI, 54-69) should determine license revocation for an unsafe driver rather than the Department of Motor Vehicles (34%; 95% CI, 28-42) or the police (30%; 95% CI, 23-37). Almost all reported they would consider driving cessation if recommended by a physician (88%; 95% CI, 82-94) or family member (71%; 95% CI, 63-79), without significant age or sex differences. Conclusions: Older drivers support mandatory age-based testing but appear more likely to follow recommendations from physicians or family members, thereby supporting a role for physician counseling, driver evaluations, and advanced driving directives.