Ronald F. Maio

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.

The epidemiology of pain in the prehospital setting

Objective. To develop national estimates of the epidemiology of pain in the prehospital setting. Methods. Cross-sectional data on a probability sample of 21,103 emergency department (ED) visits from the 1999 National Hospital Ambulatory Medical Care Survey were analyzed. For patients arriving by ambulance, the frequencies (95% confidence intervals) of patients presenting with no level of pain reported (data unknown or missing) and those reporting no, mild, and moderate or severe pain were determined. The reasons for visit among those with moderate or severe pain, and the ED narcotic analgesic use among those with pain information reported and not reported, were also determined. >Results. Of the 102.8 million patients visiting the ED in 1999, 14.5 million arrived by ambulance. Fifty-three percent (49-58%) were female. Seven million six hundred thousand [52% (48-56%)] had no information on presenting level of pain reported, 2.0 million [14% (2-25%)] had no pain, 2.0 million [14% (3-25%)] had mild pain, and 2.9 million [20% (12-29%)] had moderate or severe pain. Among those with moderate or severe pain, the most common reasons for visit were injuries 27% (11-43%) and non-injury musculoskeletal symptoms 18% (0-39%). Narcotic analgesics were ordered or continued in 13% (0-29%) of those with no presenting level of pain recorded and 21% (9-34%) of those for whom the presenting level of pain was recorded. >Conclusion. Pain is a common condition among prehospital patients: 20% reported moderate to severe pain. Given the use of narcotic analgesics among those for whom pain information was not reported, this is likely a conservative estimate.

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.

Rural motor vehicle crash mortality: The role of crash severity and medical resources

We did a retrospective case control study to examine the relationship between the risk of dying for Michigan motor vehicle crash (MVC) drivers and the type of county (rural/nonrural) of crash occurrence, while adjusting for crash characteristics, age, sex, and the medical resources in the county of crash occurrence. The 1987 Michigan Accident Census was used to obtain data regarding all MVC driver nonsurvivors (733) and a random sample of all surviving drivers (2,483). County of crash occurrence was defined as rural or nonrural. The crash characteristics analyzed were vehicle deformity, seat belt use, and drivability of the vehicle from the scene. Age and sex of the driver were also analyzed. Medical resource characteristics for the county of crash occurrence were measured as the number of resources per square mile for each of the following: ambulances, emergency medical technicians (EMT), acute care hospital beds, and operating rooms, surgeons and emergency physicians. Also considered were the number and level of emergency rooms in the county of crash occurrence along with the maximum level of prehospital care available (basic life support versus advanced life support) in a county. Before adjusting, the relative risk (RR) for rural MVC drivers dying, compared to their nonrural counterparts, was 1.96. Adjustment for crash characteristics, age, and sex (using logistic regression) decreased the RR to 1.51. An attempt to add medical resource variables to the model resulted in high correlation with the rural/nonrural variable, as well as with each other. This multi-collinearity prevented us from providing a simple explanation of the role of medical resource variables as predictors of survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Crash characteristics and injuries of victims impaired by alcohol versus illicit drugs

Alcohol has long been associated with injury, but the relationship between other drugs and injury is less clear. Blood samples from 894 patients presenting to two Emergency Departments for treatment of motor vehicle injury sustained in passenger cars, station wagons, vans and pickup trucks, were tested for alcohol and other drugs. Results were related to demographic characteristics, including prior history of alcohol and drug use; crash characteristics; and injury characteristics. Alcohol was associated with more severe crashes, but other drugs, in the absence of alcohol, were not. The crashes involving drugs but no alcohol were very similar to those involving neither alcohol nor drugs.

Health status, not head injury, predicts concussion symptoms after minor injury.

OBJECTIVE Postconcussion (PC) syndrome etiology remains poorly understood. We sought to examine predictors of persistent PC symptoms after minor injury. METHODS Health status, symptom, and injury information were obtained on a sample of patients presenting to the emergency department after minor injury. Postconcussion and cognitive symptoms were assessed at 1, 3, and 12 months. RESULTS Among 507 patients enrolled, 339 had head injury. Repeated-measures logistic regression modeling of PC and cognitive symptom presence across time indicated that baseline mental health status and physical health status were most predictive of persistent symptoms. In contrast, head injury presence did not predict persistent PC syndrome. DISCUSSION Baseline mental health status and physical health status were associated with persistent PC syndrome after minor injury, but head injury status was not. Further studies of PC syndrome pathogenesis are needed.

GEOGRAPHIC VARIATION IN PREVENTABLE DEATHS FROM MOTOR VEHICLE CRASHES

OBJECTIVE In Michigan, drivers in rural motor vehicle crashes (MVCs) are twice as likely to die as nonrural drivers: this could be due to variation in the quality of acute trauma care. This study tests the hypothesis that the preventable death rate (PDR) is higher and that anatomic injury severity is lower for rural compared to nonrural MVC fatalities. DESIGN Retrospective cohort study. METHODS Autopsy results from MVC victims of three rural counties and one nonrural county were reviewed. The time period was 1986-1991. Using the Abbreviated Injury Scale, 1985 version (AIS-85), Injury Severity Scores (ISSs) and Anatomical Profile G scores were calculated. Preventability was determined based on ISSs (< 59) and AIS scores in the head region (< 5). Students t test and the chi-squared test were used for analysis; a p value of < 0.05 was considered statistically significant. RESULTS 143 rural and 306 nonrural fatalities were analyzed. The rural PDR was 37.1% and nonrural 48.0% (p < 0.05). ISSs and also G scores were significantly different between rural (54.8; -2.1) and nonrural (50.2; -1.2) areas. CONCLUSION This study suggests that regional variation in the quality of acute trauma care is not a significant factor in regional variation in MVC mortality.

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.

Prevalence of domestic violence and associated factors among women on a trauma service

BACKGROUND Despite the increasing recognition of the problem of domestic violence (DV), it has not been studied in surgical populations. METHODS Eligible patients underwent screening for a recent history of DV and alcohol abuse (AA). Other demographic, health, and injury-related data were also collected. RESULTS Of 127 subjects entered into the study, 18% screened positive for DV and 21% screened positive for AA. Of those screening positive for DV, 65% screened positive for AA compared with 12% of those screening negative for DV (p < 0.001.) Screening for DV was recommended by a vast majority of subjects, with only 6% of subjects responding that it was not appropriate. CONCLUSION Both DV and AA have a high prevalence among female trauma patients admitted to trauma centers. Nearly all subjects recommended screening for DV. Screening for DV should be incorporated into the routine care of female trauma patients.

Alcohol effects on motor vehicle crash injury.

CONTEXT Although alcohol is frequently present in injured patients, whether it exacerbates injury and whether tolerance to alcohol changes such a relationship is less clear. Most clinical studies do not consider other important predictors of injury, making interpretation of their findings problematic. OBJECTIVE To examine alcohols role in injuries, taking into account other important factors, and to examine the effect of tolerance, if any. DESIGN Prospective cohort study. SETTING University hospital and community hospital emergency departments and morgue. PATIENTS 1362 Motor Vehicle Crash patients age >/=18, treated and released, admitted, and deceased. MAIN OUTCOME MEASURES Excess injury measured by Injury Severity Scale (ISS) 90, Weighted Revised Trauma Score (WRTS), and G-Score. RESULTS Using regression analysis, the best predictors of injury severity were vehicle crush (TAD), safety belt use, and their interaction, and age. Alcohol use further predicted injury. Using the final regression model, the effect of alcohol was to increase ISS90, on average, by about 30% (from a predicted ISS90 of 5.1 to 6.8, all else being equal). The adjusted odds ratio for serious injury (ISS90>15), was 1.59 for a patient with a positive blood alcohol concentration (alc+) compared to a alc- patient. This potentiating effect is seen even for patients with low levels of alcohol (<22 mmol/liter; <0.100 BAC) but is not linear with increasing alcohol level. Tolerance to alcohol did not affect the potentiation of injury by alcohol. CONCLUSION When other relevant variables are considered, alcohol increases injury, but the effects of alcohol level and alcohol tolerance are less clear. These findings have important implications for injury prevention, treatment, and research.