Sheila A. Turris

Reducing Delay for Women Seeking Treatment in the Emergency Department for Symptoms of Potential Cardiac Illness

INTRODUCTION Despite more than 2 decades of research, delay in seeking treatment is a persistent clinical issue. Because of the often time-limited efficacy of therapies for acute myocardial infarction, nowhere is this of more concern than in the case of seeking treatment for symptoms indicative of potential cardiac illness. Women are frequently reported to delay longer than their male counterparts when seeking treatment for similar symptoms of cardiac nature. Women may be at particular risk of delay because they often live alone and are a decade older then men at the onset of their heart disease. METHODS In this grounded theory study, womens experiences of emergency department care as they relate to seeking treatment for the symptoms of a potential cardiac event were explored. Seventeen interviews were carried out with 16 women who sought care in 1 of 2 Canadian, urban, emergency departments between June 2005 and June 2006, and 100 hours of naturalistic observation were completed. RESULTS The core category was maintaining personal, social, and physical integrity. The participants strove to make sense of their symptoms and to act on those symptoms in ways congruent with maintaining integrity. The results of this study indicate that some concrete strategies can be used by emergency nurses to influence womens decisions about seeking treatment for the symptoms of a potential cardiac event. DISCUSSION Health care professionals draw on the scientific model to understand and interpret the meaning of symptoms. In contrast, women draw on personal experience. Understanding how women make decisions about their symptoms will help health care providers intervene to minimize delay.

Shortening the Wait: A Strategy to Reduce Waiting Times in the Emergency Department

Emergency Department crowding (EDC), extended wait times, and the issues arising as a result are well described in the health-care literature. Accordingly, reducing waiting times has become a focus across Canada. Less-urgent patient presentations represent a large proportion of the individuals presenting for care in Canadian emergency departments (ED). This patient population contributes to congestion in the ED. In light of these issues, an innovative program is being trialed at Burnaby Hospital, in the lower mainland of British Columbia. The goals of the program include: a reduction of EDC, a shortening of the duration of time between patient presentation and treatment, and an increase reported levels of patient satisfaction.

Mass-gathering Medicine: Risks and Patient Presentations at a 2-Day Electronic Dance Music Event

INTRODUCTION Music festivals, including electronic dance music events (EDMEs), increasingly are common in Canada and internationally. Part of a US

Mass gathering medicine: a practical means of enhancing disaster preparedness in Canada

4.5 billion industry annually, the target audience is youth and young adults aged 15-25 years. Little is known about the impact of these events on local emergency departments (EDs). METHODS Drawing on prospective data over a 2-day EDME, the authors of this study employed mixed methods to describe the case mix and prospectively compared patient presentation rate (PPR) and ambulance transfer rate (ATR) between a first aid (FA) only and a higher level of care (HLC) model. RESULTS There were 20,301 ticketed attendees. Seventy patient encounters were recorded over two days. The average age was 19.1 years. Roughly 69% were female (n=48/70). Forty-six percent of those seen in the main medical area were under the age of 19 years (n=32/70). The average length of stay in the main medical area was 70.8 minutes. The overall PPR was 4.09 per 1,000 attendees. The ATR with FA only would have been 1.98; ATR with HLC model was 0.52. The presence of an on-site HLC team had a significant positive effect on avoiding ambulance transfers. DISCUSSION Twenty-nine ambulance transfers and ED visits were avoided by the presence of an on-site HLC medical team. Reduction of impact to the public health care system was substantial. CONCLUSIONS Electronic dance music events have predictable risks and patient presentations, and appropriate on-site health care resources may reduce significantly the impact on the prehospital and emergency health resources in the host community.

Medical support for the 2009 World Police and Fire Games: a descriptive analysis of a large-scale participation event and its impact.

BACKGROUND We explore the health care literature and draw on two decades of experience in the provision of medical care at mass gatherings and special events to illustrate the complementary aspects of mass gathering medical support and disaster medicine. Most communities have occasions during which large numbers of people assemble in public or private spaces for the purpose of celebrating or participating in musical, sporting, cultural, religious, political, and other events. Collectively, these events are referred to as mass gatherings. The planning, preparation, and delivery of health-related services at mass gatherings are understood to be within the discipline of emergency medicine. As well, we note that owing to international events in recent years, there has been a heightened awareness of and interest in disaster medicine and the level of community preparedness for disasters. We propose that a synergy exists between mass gathering medicine and disaster medicine. METHOD Literature review and comparative analysis. RESULTS Many aspects of the provision of medical support for mass gathering events overlap with the skill set and expertise required to plan and implement a successful medical response to a natural disaster, terrorist incident, or other form of disaster. CONCLUSIONS There are several practical opportunities to link the two fields in a proactive manner. These opportunities should be pursued as a way to improve the level of disaster preparedness at the municipal, provincial, and national levels.

Mass-gathering medicine: creation of an online event and patient registry.

INTRODUCTION In the summer of 2009, British Columbia hosted the World Police and Fire Games (WPFG). The event brought together 10,599 athletes from 55 countries. In this descriptive, Canadian study, the composition of the medical team is analyzed, the unique challenges faced are discussed, and an analysis of the illness and injury rates is presented. This event occurred during a labor dispute affecting the sole provider of emergency ambulance service in the jurisdiction, which necessitated additional planning and resource allocation. As such, the context of this event as it relates to the literature on mass gathering medicine is discussed with a focus on how large-scale public events can impact emergency services for the community. METHODS This is a case report study. RESULTS There were 1,462 patient encounters. The majority involved musculo-skeletal injuries (53.8%). The patient presentation rate (PPR) was 109.40/1,000. The medical transfer rate (MTR) was 2.32/1,000. The ambulance transfer rate (ATR) for the 2009 WPFG was 0.52/1,000. In total, 31 patients were transported to the hospital, the majority for diagnostic evaluation. Only seven calls were placed to 9-1-1 for emergency ambulance service. CONCLUSIONS The 2009 WPFG was a mass-gathering sporting event that presented specific challenges in relation to medical support. Despite relatively high patient presentation rates, the widely spread geography of the event, and a reduced ability to depend on 9-1-1 emergency medical services, there was minimal impact on local emergency services. Adequate planning and preparation is crucial for events that have the potential to degrade existing public resources and access to emergency health services for participants and the public at large.

Triage During Mass Gatherings

UNLABELLED INTRODUCTION/PROBLEM: A review of the mass-gathering medicine literature confirms that the research community currently lacks a standardized approach to data collection and reporting in relation to large-scale community events. This lack of consistency, particularly with regard to event characteristics, patient characteristics, acuity determination, and reporting of illness and injury rates makes comparisons between and across events difficult. In addition, a lack of access to good data across events makes planning medical support on-site, for transport, and at receiving hospitals, challenging. This report describes the development of an Internet-hosted, secure registry for event and patient data in relation to mass gatherings. METHODS Descriptive; development and pilot testing of a Web-based event and patient registry. RESULTS Several iterations of the registry have resulted in a cross-event platform for standardized data collection at a variety of events. Registry and reporting field descriptions, successes, and challenges are discussed based on pilot testing and early implementation over two years of event enrollment. CONCLUSION The Mass-Gathering Medicine Event and Patient Registry provides an effective tool for recording and reporting both event and patient-related variables in the context of mass-gathering events. Standardizing data collection will serve researchers and policy makers well. The structure of the database permits numerous queries to be written to generate standardized reports of similar and dissimilar events, which supports hypothesis generation and the development of theoretical foundations in mass-gathering medicine.

Enhancing the minimum data set for mass-gathering research and evaluation: an integrative literature review.

Triage is a complex process and is one means for determining which patients most need access to limited resources. Triage has been studied extensively, particularly in relation to triage in overcrowded emergency departments, where individuals presenting for treatment often are competing for the available stretchers. Research also has been done in relation to the use of prehospital and field triage during mass-casualty incidents and disasters. In contrast, scant research has been done to develop and test an effective triage approach for use in mass-gathering and mass-participation events, although there is a growing body of knowledge regarding the health needs of persons attending large events. Existing triage and acuity scoring systems are suboptimal for this unique population, as these events can involve high patient presentation rates (PPR) and, occasionally, critically ill patients. Mass-gathering events are dangerous; a higher incidence of injury occurs than would be expected from general population statistics. The need for an effective triage and acuity scoring system for use during mass gatherings is clear, as these events not only create multiple patient encounters, but also have the potential to become mass-casualty incidents. Furthermore, triage during a large-scale disaster or mass-casualty incident requires that multiple, local agencies work together, necessitating a common language for triage and acuity scoring. In reviewing existing literature with regard to triage systems that might be employed for this population, it is noted that existing systems are biased toward traumatic injuries, usually ignoring mitigating factors such as alcohol and drug use and environmental exposures. Moreover, there is a substantial amount of over-triage that occurs with existing prehospital triage systems, which may lead to misallocation of limited resources. This manuscript presents a review of the available literature and proposes a triage system for use during mass gatherings that also may be used in the setting of mass-casualty incidents or disaster responses.

Mass-gathering health research foundational theory: Part 1 - population models for mass gatherings

INTRODUCTION In 2012, a minimum data set (MDS) was proposed to enable the standardized collection of biomedical data across various mass gatherings. However, the existing 2012 MDS could be enhanced to allow for its uptake and usability in the international context. The 2012 MDS is arguably Australian-centric and not substantially informed by the literature. As such, an MDS with contributions from the literature and application in the international settings is required. METHODS This research used an integrative literature review design. Manuscripts were collected using keyword searches from databases and journal content pages from 2003 through 2013. Data were analyzed and categorized using the existing 2012 MDS as a framework. RESULTS In total, 19 manuscripts were identified that met the inclusion criteria. Variation in the patient presentation types was described in the literature from the mass-gathering papers reviewed. Patient presentation types identified in the literature review were compared to the 2012 MDS. As a result, 16 high-level patient presentation types were identified that were not included in the 2012 MDS. CONCLUSION Adding patient presentation types to the 2012 MDS ensures that the collection of biomedical data for mass-gathering health research and evaluation remains contemporary and comprehensive. This review proposes the addition of 16 high-level patient presentation categories to the 2012 MDS in the following broad areas: gastrointestinal, obstetrics and gynecology, minor illness, mental health, and patient outcomes. Additionally, a section for self-treatment has been added, which was previously not included in the 2012 MDS, but was widely reported in the literature.

Minimum data set for mass-gatherings health research and evaluation: a response.

BACKGROUND The science underpinning the study of mass-gathering health (MGH) is developing rapidly. Current knowledge fails to adequately inform the understanding of the science of mass gatherings (MGs) because of the lack of theory development and adequate conceptual analysis. Defining populations of interest in the context of MGs is required to permit meaningful comparison and meta-analysis between events. Process A critique of existing definitions and descriptions of MGs was undertaken. Analyzing gaps in current knowledge, the authors sought to delineate the populations affected by MGs, employing a consensus approach to formulating a population model. The proposed conceptual model evolved through face-to-face group meetings, structured break out sessions, asynchronous collaboration, and virtual international meetings. Findings and Interpretation Reporting on the incidence of health conditions at specific MGs, and comparing those rates between and across events, requires a common understanding of the denominators, or the total populations in question. There are many, nested populations to consider within a MG, such as the population of patients, the population of medical services providers, the population of attendees/audience/participants, the crew, contractors, staff, and volunteers, as well as the population of the host community affected by, but not necessarily attending, the event. A pictorial representation of a basic population model was generated, followed by a more complex representation, capturing a global-health perspective, as well as academically- and operationally-relevant divisions in MG populations. CONCLUSIONS Consistent definitions of MG populations will support more rigorous data collection. This, in turn, will support meta-analysis and pooling of data sources internationally, creating a foundation for risk assessment as well as illness and injury prediction modeling. Ultimately, more rigorous data collection will support methodology for evaluating health promotion, harm reduction, and clinical-response interventions at MGs. Delineating MG populations progresses the current body of knowledge of MGs and informs the understanding of the full scope of their health effects.