Browsing by Subject "emergency medicine"

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    Important Pediatric Conditions in Low- and Middle-Income Countries: A Clinician and Data-Driven Approach
    (2022) Kozhumam, Arthi Shankar

    Background: Emergency care sensitive conditions are defined as those for which rapid diagnosis and early intervention improve patient outcomes. This thesis aimed to develop a list of important pediatric conditions in low- and middle-income countries (LMIC) to be used for further studies on pediatric epidemiology and resource utilization. Methods: A survey of 79 conditions was sent to LMIC physicians, who rated each condition on three categories (time sensitivity, preventability, and commonality) on a scale of 1-9. Responses were matched to Brazil pediatric hospitalization, ambulatory, and mortality data from 2015-2020. Results: 17 physicians completed the first Round of the survey, and 3 of these (17.65%) completed the second Round. Overall, 67 of the 79 (84.21%) were rated as highly time-sensitive and 26 (32.91%) highly preventable. Survey conditions with the highest ratings overall or country overlap (n=11), that were country-specific but highly rated in all three categories (n=8), or that comprised ~1%+ of hospitalizations (n=9), ~0.5%+ of ambulatory visits (n=6), and ~0.5%+ of mortality cases (n=8) were combined with the most common acute non-elective causes of hospitalizations (n=7) and mortality (n=9) into a list of 29 consolidated conditions overall (excluding overlap). These 29 accounted for 37.83% of hospitalizations, 8.97% of ambulatory visits, and 29.17% of mortality cases. 31 of the 79 survey conditions were age-specific and 32 context-specific. Conclusions: These 29 should be targeted in future health system utilization and burden studies. The modified Delphi approach is important in reaching provider consensus.

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    Patterns, predictors, variations, and temporal trends in emergency medical service hospital prenotification for acute ischemic stroke.
    (J Am Heart Assoc, 2012-08) Lin, Cheryl B; Peterson, Eric D; Smith, Eric E; Saver, Jeffrey L; Liang, Li; Xian, Ying; Olson, Daiwai M; Shah, Bimal R; Hernandez, Adrian F; Schwamm, Lee H; Fonarow, Gregg C
    BACKGROUND#ENTITYSTARTX02014;: Emergency medical services (EMS) hospital prenotification of an incoming stroke patient is guideline recommended as a means of increasing the timeliness with which stroke patients are evaluated and treated. Still, data are limited with regard to national use of, variations in, and temporal trends in EMS prenotification and associated predictors of its use. METHODS AND RESULTS#ENTITYSTARTX02014;: We examined 371 988 patients with acute ischemic stroke who were transported by EMS and enrolled in 1585 hospitals participating in Get With The Guidelines-Stroke from April 1, 2003, through March 31, 2011. Prenotification occurred in 249 197 EMS-transported patients (67.0%) and varied widely by hospital (range, 0% to 100%). Substantial variations by geographic regions and by state, ranging from 19.7% in Washington, DC, to 93.4% in Montana, also were noted. Patient factors associated with lower use of prenotification included older age, diabetes mellitus, and peripheral vascular disease. Prenotification was less likely for black patients than for white patients (adjusted odds ratio 0.94, 95% confidence interval 0.92-0.97, P<0.0001). Hospital factors associated with greater EMS prenotification use were absence of academic affiliation, higher annual volume of tissue plasminogen activator administration, and geographic location outside the Northeast. Temporal improvements in prenotification rates showed a modest general increase, from 58.0% in 2003 to 67.3% in 2011 (P temporal trend <0.0001). CONCLUSIONS#ENTITYSTARTX02014;: EMS hospital prenotification is guideline recommended, yet among patients transported to Get With The Guidelines-Stroke hospitals it is not provided for 1 in 3 EMS-arriving patients with acute ischemic stroke and varies substantially by hospital, state, and region. These results support the need for enhanced implementation of stroke systems of care. (J Am Heart Assoc. 2012;1:e002345 doi: 10.1161/JAHA.112.002345.).
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    Provocative biomarker stress test: stress-delta N-terminal pro-B type natriuretic peptide.
    (Open Heart, 2018-01) Limkakeng, Alexander T; Leahy, J Clancy; Griffin, S Michelle; Lokhnygina, Yuliya; Jaffa, Elias; Christenson, Robert H; Newby, L Kristin
    Objective:Stress testing is commonly performed in emergency department (ED) patients with suspected acute coronary syndrome (ACS). We hypothesised that changes in N-terminal pro-B type natriuretic peptide (NT-proBNP) concentrations from baseline to post-stress testing (stress-delta values) differentiate patients with ischaemic stress tests from controls. Methods:We prospectively enrolled 320 adult patients with suspected ACS in an ED-based observation unit who were undergoing exercise stress echocardiography. We measured plasma NT-proBNP concentrations at baseline and at 2 and 4  hours post-stress and compared stress-delta NT-proBNP between patients with abnormal stress tests versus controls using non-parametric statistics (Wilcoxon test) due to skew. We calculated the diagnostic test characteristics of stress-delta NT-proBNP for myocardial ischaemia on imaging. Results:Among 320 participants, the median age was 51 (IQR 44-59) years, 147 (45.9%) were men, and 122 (38.1%) were African-American. Twenty-six (8.1%) had myocardial ischaemia. Static and stress-deltas NT-proBNP differed at all time points between groups. The median stress-deltas at 2  hours were 10.4 (IQR 6.0-51.7) ng/L vs 1.7 (IQR -0.4 to 8.7) ng/L, and at 4  hours were 14.8 (IQR 5.0-22.3) ng/L vs 1.0 (-2.0 to 10.3) ng/L for patients with ischaemia versus those without. Areas under the receiver operating curves were 0.716 and 0.719 for 2-hour and 4-hour stress-deltas, respectively. After adjusting for baseline NT-proBNP levels, the 4-hour stress-delta NT-proBNP remained significantly different between the groups (p=0.009). Conclusion:Among patients with ischaemic stress tests, static and 4-hour stress-delta NT-proBNP values were significantly higher. Further study is needed to determine if stress-delta NT-proBNP is a useful adjunct to stress testing.
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    The Burden of Non-communicable Disease in Low-Income Countries: A Retrospective Analysis of Casualty Department Injury Patterns in Moshi, Tanzania
    (2011) Casey, Erica Rae

    Injuries represent a significant and growing public health concern in the developing world. Road traffic injuries in particular contribute to a large extent the increasing number of injury victims in low-income countries. The incidence and types of injuries, their impact on patients and the health care system in the countries of East Africa has received limited attention. This study attempts to examine the number and types of injuries, mechanism of injury, and short-term outcomes in a patient population at a referral and consultant hospital in the Kilimanjaro region of Tanzania.

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    Use of the consolidated framework for implementation research in a mixed methods evaluation of the EQUIPPED medication safety program in four academic health system emergency departments.
    (Frontiers in health services, 2022-01) Kegler, Michelle C; Rana, Shaheen; Vandenberg, Ann E; Hastings, S Nicole; Hwang, Ula; Eucker, Stephanie A; Vaughan, Camille P

    Background

    Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) is an effective quality improvement program initially designed in the Veterans Administration (VA) health care system to reduce potentially inappropriate medication prescribing for adults aged 65 years and older. This study examined factors that influence implementation of EQUIPPED in EDs from four distinct, non-VA academic health systems using a convergent mixed methods design that operationalized the Consolidated Framework for Implementation Research (CFIR). Fidelity of delivery served as the primary implementation outcome.

    Materials and methods

    Four EDs implemented EQUIPPED sequentially from 2017 to 2021. Using program records, we scored each ED on a 12-point fidelity index calculated by adding the scores (1-3) for each of four components of the EQUIPPED program: provider receipt of didactic education, one-on-one academic detailing, monthly provider feedback reports, and use of order sets. We comparatively analyzed qualitative data from focus groups with each of the four implementation teams (n = 22) and data from CFIR-based surveys of ED providers (108/234, response rate of 46.2%) to identify CFIR constructs that distinguished EDs with higher vs. lower levels of implementation.

    Results

    Overall, three sites demonstrated higher levels of implementation (scoring 8-9 of 12) and one ED exhibited a lower level (scoring 5 of 12). Two constructs distinguished between levels of implementation as measured through both quantitative and qualitative approaches: patient needs and resources, and organizational culture. Implementation climate distinguished level of implementation in the qualitative analysis only. Networks and communication, and leadership engagement distinguished level of implementation in the quantitative analysis only.

    Discussion

    Using CFIR, we demonstrate how a range of factors influence a critical implementation outcome and build an evidence-based approach on how to prime an organizational setting, such as an academic health system ED, for successful implementation.

    Conclusion

    This study provides insights into implementation of evidence-informed programs targeting medication safety in ED settings and serves as a potential model for how to integrate theory-based qualitative and quantitative methods in implementation studies.