Publications by authors named "Jane H Brice"

70 Publications

Characteristics, clinical care, and disposition barriers for mental health patients boarding in the emergency department.

Am J Emerg Med 2020 Nov 12. Epub 2020 Nov 12.

UNC School of Medicine, UNC Chapel Hill, Chapel Hill, NC, United States of America. Electronic address:

Background And Objectives: Lack of mental health resources, such as inpatient psychiatric beds, has increased frequency and duration of boarding for mental health patients presenting to U.S. emergency departments (EDs). The purpose of this study is to describe characteristics of mental health patients with an ED length of stay of one week or longer and to identify barriers to their disposition.

Methods: This study was conducted in an academic ED in which emergency psychiatric evaluations and care are provided by a Psychiatric Emergency Services (PES) team contained within the Department of Emergency Medicine. Prolonged boarding was defined as an ED length of stay of 7 days or more. Pediatric, adult, and geriatric mental health patients with prolonged ED boarding from January 1 to August 31, 2019 were included. This study includes prospective data collection of the boarding group and retrospective identification and data collection of a comparison group of non-barding patients over the same 8-month period to compare patient characteristics and outcomes for each group.

Results: Between January 1 and August 31, 2019, the PES team completed 2,745 new assessments of mental health patients, of whom 39 met criteria for prolonged ED boarding. The following characteristics were associated with boarding: child (8%), male (64%), having Medicaid (49%) or both Medicaid and Medicare (18%), and having either a neurodevelopmental (15%) or neurocognitive disorder (15%) with a median stay of 18 days. Barriers to discharge included being declined from all state inpatient psychiatric hospitals (69%), declined from community living environments (21%), or declined from both (10%). The most common ED non-boarding patients were: Caucasian (64%), have a diagnosis of unspecified mental disorder (including suicidal ideation) or other specified mental disorder (59%) and have private insurance (42%) with a median stay of 1 day.

Conclusion: In this study of mental health patients with prolonged ED stays, the primary barrier to disposition was the lack of patient acceptance to inpatient psychiatric hospitals, community settings, or other housing. Early identification of potential prolonged boarding, quality treatment and care for those patients, and effective case management, may resolve the ongoing challenges of boarding within the ED.
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http://dx.doi.org/10.1016/j.ajem.2020.11.021DOI Listing
November 2020

COVID-19 Pandemic: The Role of EMS Physicians in a Community Response Effort.

Prehosp Emerg Care 2021 Jan-Feb;25(1):8-15. Epub 2020 Nov 11.

The COVID-19 pandemic is a worldwide historical event that will continue to affect nearly every aspect of ordinary life, including affecting our economic, political, and healthcare eco-systems. An effective pandemic response demands a coordinated and integrated response across community healthcare stakeholders, including Public Health and Emergency Management Officials. EMS systems are in a unique position and perform an essential role on the frontlines of COVID-19, including facilitating coordination of response efforts to COVID-19 within their communities while supporting public health mitigation efforts to slow the spread of the SARS-CoV-2. EMS physicians serve their communities at a unique intersection as clinical leaders, population health experts, and advocates. This paper examines and recommends crucial roles for EMS physician leaders as communities work together in pandemic response.
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http://dx.doi.org/10.1080/10903127.2020.1838676DOI Listing
January 2021

Opportunities for Emergency Medical Services Intervention to Prevent Opioid Overdose Mortality.

Prehosp Emerg Care 2021 Mar-Apr;25(2):182-190. Epub 2020 Apr 2.

Objectives: The opioid crisis is a growing cause of mortality in the United States and may be mitigated by innovative approaches to identifying individuals at-risk of fatal opioid overdose. We examined Emergency Medical Services (EMS) utilization among a cohort of individuals who died from opioid overdose in order to identify potential opportunities for intervention. : Individuals who died of unintentional opioid overdose in a large North Carolina county between 01/01/2014 and 12/31/2016 were studied in a retrospective cohort. Death records obtained from North Carolina Vital Records were linked to EMS patient care records obtained from the county EMS System in order to describe the EMS encounters of each decedent in the year preceding their death. Patient demographics and EMS encounters were assessed to identify encounter characteristics that may be targeted for intervention. Chi-square tests and odds ratios were used to evaluate and characterize the statistical significance of differences in EMS utilization. : Of the 218 individuals who died from unintentional opioid overdose in the study interval, 30% (n = 66) utilized EMS in the year before their death and 17% (n = 38) had at least one EMS encounter with documented drug or alcohol use (i.e. "drug-related encounter"). The mean age at death was 38 (range 19-74) years, 30% were female, 89% were White, and 8% were Black/African American. Factors associated with higher incidence of EMS utilization included age (<.001), gender (=.006), and race (001). Decedents aged 56-65 had the highest EMS utilization (47%) and patients aged <25 and 25-35 had more drug-related EMS encounters (29% and 20%, respectively). The most common reasons for EMS utilization were "other medical" (27%), "non-traumatic pain" (20%), "traumatic injury" (16%), and "poisoning/drug ingestion" (14%). Drug or alcohol use was documented by EMS in 33% of all encounters and an opioid prescription was reported in 22% of encounters. Nearly one-third of individuals who died from accidental opioid overdose utilized EMS in the year before their death and nearly one-fifth had a drug-related encounter. EMS encounters may present an opportunity to identify individuals at-risk of opioid overdose and, ultimately, reduce overdose mortality.
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http://dx.doi.org/10.1080/10903127.2020.1740363DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7529698PMC
June 2021

The Triage of Older Adults with Physiologic Markers of Serious Injury Using a State-Wide Prehospital Plan.

Prehosp Disaster Med 2019 Oct 13;34(5):497-505. Epub 2019 Sep 13.

Department of Emergency Medicine, University of North Carolina, Chapel Hill, North CarolinaUSA.

Introduction: In January of 2010, North Carolina (NC) USA implemented state-wide Trauma Triage Destination Plans (TTDPs) to provide standardized guidelines for Emergency Medical Services (EMS) decision making. No study exists to evaluate whether triage behavior has changed for geriatric trauma patients.

Hypothesis/problem: The impact of the NC TTDPs was investigated on EMS triage of geriatric trauma patients meeting physiologic criteria of serious injury, primarily based on whether these patients were transported to a trauma center.

Methods: This is a retrospective cohort study of geriatric trauma patients transported by EMS from March 1, 2009 through September 30, 2009 (pre-TTDP) and March 1, 2010 through September 30, 2010 (post-TTDP) meeting the following inclusion criteria: (1) age 50 years or older; (2) transported to a hospital by NC EMS; (3) experienced an injury; and (4) meeting one or more of the NC TTDP's physiologic criteria for trauma (n = 5,345). Data were obtained from the Prehospital Medical Information System (PreMIS). Data collected included proportions of patients transported to a trauma center categorized by specific physiologic criteria, age category, and distance from a trauma center.

Results: The proportion of patients transported to a trauma center pre-TTDP (24.4% [95% CI 22.7%-26.1%]; n = 604) was similar to the proportion post-TTDP (24.4% [95% CI 22.9%-26.0%]; n = 700). For patients meeting specific physiologic triage criteria, the proportions of patients transported to a trauma center were also similar pre- and post-TTDP: systolic blood pressure <90 mmHg (22.5% versus 23.5%); respiratory rate <10 or >29 (23.2% versus 22.6%); and Glascow Coma Scale (GCS) score <13 (26.0% versus 26.4%). Patients aged 80 years or older were less likely to be transported to a trauma center than younger patients in both the pre- and post-TTDP periods.

Conclusions: State-wide implementation of a TTDP had no discernible effect on the proportion of patients 50 years and older transported to a trauma center. Under-triage remained common and became increasingly prevalent among the oldest adults. Research to understand the uptake of guidelines and protocols into EMS practice is critical to improving care for older adults in the prehospital environment.
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http://dx.doi.org/10.1017/S1049023X19004825DOI Listing
October 2019

Availability of Hospital Resources and Specialty Services for Stroke Care in North Carolina.

South Med J 2019 06;112(6):331-337

From the Department of Emergency Medicine, the Department of Biostatistics, EMS Performance Improvement Center, Department of Neurology, and the Davis Library, University of North Carolina at Chapel Hill.

Objectives: Effective regionalization of acute stroke care requires assessment and coordination of limited hospital resources. We described the availability of stroke-specific hospital resources (neurology specialty physicians and neuro-intensive care unit [neuro-ICU] bed capacity) for North Carolina overall and by region and population density. We also assessed daily trends in hospital bed availability.

Methods: This statewide descriptive study was conducted with data from the State Medical Asset Resource Tracking Tool (SMARTT), a Web-based system used by North Carolina to track available medical resources within the state. The SMARTT system was queried for stroke-specific physician and bed resources at each North Carolina hospital during a 1-year period (June 2015-May 2016), including daily availability of neuro-ICU beds. We compared hospital resources by geographic region and population density (metropolitan, urban, and rural).

Results: Data from 108 acute care hospitals located in 75 of 100 counties in North Carolina were included in the analysis. Fifty-seven percent of hospitals had no neurology specialty physicians. Western and eastern North Carolina had the lowest prevalence of these physicians. Most hospitals (88%) had general ICUs, whereas only 17 hospitals (16%) had neuro-ICUs. Neuro-ICUs were concentrated in metropolitan areas and in central North Carolina. On average, there were 276 general ICU and 27 neuro-ICU beds available statewide each day. Daily neuro-ICU bed availability was lowest in eastern and southeastern regions and during the week compared with weekends.

Conclusions: In North Carolina, stroke-specific hospital subspecialists and resources are not distributed evenly across the state. Daily bed availability, particularly in neuro-ICUs, is lacking in rural areas and noncentral regions and appears to decrease on weekdays. Regionalization of stroke care needs to consider the geographic distribution and daily variability of hospital resources.
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http://dx.doi.org/10.14423/SMJ.0000000000000986DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6640838PMC
June 2019

Assessment of Key Health and Wellness Indicators Among North Carolina Emergency Medical Service Providers.

Prehosp Emerg Care 2019 Mar-Apr;23(2):179-186. Epub 2018 Aug 23.

Objective: The objective of this study was to characterize key health indicators in Emergency Medical Services (EMS) personnel and identify areas for intervention in order to ensure a strong and capable emergency health workforce.

Methods: Participants were EMS personnel delivering patients to 4 regional tertiary care emergency departments within North Carolina (NC). After transferring patient care and agreeing to participate, height, weight, and blood pressure (BP) measurements were recorded and each participant completed a questionnaire regarding demographics, activity levels, alcohol consumption, smoking, and medical history. Data were analyzed descriptively.

Results: A sample of 452 EMS personnel from across NC was enrolled. The cohort was predominantly male (74.1%) and employed full-time (85.5%). The prevalence of overweight and obesity (80.3%) among EMS personnel was higher than the NC population (65.6%) and the general United States (US) population (70.8%). A previous diagnosis of high BP was reported by only 18.3% of participants, but 65.1% had elevated BP at the time of measurement. Alcohol consumption in the past 30 days among participants (55.4%) was slightly higher than state estimates (48.0%) and similar to national estimates (57.1%). However, heavy drinking (22.2%) and binge drinking (28.8%) were reported at much higher rates than state (5.6% and 15.2%, respectively) and national (6.6% and 18.3%, respectively) estimates. The prevalence of current smoking (21.5%) and quit attempts (48.8%) in the cohort was similar to state (21.8% and 55.0%, respectively) and national (21.2% and 55.7%, respectively) estimates. Likewise, the proportion of EMS providers meeting the Center for Disease Control's activity guidelines (49.6%) was similar to that found in the NC (46.8%) and the general US (48.0%) populations.

Conclusions: These findings suggest a high prevalence of overweight and obesity, heavy drinking, binge drinking, and high BP among NC EMS personnel. Similar to fire service personnel, these rates are higher than the general US population. As such, they suggest areas where intervention would have the greatest positive impact on the health and performance of the EMS workforce.
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http://dx.doi.org/10.1080/10903127.2018.1489017DOI Listing
July 2019

Elder Abuse Identification in the Prehospital Setting: An Examination of State Emergency Medical Services Protocols.

J Am Geriatr Soc 2018 05 22;66(5):962-968. Epub 2018 Mar 22.

Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Objectives: To describe statewide emergency medical service (EMS) protocols relating to identification, management, and reporting of elder abuse in the prehospital setting.

Design: Cross-sectional analysis.

Setting: Statewide EMS protocols in the United States.

Participants: Publicly available statewide EMS protocols identified from published literature, http://EMSprotocols.org, and each state's public health website.

Measurements: Protocols were reviewed to determine whether elder abuse was mentioned, elder abuse was defined, potential indicators of elder abuse were listed, management of older adults experiencing abuse was described, and instructions regarding reporting were provided. EMS protocols for child abuse were reviewed in the same manner for the purpose of comparison.

Results: Of the 35 publicly available statewide EMS protocols, only 14 (40.0%) mention elder abuse. Of protocols that mention elder abuse, 6 (42.9%) define elder abuse, 10 (71.4%) describe indicators of elder abuse, 8 (57.1%) provide instruction regarding management, and 12 (85.7%) provide instruction regarding reporting. Almost twice as many states met each of these metrics for child abuse.

Conclusion: Statewide EMS protocols for elder abuse vary in regard to identification, management, and reporting, with the majority of states having no content on this subject. Expansion and standardization of protocols may increase the identification of elder abuse.
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http://dx.doi.org/10.1111/jgs.15329DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5992078PMC
May 2018

Effect of Dial-Out Prefix Change on 9-1-1 Calls at a Large State University.

Prehosp Emerg Care 2018 Nov-Dec;22(6):773-777. Epub 2018 Mar 9.

Background: Accessing the emergency medical services system via 9-1-1 operators is an effective way for patients to seek urgent health care; however, technological advances and telecommunication practices inundate the 9-1-1 and emergency services infrastructure with unintentional calls that delay response efforts to legitimate medical emergencies.

Objective: To determine whether the change in university-wide dial-out prefix from "9" to "7" reduced unnecessary calls to a 9-1-1 call center.

Methods: This is a retrospective study conducted utilizing information obtained from the University of North Carolina at Chapel Hill (UNC) Department of Public Safety (DPS) call center. Call center calls received during pre-change, intervening, and post-change periods were included in the study. The cost savings, defined in time and money, resulting from the prefix change were also examined.

Results: A total of 33,646 calls were made during the study period (January 11, 2010 through December 31, 2012) and included in the analysis. The prefix change was found to reduce the rate of invalid calls to the call center by 319 calls per month, resulting in a 43% reduction in total calls to the call center while preserving the rate of valid calls. The largest decrease occurred in hang-up calls (a decrease of 232 calls per month), especially those originating from the university. The prefix change was found to save the UNC DPS telecommunications division approximately $798.82 per month and the police officer division approximately $3,874.95 per month.

Conclusion: A prefix change was not only beneficial to the UNC community but it also has potentially wide-reaching effects. A reduction of invalid 9-1-1 calls translates to telecommunicators having more time available to handle true emergencies, phone lines remaining available for true emergencies, and police officers dedicating more time and effort to matters that necessitate officer assistance. Based on the call decrease seen with the prefix change, this study may be used as evidence to advocate for a change of dial-out codes beginning with "9."
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http://dx.doi.org/10.1080/10903127.2018.1441929DOI Listing
June 2019

Survey of Hospital Employees' Personal Preparedness and Willingness to Work Following a Disaster.

South Med J 2017 08;110(8):516-522

From the Department of Emergency Medicine, University of North Carolina, Chapel Hill.

Objectives: Little is known about the personal readiness of hospital staff for disasters. As many as 30% of hospital staff say that they plan not to report for work during a large-scale disaster. We sought to understand the personal disaster preparedness for hospital staff.

Methods: Surveys were distributed to the staff of a large academic tertiary-care hospital by either a paper-based version distributed through the departmental safety coordinators or a Web-based version distributed through employee e-mail services, depending on employee familiarity with and access to computer services. Surveys assessed the demographic variables and characteristics of personal readiness for disaster.

Results: Of the individuals who accessed the survey, 1334 (95.9%) enrolled in it. Women made up 75% of the respondents, with a mean age of 43 years. Respondents had worked at the hospital an average of 9 years, with the majority (90%) being full-time employees. Most households (93%) reported ≤4 members, 6% supported a person with special medical needs, and 17% were headed by a single parent. A small number (24%) of respondents reported an established meeting place for reuniting households during a disaster. Many reported stockpiling a 3-day supply of food (86%) and a 3-day supply of water (51%). Eighteen percent of respondents were not aware of workplace evacuation plans. Most respondents were willing to report to work for natural disasters (eg, tornado, snowstorm; all categories >65%), but fewer respondents were willing to report during events such as an influenza epidemic (54%), a biological outbreak (41%), a chemical exposure, (40%), or a radiation exposure (39%). Multivariate analysis revealed being female, having a child in the household younger than 6 years old, and having a child in school lowered the likelihood of being willing to report to work in two or more event types, whereas pet ownership, being a clinical healthcare worker, and being familiar with the work emergency plan increased the likelihood.

Conclusions: Despite being employed at the same facility for a prolonged period, employees reported being willing to report for work at a low rate in a variety of disasters. Subjects reported suboptimal personal preparedness for disaster, which may further limit the number of staff who will report for work. Hospitals should promote personal disaster preparedness for staff and explore staffing models with an understanding of reduced staff availability during disasters.
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http://dx.doi.org/10.14423/SMJ.0000000000000680DOI Listing
August 2017

Repeated Emergency Medical Services Use by Older Adults: Analysis of a Comprehensive Statewide Database.

Ann Emerg Med 2017 Oct 27;70(4):506-515.e3. Epub 2017 May 27.

Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC.

Study Objective: The objective of this study is to characterize repeated emergency medical services (EMS) transports among older adults across a large and socioeconomically diverse region.

Methods: Using the North Carolina Prehospital Medical Information System, we analyzed the frequency of repeated EMS transports within 30 days of an index EMS transport among adults aged 65 years and older from 2010 to 2015. We used multivariable logistic regressions to determine characteristics associated with repeated EMS transport.

Results: During the 6-year period, EMS performed 1,711,669 transports for 689,664 unique older adults in North Carolina. Of these, 303,099 transports (17.7%) were followed by another transport of the same patient within 30 days. The key characteristics associated with an increased adjusted odds ratio of repeated transport within 30 days include transport from an institutionalized setting (odds ratio [OR] 1.42; 95% confidence interval [CI] 1.38 to 1.47), blacks compared with whites (OR 1.29; 95% CI 1.24 to 1.33), a dispatch complaint of psychiatric problems (OR 1.38; 95% CI 1.25 to 1.52), back pain (OR 1.35; 95% CI 1.26 to 1.45), breathing problems (OR 1.21; 95% CI 1.15 to 1.30), and diabetic problems (OR 1.14; 95% CI 1.06 to 1.22). Falls accounted for 15.6% of all transports and had a modest association with repeated transports (OR 1.07; 95% CI 1.00 to 1.14).

Conclusion: More than 1 in 6 EMS transports of older adults in North Carolina are followed by a repeated transport of the same patient within 30 days. Patient characteristics and chief complaints may identify increased risk for repeated transport and suggest the potential for targeted interventions to improve outcomes and manage EMS use.
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http://dx.doi.org/10.1016/j.annemergmed.2017.03.058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5614807PMC
October 2017

Prehospital Fluid Administration in Trauma Patients: A Survey of State Protocols.

Prehosp Emerg Care 2017 Sep-Oct;21(5):605-609. Epub 2017 May 8.

Objective: The optimal resuscitation approach during the initial treatment of hypotensive trauma patients remains unknown, but some clinical trials have observed a survival benefit from restricting fluid administration prior to definitive hemorrhage control. We sought to characterize emergency medical services (EMS) protocols for the administration of intravenous fluids in this setting.

Methods: Publicly accessible statewide EMS protocols for the treatment of hypotensive trauma patients were included and characterized by: 1) goal of fluid administration, 2) dosing strategy, 3) maximum dose, 4) type of fluid, and 5) specific protocols for head trauma, if present.

Results: Of the 27 states with a publicly available, statewide protocol, 21 have a numeric systolic blood pressure (SBP) target for resuscitation. Of these, 16 describe a goal of maintaining SBP ≥90 mmHg with or without additional goals, three specify a goal that is less than 90 mmHg, and two specify a goal ≥100 mHg. Dosing strategies also vary and include both standard bolus strategies (200 mL, 250 mL, 500 mL, and 1 L with repeat) as well as weight-based strategies (20 mL/kg). Nine states specify a maximum dose of 2 L without medical control. Fifteen protocols recommend the use of normal saline, 1 recommends the use of lactated Ringer's, and 11 recommend the use of either normal saline or lactated Ringer's. Nine states have distinct protocols for patients with head trauma, all of which indicate maintaining a higher SBP than for trauma patients without head trauma.

Conclusion: State EMS protocols for fluid administration for hypotensive trauma patients vary in regard to SBP goal, fluid dose, and fluid type. Clinical trials to determine the optimal use of intravenous fluids for hypotensive trauma patients are needed to define the optimal approach.
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http://dx.doi.org/10.1080/10903127.2017.1315202DOI Listing
July 2018

Evaluation of the Implementation of the Trauma Triage and Destination Plan on the Field Triage of Injured Patients in North Carolina.

Prehosp Emerg Care 2017 Sep-Oct;21(5):591-604. Epub 2017 Apr 19.

Objective: Timely triage and appropriate destination decision making for injured patients are central challenges faced by emergency medical services (EMS) systems. In 2010, North Carolina (NC) adopted a statewide Trauma Triage and Destination Plan (TTDP) based on the CDC's Field Triage Guidelines to better address these challenges. We sought to characterize the implementation of these guidelines by quantifying their effect on multiple metrics of patient care.

Methods: We employed a retrospective pre-post study design utilizing a statewide EMS medical record database. We assessed several metrics of patient care-including changes in destination choice, appropriateness of EMS destination, transit time to first hospital, transit time to definitive care, and others-in a six-month period in the year before and after the implementation of the guidelines.

Results: We evaluated a total of 190,307 EMS encounters pre- (n = 93,927) and post-implementation (n = 96,380). Among all patients, there was not a significant difference in the percentage transported to a community hospital or Level I, II, or III trauma center as their first destination. Among those patients meeting TTDP guidelines for transport to a trauma center, the number transported to a Level I or II trauma center decreased 1.0% from 30.6% (n = 2,911) to 29.6% (n = 2,954) (95% CI: -0.2%, 2.2%). Those transported to a Level I trauma center decreased 0.4% from 21.2% to 20.8% in the post-period (95% CI: -0.7%, 1.5%). There were also no significant changes in EMS scene times (14.0 pre-, 14.1 post-) and transport times (12.9 pre-, 13.0 post-). While scene distance from a Level I trauma center showed a decreased likelihood of transport to that center, there was an overall post-implementation increase of 2.5% from 18.0% to 20.5% (95% CI: -3.6%, -1.3%) in transport to a Level I trauma center among patients meeting anatomic criteria across all distance ranges.

Conclusions: We found that implementation of region-specific destination plans based on the Field Triage Guidelines had little effect on selected hospital destination, scene times, transport times, and other metrics of EMS decision making and effectiveness. We suspect this is due to delays in information dissemination and adoption by field providers.
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http://dx.doi.org/10.1080/10903127.2017.1308606DOI Listing
July 2018

Prehospital Triage of Injured Older Adults: Thinking Slow Inside the Golden Hour.

J Am Geriatr Soc 2016 10 24;64(10):1941-1943. Epub 2016 Aug 24.

Department of Emergency Medicine, University of North Carolina, Chapel Hill, North Carolina.

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http://dx.doi.org/10.1111/jgs.14405DOI Listing
October 2016

Comparison of brief health literacy screens in the emergency department.

J Health Commun 2015 25;20(5):539-45. Epub 2015 Mar 25.

a University of North Carolina School of Medicine , Chapel Hill , North Carolina , USA.

Measuring health literacy efficiently yet accurately is of interest both clinically and in research. The authors examined 6 brief health literacy measures and compared their categorization of patient health literacy levels and their comparative associations with patients' health status. The authors assessed 400 emergency department patients with the Short Test of Functional Health Literacy in Adults, the Newest Vital Sign, Single Item Literacy Screen, brief screening questions, Rapid Estimate of Adult Literacy in Medicine-Revised, and the Medical Term Recognition Test. The authors analyzed data using Spearman's correlation coefficients and ran separate logistic regressions for each instrument for patient self-reported health status. Tests differed in the proportion of patients' skills classified as adequate, but all instruments were significantly correlated; instruments targeting similar skills were more strongly correlated. Scoring poorly on any instrument was significantly associated with worse health status after adjusting for age, sex and race, with a score in the combined inadequate/marginal category on the Short Test of Functional Health Literacy in Adults carrying the largest risk (OR = 2.94, 95% CI [1.23, 7.05]). Future research will need to further elaborate instrument differences in predicting different outcomes.
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http://dx.doi.org/10.1080/10810730.2014.999893DOI Listing
July 2015

A prospective cohort study of medication reconciliation using pharmacy technicians in the emergency department to reduce medication errors among admitted patients.

J Emerg Med 2015 Feb 20;48(2):230-8. Epub 2014 Nov 20.

Department of Emergency Medicine, University of North Carolina, Chapel Hill, North Carolina.

Background: The collection of a complete, verified medication history is essential to patient safety. The involvement of clinical pharmacists has been shown to improve the completeness and accuracy of medication histories; however, to our knowledge, involvement of pharmacy technicians has not been studied.

Objective: Our aim was to determine whether verification of medication histories by pharmacy technicians in the emergency department (ED) would result in fewer errors in inpatient medication regimens compared to verification by the admitting physician team.

Methods: We performed a prospective cohort study of adult ED patients admitted for continuing care. In the intervention group, medication reconciliation was performed by pharmacy technicians in the ED before the creation of physician admitting orders. In the control group, pharmacy technicians conducted their history taking later, after admission. Initial admitting orders were then compared to the pharmacy technicians' medication reconciliation taken before admission (intervention group) or after admission (control group). Medication discrepancies were classified and determined to be justified or unjustified. Unjustified discrepancies were rated for harm potential.

Results: In our cohort of 113 intervention and 75 control subjects, the mean age was 55 years (standard deviation [SD] 16 years); 96 patients (51%) were male. In the intervention group, 566 changes to home medications were observed on admission; 352 (62%) were unjustified. Among controls, 406 changes to home medications were observed; 228 (56%) were unjustified. This difference was not statistically significant (p = 0.0586). The rate of unjustified medication changes per patient was likewise not significantly different (3.14 [SD 2.98] in interventions vs. 3.17 [SD 2.81] in controls; p = 0.9570). The rate of medical errors did not differ between study groups, nor did severity ratings of unjustified changes.

Conclusions: Medication reconciliation by pharmacy technicians in the ED did not lead to a significant reduction in unjustified medication discrepancies.
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http://dx.doi.org/10.1016/j.jemermed.2014.09.065DOI Listing
February 2015

A geographic information system analysis of the impact of a statewide acute stroke emergency medical services routing protocol on community hospital bypass.

J Stroke Cerebrovasc Dis 2014 Nov-Dec;23(10):2800-2808. Epub 2014 Oct 5.

Mecklenburg EMS Agency, Charlotte, North Carolina.

Background: Our goal was to determine if a statewide Emergency Medical Services (EMSs) Stroke Triage and Destination Plan (STDP), specifying bypass of hospitals unable to routinely treat stroke patients with thrombolytics (community hospitals), changed bypass frequency of those hospitals.

Methods: Using a statewide EMS database, we identified stroke patients eligible for community hospital bypass and compared bypass frequency 1-year before and after STDP implementation.

Results: Symptom onset time was missing for 48% of pre-STDP (n = 2385) and 29% of post-STDP (n = 1612) cases. Of the remaining cases with geocodable scene addresses, 58% (1301) in the pre-STDP group and 61% (2,078) in the post-STDP group were ineligible for bypass, because a community hospital was not the closest hospital to the stroke event location. Because of missing data records for some EMS agencies in 1 or both study periods, we included EMS agencies from only 49 of 100 North Carolina counties in our analysis. Additionally, we found conflicting hospital classifications by different EMS agencies for 35% of all hospitals (n = 38 of 108). Given these limitations, we found similar community hospital bypass rates before and after STDP implementation (64%, n = 332 of 520 vs. 63%, n = 345 of 552; P = .65).

Conclusions: Missing symptom duration time and data records in our state's EMS data system, along with conflicting hospital classifications between EMS agencies limit the ability to study statewide stroke routing protocols. Bypass policies may apply to a minority of patients because a community hospital is not the closest hospital to most stroke events. Given these limitations, we found no difference in community hospital bypass rates after implementation of the STDP.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.07.004DOI Listing
November 2015

Over-commitment of EMS personnel in North Carolina with implications for disaster planning.

Prehosp Emerg Care 2015 Apr-Jun;19(2):247-53. Epub 2014 Oct 7.

Background: While large-scale disasters are uncommon, our society relies on emergency personnel to be available to respond and act. Faith in their availability may lead to a false sense of security. Many emergency personnel obligate themselves to more than one agency and so may be overcommitted, leaving agencies with unfilled positions in a disaster. We sought to describe the frequency of overcommitment of emergency medical services (EMS) personnel in North Carolina.

Methods: We conducted a cross-sectional study utilizing the Credentialing Information System (CIS) of the North Carolina Office of EMS. The CIS database manages demographic and certification information for all EMS personnel in North Carolina. The state is divided into 100 EMS systems based on county boundaries. Utilizing de-identified provider data from the CIS, we collected system(s) affiliation(s) and level of certification. To calculate an overcommitment rate per system, we divided the number of personnel with more than one system affiliation by total number of system roster personnel. To compare urbanicity and certification level with overcommitment, analysis of variance and the chi-square test were used, respectively.

Results: North Carolina credentials 14,717 EMS providers (8,346 EMT, 1,709 EMT-intermediate (EMT-I), 4,662 EMT-paramedic (EMT-P)). Of these, 10,928 (74%) are affiliated with a single system. Of the 3,789 committed to more than one system, 3,020 (21%) were committed to two systems, 571 (4%) to three, 138 (1%) to four, and 60 (<1%) to five or more. EMT-Is and EMT-Ps were more likely to be overcommitted when compared to EMTs (37, 32, 20% respectively, p < 0.0001). Statewide, the median overcommitment rate for EMS systems was 24% (IQR 16-37%). Personnel working in systems servicing less densely populated areas were more likely to be overcommitted: 33% wilderness, 29% rural, 20% suburban and 11% urban (p < 0.0001). Additionally, 40% wilderness, 23% rural, 4% suburban, and 0% urban systems had >37% of their personnel engaged in 9-1-1 response in more than one system.

Conclusion: Many EMS personnel have multiple EMS commitments. Disaster planners and emergency managers should consider overcommitment of emergency responders when calculating the work force on which they can rely.
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http://dx.doi.org/10.3109/10903127.2014.959218DOI Listing
March 2016

Accuracy of EMS Trauma Transport Destination Plans in North Carolina.

Prehosp Emerg Care 2015 January-March;19(1):53-60. Epub 2014 May 30.

Abstract Objective. Planning for time-sensitive injury may allow emergency medical services (EMS) systems to more accurately triage patients meeting accepted criteria to facilities most capable of providing life-saving treatment. In 2010, North Carolina (NC) implemented statewide Trauma Triage and Destination Plans (TTDPs) in all 100 of North Carolina's county-defined EMS systems. Each system was responsible for identifying the specific destination hospitals with appropriate resources to treat trauma patients. We sought to characterize the accuracy of their hospital designations. Methods. In this cross-sectional study, we collected TTDPs for each county-defined EMS system, including their assigned hospital capabilities (i.e., trauma center or community hospital). We conducted a survey with each EMS system to determine how their TTDP was constructed and maintained, as well as with each TTDP-designated hospital to verify their capabilities. We determined the accuracy of the EMS assigned hospital designations by comparing them to the hospital's reported capabilities. Results. The 100 NC EMS systems provided 380 designations for 112 hospitals. TTDPs were created by EMS administrators and medical directors, with only 55% of EMS systems engaging a hospital representative in the plan creation. Compared to the actual hospital capabilities, 97% of the EMS TTDP designations were correct. Twelve hospital designations were incorrect and the majority (10) overestimated hospital capabilities. Of the 100 EMS systems, 7 misclassified hospitals in their TTDP. EMS systems that did not verify their local hospitals' capabilities during TTDP development were more likely to incorrectly categorize a hospital's capabilities (p = 0.001). Conclusions. A small number of EMS systems misclassified hospitals in their TTDP, but most plans accurately reflected hospital capabilities. Misclassification occurred more often in systems that did not consult local hospitals prior to developing their TTDP. The potential of the TTDP to improve communication between EMS agencies and the facilities with which they work has not been fully realized. EMS agencies or systems should verify local hospital capabilities when engaging in destination planning efforts.
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http://dx.doi.org/10.3109/10903127.2014.916021DOI Listing
May 2014

Out-of-hospital stroke screen accuracy in a state with an emergency medical services protocol for routing patients to acute stroke centers.

Ann Emerg Med 2014 Nov 18;64(5):509-15. Epub 2014 Apr 18.

Mecklenburg EMS Agency, Charlotte, NC.

Study Objective: Emergency medical services (EMS) protocols, which route patients with suspected stroke to stroke centers, rely on the use of accurate stroke screening criteria. Our goal is to conduct a statewide EMS agency evaluation of the accuracies of the Cincinnati Prehospital Stroke Scale (CPSS) and the Los Angeles Prehospital Stroke Screen (LAPSS) for identifying acute stroke patients.

Methods: We conducted a retrospective study in North Carolina by linking a statewide EMS database to a hospital database, using validated deterministic matching. We compared EMS CPSS or LAPSS results (positive or negative) to the emergency department diagnosis International Classification of Diseases, Ninth Revision codes. We calculated sensitivity, specificity, and positive and negative likelihood ratios for the EMS diagnosis of stroke, using each screening tool.

Results: We included 1,217 CPSS patients and 1,225 LAPSS patients evaluated by 117 EMS agencies from 94 North Carolina counties. Most EMS agencies contributing data had high annual patient volumes and were governmental agencies with nonvolunteer, emergency medical technician-paramedic service level providers. The CPSS had a sensitivity of 80% (95% confidence interval [CI] 77% to 83%) versus 74% (95% CI 71% to 77%) for the LAPSS. Each had a specificity of 48% (CPSS 95% CI 44% to 52%; LAPSS 95% CI 43% to 53%).

Conclusion: The CPSS and LAPSS had similar test characteristics, with each having only limited specificity. Development of stroke screening scales that optimize both sensitivity and specificity is required if these are to be used to determine transport diversion to acute stroke centers.
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November 2014

Single-item or two-item literacy screener to predict the S-TOFHLA among adult hemodialysis patients.

Patient Educ Couns 2014 Jan 12;94(1):71-5. Epub 2013 Oct 12.

Department of Medicine, University of North Carolina, Chapel Hill, USA.

Objective: We compared single-item (SILS) and two-item (TILS) literacy screeners in predicting Short Test of Functional Health Literacy in Adults (S-TOFHLA) scores.

Methods: Adult hemodialysis patients completed SILS, which determines need for assistance when reading written medical information; TILS (last grade completed and self-reported reading ability); and S-TOFHLA. Receiver operator characteristic curves (ROC) and stratum specific likelihoods were calculated.

Results: Of 227 participants, median S-TOFHLA was 24 (IQR 15-34). 129 (55%) participants had adequate, 70 (30%) inadequate, and 37 (16%) marginal health literacy. SILS and TILS predicted S-TOFHLA scores equivalently. Test characteristics predicting inadequate health literacy were: SILS sensitivity for threshold >1, 54% (95%CI: 44, 64), for >2, 39% (29, 49) and specificity for >1, 73% (64, 80), for >2, 93% (87, 97), area under the ROC of 0.67 (0.60-0.74); TILS sensitivity for threshold >1, 72% (62, 80), for >2, 30% (21, 40) and specificity for >1, 54% (45, 63), for >2, 86% (79, 92), area under the ROC of 0.66 (0.59-0.73).

Conclusion: SILS and TILS had similar test characteristics in predicting S-TOFHLA.

Practice Implications: While a positive result on either test increases the likelihood that a patient has low health literacy, the SILS is easier to administer and score.
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http://dx.doi.org/10.1016/j.pec.2013.09.020DOI Listing
January 2014

Development of an EMS curriculum.

Prehosp Emerg Care 2014 Jan-Mar;18(1):98-105. Epub 2013 Oct 24.

from the Department of Emergency Medicine, The University of North Carolina School of Medicine , Chapel Hill, North Carolina (JHB) , Department of Emergency Medicine, University of Virginia , Charlottesville, Virginia (DGP) , Department of Emergency Medicine, Medical College of Wisconsin , Milwaukee, Wisconsin (JML) , Department of Emergency Medicine, University of New Mexico , Albuquerque, New Mexico (DAB) , Division of Emergency Medicine, Department of Surgery, University of Texas Southwestern , Dallas, Texas (KJR) , Department of Medicine, University of Toronto , Toronto, Ontario , Canada .

Emergency medical services (EMS) became an American Board of Medical Specialties (ABMS) approved subspecialty of emergency medicine in September 2010. Achieving specialty or subspecialty recognition in an area of medical practice requires a unique body of knowledge, a scientific basis for the practice, a significant number of physicians who dedicate a portion of their practice to the area, and a sufficient number of fellowship programs. To prepare EMS fellows for successful completion of fellowship training, a lifetime of subspecialty practice, and certification examination, a formalized structured fellowship curriculum is necessary. A functional curriculum is one that takes the entire body of knowledge necessary to appropriately practice in the identified area and codifies it into a training blueprint to ensure that all of the items are covered over the prescribed training period. A curriculum can be as detailed as desired but typically all major headings and subheadings of the core content are identified and addressed. Common curricular components, specific to each area of the core content, include goals and objectives, implementation methods, evaluation, and outcomes assessment methods. Implementation methods can include simulation, observations, didactics, and experiential elements. Evaluation and outcomes assessment methods can include direct observation of patient assessment and treatment skills, structured patient simulations, 360° feedback, written and oral testing, and retrospective chart reviews. This paper describes a curriculum that is congruent with the current EMS core content, as well as providing a 12-month format to deploy the curriculum in an EMS fellowship program. Key words: curriculum; education; emergency medical services; fellowships and scholarships.
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June 2014

An evaluation of emergency medical services stroke protocols and scene times.

Prehosp Emerg Care 2014 Jan-Mar;18(1):15-21. Epub 2013 Sep 12.

Received May 15, 2013 from the Departments of Epidemiology (MDP, KRE, WDR) and Biostatistics (CMS), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the Department of Emergency Medicine (JHB, CM), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and SRA International (KMR), Durham, North Carolina. Revision received June 14, 2013; accepted for publication June 20, 2013.

Background: Acute stroke patients require immediate medical attention. Therefore, American Stroke Association guidelines recommend that for suspected stroke cases, emergency medical services (EMS) personnel spend less than 15 minutes on-scene at least 90% of the time. However, not all EMS providers include specific scene time limits in their stroke patient care protocols.

Objective: We sought to determine whether having a protocol with a specific scene time limit was associated with less time EMS spent on scene. Methods. Stroke protocols from the 100 EMS systems in North Carolina were collected and abstracted for scene time instructions. Suspected stroke events occurring in 2009 were analyzed using data from the North Carolina Prehospital Medical Information System. Scene time was defined as the time from EMS arrival at the scene to departure with the patient. Quantile regression was used to estimate how the 90th percentile of the scene time distribution varied by systems with protocol instructions limiting scene time, adjusting for system patient volume and metropolitan status.

Results: In 2009, 23 EMS systems in North Carolina had no instructions regarding scene time; 73 had general instructions to minimize scene time; and 4 had a specific limit for scene time (i.e., 10 or 15 min). Among 9,723 eligible suspected stroke events, mean scene time was 15.9 minutes (standard deviation 6.9 min) and median scene time was 15.0 minutes (90th percentile 24.3 min). In adjusted quantile regression models, the estimated reduction in the 90th percentile scene time, comparing protocols with a specific time limit to no instructions, was 2.2 minutes (95% confidence interval 1.3, 3.1 min). The difference in 90th percentile scene time between general and absent instructions was not statistically different (0.7 min [95% confidence interval -0.1, 1.4 min]).

Conclusion: Protocols with specific scene time limits were associated with EMS crews spending less time at the scene while general instructions were not. These findings suggest EMS systems can modestly improve scene times for stroke by specifying a time limit in their protocols.
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http://dx.doi.org/10.3109/10903127.2013.825354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3973028PMC
June 2014

Emergency medical services capacity for prehospital stroke care in North Carolina.

Prev Chronic Dis 2013 Sep 5;10:E149. Epub 2013 Sep 5.

Department of Epidemiology, Cardiovascular Disease Program, 137 E Franklin St., Chapel Hill, NC 27514, USA.

Introduction: Prior assessments of emergency medical services (EMS) stroke capacity found deficiencies in education and training, use of protocols and screening tools, and planning for the transport of patients. A 2001 survey of North Carolina EMS providers found many EMS systems lacked basic stroke services. Recent statewide efforts have sought to standardize and improve prehospital stroke care. The objective of this study was to assess EMS stroke care capacity in North Carolina and evaluate statewide changes since 2001.

Methods: In June 2012, we conducted a web-based survey on stroke education and training and stroke care practices and policies among all EMS systems in North Carolina. We used the McNemar test to assess changes from 2001 to 2012.

Results: Of 100 EMS systems in North Carolina, 98 responded to our survey. Most systems reported providing stroke education and training (95%) to EMS personnel, using a validated stroke scale or screening tool (96%), and having a hospital prenotification policy (98%). Many were suboptimal in covering basic stroke educational topics (71%), always communicating stroke screen results to the destination hospital (46%), and always using a written destination plan (49%). Among 70 EMS systems for which we had data for 2001 and 2012, we observed significant improvements in education on stroke scales or screening tools (61% to 93%, P < .001) and use of validated stroke scales or screening tools (23% to 96%, P < .001).

Conclusion: Major improvements in EMS stroke care, especially in prehospital stroke screening, have occurred in North Carolina in the past decade, whereas other practices and policies, including use of destination plans, remain in need of improvement.
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http://dx.doi.org/10.5888/pcd10.130035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3767834PMC
September 2013

Death in the field: teaching paramedics to deliver effective death notifications using the educational intervention "GRIEV_ING".

Prehosp Emerg Care 2013 Oct-Dec;17(4):501-10. Epub 2013 Jun 27.

Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.

Introduction: Emergency medical services (EMS) personnel are rarely trained in death notification despite frequently terminating resuscitation in the field. As research continues to validate guidelines for the termination of resuscitation (TOR) and reputable organizations such as NAEMSP lend support to such protocols, death notification in the field will continue to increase. We sought to test the hypothesis that a learning module, GRIEV_ING, which teaches a structured method for death notification, will improve the confidence, competency, and communication skills of EMS personnel in death notification.

Methods: The GRIEV_ING didactic session consisted of a 90-minute education session composed of a didactic lecture, small group breakout session, and role-plays. This was both preceded and followed by a 15-minute case role-play using trained standardized survivors. To assess performance we used a pre-post design with 3 quantitative measures: confidence, competency, and, communication. Paramedics from the local EMS agency participated in the education as a part of continuing education. Pre-post differences were measured using a paired t-test and McNemar's test.

Results: Thirty EMS personnel consented and participated. Confidence and competency demonstrated statistically significant improvements: confidence (percent change in scores = 11.4%, p < 0.0001) and competency (percent change in scores = 13.9%, p = 0.0001). Communication skill scores were relatively unchanged in pre-post test analysis (percent change in scores = 0.4, p = 0.9).

Conclusion: This study demonstrated that educating paramedics to use a structured communication model based on the GRIEV_ING mnemonic improved confidence and competence of EMS personnel delivering death notification.
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http://dx.doi.org/10.3109/10903127.2013.804135DOI Listing
April 2014

The relationship between functional health literacy and adherence to emergency department discharge instructions among Spanish-speaking patients.

J Natl Med Assoc 2012 Nov-Dec;104(11-12):521-7

Swedish Family Medicine Residency, Littleton, Colorado, USA.

Introduction: Adherence to emergency department (ED) discharge instructions among immigrant Spanish-speaking populations in the United States is suboptimal. Our objectives were to: (1) investigate associations between functional health literacy (FHL) and ED discharge instruction adherence in Spanish-speaking populations, and (2) compare the ED adherence rates of Spanish speakersto English speakers.

Methods: Using a matched cohort design, the FHL of adult native Spanish speakers in a tertiary care ED was assessed using the Test of Functional Health Literacy of Adults in Spanish (TOHFLA-S). Gender-matched and age-matched native English speakers were assessed using TOHFLA. TOFHLA scores range from 1 to 100 with adequate FHL cutoff at 74. Excluded patients were those aged less than 19 years, unwilling, prisoners, institutionalized, extremely ill, with a psychiatric complaint, in receipt of nonspecific instructions for follow-up, or with poor vision. A second interview assessed adherence with follow-up appointments and filling prescriptions.

Results: Fifty matched pairs were enrolled. Spanish speakers were less likely to understand discharge instructions (Spanish speakers, 78%; English speakers, 94%; p < .0001) or to keep follow-up appointments (Spanish speakers, 46%; English speakers, 83%; p <.0001). TOFHLA for Spanish speakers averaged 62 vs 93 for English speakers (p < .0001). FHL was associated with understanding of and adherence to discharge instructions for Spanish speakers. Further, Spanish speakers reported lack of understanding as a primary reason for nonadherence.

Conclusion: Spanish-speaking patients were less likely to comply with discharge instructions and scored lower on a test of FHL than English-speaking patients. Poor adherence to ED discharge instructions was associated with lower FHL scores for our Spanish-speaking population. Alternative methods of providing discharge instructions to this population of patients should be explored.
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http://dx.doi.org/10.1016/s0027-9684(15)30218-2DOI Listing
July 2013

Level of disaster preparedness in patients visiting the emergency department: results of the civilian assessment of readiness for disaster (CARD) survey.

Prehosp Disaster Med 2013 Apr 14;28(2):127-31. Epub 2013 Jan 14.

University of North Carolina School of Medicine, Chapel Hill, North Carolina 27599-7594, USA.

Background: Patients seeking care in public hospitals are often resource-limited populations who have in past disasters become the most vulnerable. The objective of this study was to determine the personal disaster preparedness of emergency department (ED) patients and to identify predictors of low levels of preparedness. It was hypothesized that vulnerable populations would be better prepared for disasters.

Methods: A prospective cross-sectional survey was conducted over a one-year period of patients seeking care in a public university hospital ED (census 65,000). Exclusion criteria were mentally impaired, institutionalized, or non-English speaking subjects. Subjects completed an anonymous survey detailing the 15 personal preparedness items from the Federal Emergency Management Agency's disaster preparedness checklist as well as demographic characteristics. Summary statistics were used to describe general preparedness. Chi-square tests were used to compare preparedness by demographics.

Results: During the study period, 857/1000 subjects completed the survey. Participants were predominantly male (57%), Caucasian (65%), middle-aged (mean 45 years), and high school graduates (83%). Seventeen percent (n = 146) reported having special needs and 8% were single parents. Most participants were not prepared: 451 (53%) had >75% of checklist items, 393 (46%) had food and water for 3 days, and 318 (37%) had food, water, and >75% of items. Level of preparedness was associated with age and parenting. Those aged 44 and older were more likely to be prepared for a disaster compared to younger respondents. (43.3% vs 31.1%, P = .0002). Similarly, single parents were more likely to be prepared than dual parenting households (47.1 vs 32.9%, P = .03).

Conclusions: This study and others have found that only the minority of any group is actually prepared for disaster. Future research should focus on ways to implement disaster preparedness education, specifically targeting vulnerable populations, then measuring the effects of educational programs to demonstrate that preparedness has increased as a result.
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http://dx.doi.org/10.1017/S1049023X12001811DOI Listing
April 2013

Evaluation of radiation exposure to pediatric trauma patients.

J Emerg Med 2013 Mar 14;44(3):646-52. Epub 2012 Dec 14.

Department of Emergency Medicine, University of North Carolina, Chapel Hill, North Carolina, USA.

Background: Pediatric trauma patients pose a diagnostic challenge to physicians. Computed tomography (CT) imaging identifies life-threatening injuries quickly and efficiently. CT radiation dose in pediatric trauma patients is a concern.

Study Objectives: We evaluated the cumulative effective dose of radiation received by pediatric blunt trauma patients and assessed characteristics of patients and studies received.

Methods: We retrospectively identified pediatric blunt trauma patients at a Level I trauma center between January 1 and December 31, 2006 utilizing the North Carolina Trauma Registry. We searched the patient radiographic history for images in the 7 days after their trauma event. We calculated cumulative effective radiation dose using dose length product and age coefficients. We collected demographic information including age, sex, mechanism of injury, hospital length of stay, and discharge status.

Results: Seventy-five pediatric blunt trauma patients with available radiographic records were included. The median age was 11.7 years; males comprised 64% of patients; median Injury Severity Score was 13.8; 64% were transfer patients; median number of CT scans during initial evaluation was 3.4 for directly seen patients and two for transferred patients. Mean effective ionizing radiation dose was 11.4 mSv for CT scans performed in the first 24 h. Sixteen percent of admitted patients had CT scans in the subsequent 6 days, with an average additional CT dose of 4 mSv. Average number of plain radiographs was five.

Conclusions: Pediatric blunt trauma patients receive a major radiation burden in their initial evaluation. Patients who are transferred from an outside facility endure an even higher dose of radiation.
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http://dx.doi.org/10.1016/j.jemermed.2012.09.035DOI Listing
March 2013

Critical airway skills and procedures.

Emerg Med Clin North Am 2013 Feb;31(1):1-28

Department of Emergency Medicine, Carolinas Medical Center, Medical Education Building, Third Floor, 1000 Blythe Boulevard, Charlotte, NC 28203, USA.

Airway management is a critical procedure and essential skill necessary for all physicians working in the emergency department. Optimal resuscitative treatment of medical and trauma patients often revolves around timely and effective airway interventions that can be challenging in the acute setting, especially in critical patients. Time-honored airway techniques and procedures combined with recent advances in rapid sequence intubation, video laryngoscopy, and further advanced airway techniques now offer emergency clinicians a wide range of exciting new options for improving this crucial component of acute care and management.
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http://dx.doi.org/10.1016/j.emc.2012.09.001DOI Listing
February 2013

Epidemiology of low-level bridge jumping in Pittsburgh: a 10-year study.

Prehosp Emerg Care 2013 Apr-Jun;17(2):155-61. Epub 2012 Nov 13.

Department of Emergency Medicine, Division of Emergency Medical Services, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7594, USA.

Background: Outcomes of patients who fall from bridges lower than 160 feet above water have been poorly characterized. Pittsburgh offers a unique setting in which to study these patients as the city has 41 major bridges, only four of which are above 70 feet.

Objective: This study examined patients who fell or jumped from Pittsburgh bridges over a 10-year period for their characteristics, injury patterns, and the effects of prehospital care on outcomes.

Methods: We conducted a retrospective cohort study of patients who jumped or fell from bridges in Pittsburgh, Pennsylvania, over a 10-year period. Subjects were identified through manual searches of three data repositories: City of Pittsburgh Bureau of Emergency Medical Services (EMS), Pittsburgh River Rescue, and Allegheny County Medical Examiner records. Data abstracted included patient name, age, gender, date of birth, and address; incident date, time, location, and river conditions; prehospital interventions; emergency department intervention; hospital disposition; evidence of prior or subsequent psychiatric admission; toxicology results or evidence of substance involvement; and causes of death.

Results: Seventy-four subjects were identified. Most were male (80%) young adults (mean age 34.3 years) who lived near the bridges from which they jumped or fell. Mortality from bridges less than 50 feet high was 18%; mortality from bridges 180 feet high was 75%. All patients who required prehospital interventions beyond warming or intravenous (IV) fluids died. Injury patterns were similar to those described for high-bridge patients, concentrated in the trunk or skull, but low-bridge injuries were milder and less common. Cause of death was predominantly drowning (84%). More than a third (47.3%) of the patients had previous psychiatric histories, but evidence of a previous attempt to jump was uncommon (5.4%).

Conclusions: People who jump from low- to medium-rise bridges may suffer injuries, but most often die from drowning. EMS interventions beyond water rescue are typically not helpful, emphasizing the importance of prevention and a water rescue plan.
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February 2014
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