document the indication for UC placement (eg, on a paper checklist or computer ... assessment of the emergency medical technicians of the Ghana Ambulance ... technicians' clinical practice of documenting out-of-hospital vital signs was ...
Research Forum Abstracts Results: A total of 13 participants completed the study. The mean oxygen saturation at 4590 feet was 96% compared with 76% at 17257 feet. Mean oxygen saturation at 11300 (on days 3 and 10) was higher (93% versus 89%) and pulse rate lower (73 versus 94) on the return trek (p⬍0.01). Correlation between oxygen saturation T and pulse rate was high (r⫽-0.82). Correlation between altitude and oxygen saturation was weak (r⫽0.25) and between altitude and pulse rate was moderate (r⫽0.57). Acute mountain sickness was most prominent during the early part of the trek, with a mean oxygen saturation of 84% in those with acute mountain sickness. Early desaturation was predictive of acute mountain sickness several days before symptom onset. Conclusion: Significant desaturation is observed in healthy trekkers hiking to 17257 feet. Pulse rate and oxygen saturation are highly correlated, and acclimatization was evident in 7 days. Although a very small group experienced symptoms of mild mountain illness, these same trekkers had higher pulse rate and lower pulse oxygen saturation compared with the main group at lower altitudes. Participants in high altitude recreational activities can monitor their pulse rate as an indirect measure of acclimatization.
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Reynolds T, Sawe HR, Lobue N, Mwafongo V/Emergency Medicine and Global Health Sciences, UCSF; and Muhimbili National Hospital, San Francisco, CA; Muhimbili National Hospital, Dar-es-Salaam, Tanzania, United Republic of
Infection Prevention Practices in Swedish Emergency Departments: Results From a Cross-sectional Survey
Yanagizawa Drott L, Schuur JD, Kurland L/Brigham and Women’s Hospital, Boston, MA; Karolinska Institutet, Stockholm, Sweden
Study Objectives: Health care-associated infections (HAIs) are a significant cause of morbidity and mortality worldwide. Adherence to evidence-based guidelines for the prevention of HAI, particularly hand hygiene (HH), is associated with lower infection rates. We aimed to describe implementation of infection prevention best practices in Swedish EDs, and to identify predictors of infection prevention practice implementation. Methods: We developed a Web-based survey based on previously tested instruments. We modified it to reflect Swedish ED practice, and piloted it with 3 Swedish emergency physicians for understandability and applicability. We emailed surveys to all Swedish ED directors up to 3 times from February to April 2012 and telephoned and emailed non-respondents. We calculated proportions, odds ratios (ORs), 95%CIs and used multivariate logistic regression to adjust for independent variables, using STATA 12. Results: Fifty eight of the 72 possible (81%) EDs responded. Twelve percent of the respondents (95%CI: 3-21%) were academic medical centers. The median annual ED volume was 30,000 (25-75%: 18,500-50,513). The majority (56%, 42-69%) reported that their ED had insufficient capacity. A little over one third (34%, 21-47%) perceived HAIs as a significant risk to ED patients compared to other patient safety issues. Hand Hygiene: Staff HH is audited by direct observation in 96% (91-100%). Of those, 98% (94-100%) provide feedback to staff on HH compliance. Among EDs that audit HH compliance, the compliance rate is reported to be 80% or more at 43% (30-57%) of EDs, 60-79% at 38% (24-51%), 40-59% at 15% (5-25%), 20-39% at 2% (0-6%) and 0-19% at 2% (0-6%). The only statistically significant predictor of high HH compliance (ⱖ80%) was auditing HH compliance at least monthly (OR 6.4, 1.5-28, P⫽0.01; Table 1). In 82% (71-92%) of EDs there was a designated HH champion (a staff member with a specific responsibility to improve HH). Fortyone percent (95%CI: 28-54%) of EDs reported participating in a project to improve HH. Catheter associated urinary tract infections (CAUTI): 59% of EDs (95%CI: 46-72%) reported having a written policy regarding indications for placement of a urinary catheter (UC). The ordering provider is required to document the indication for UC placement (eg, on a paper checklist or computer prompt) in 38% (25-51%). Almost half, (49%, 36-63%), have a champion for the prevention of CAUTI, but only 21% (10-31%) report participating in a project to reduce CAUTI. When catheters placed in the ED result in CAUTI, 11% (2-19%) of EDs are notified about this complication. Clostridium difficile (C. diff): Written guidelines for management of C. diff were present in 80% (6991%) of EDs, but no EDs reported seeing a patient in the last year who later died from C. diff or required an emergency colectomy. Conclusion: Our study documents current infection prevention practice in Swedish EDs - an as yet unstudied area. Frequent auditing of HH compliance can impact HH compliance rates. Swedish EDs report higher HH compliance than published estimates from U.S. EDs.
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Most Frequent Adult and Pediatric Diagnoses Among 60,000 Patients Seen in a New Urban Emergency Department in Dar Es Salaam, Tanzania
Background: In 2010, the first dedicated emergency department (EMD) in Tanzania was established at the public Muhimbili National Hospital, the largest hospital in the country, via a public-private partnership between Tanzania’s Ministry of Health and Social Welfare, and Abbott Fund Tanzania. Study Objective: To describe the most common diagnoses and basic demographics of patients seen in the first 2 years of the first emergency department in Tanzania. Methods: We reviewed handwritten patient logbooks containing basic patient demographic information and final diagnoses for patients seen in the Muhimbili National Hospital emergency department from January 2010 through December 2011. We entered these into an electronic database and manually coded diagnoses into Clinical Classifications Software categories. All Clinical Classifications Software categorizations were reviewed by a least 2 physician researchers and any disagreements were mediated by a third researcher. Results: We reviewed 60,534 patient entries and assigned Clinical Classifications Software categories to each. Four thousand 9 hundred and thirty-eight patients (8.2%) had no diagnosis or an illegible diagnosis entered in the log These were categorized under Clinical Classifications Software 18 (“Residual codes; unclassified”). Thirty-nine percent (23,610) of patients were female. Three thousand four hundred and twenty-one (5%) patients had no age data entered. Of the 57,113 patients for whom age data was available, 8,917 (15.6%) were aged 5 or under; and 14,852 (26%) were under 18 years of age. Fourteen thousand nine hundred fifty-five patients (24.7%) were diagnosed with injuries, including 3,029 children under 18 and 1,261 children under 5 and under. Other common specific diagnoses in children 18 years of age and younger were: anemia 7.95%, other infections 7.95%, other ear and sense organ disorders 6.08%, and pneumonia 5.89%. Other common specific diagnoses in adults were: mental illness 7.73%, Intracranial Injury 6.03% Anemia 4.10%, and Retention of urine 3.64%. Conclusions: A dedicated emergency department in an urban setting in Tanzania sees a very high volume of patients with a significant proportion of children and very young children. Injuries were very common in children and adults.
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Knowledge, Attitudes and Practices Regarding Vital Signs Amongst EMTs of the Ghana Ambulance Service
Mould-Millman C, Akoriyea SK, Zakariah AN, Sasser SM, Isakov A, Lynch CL/ Emory University, Atlanta, GA; National Ambulance Service, Ministry of Health, Accra, Ghana; Duke University School of Medicine, Durham, NC
Study Objectives: Accurately checking and interpreting vital signs constitutes a fundamental and critical part of patient care. As part of a preliminary educational assessment of the emergency medical technicians of the Ghana Ambulance Service, this study aims to describe emergency medical technicians’ knowledge, attitudes and practices regarding vital signs in trauma patients. Methods: A pre-tested questionnaire was verbally administrated in a standardized manner by one investigator to Ghana Ambulance Service emergency medical
Annals of Emergency Medicine S39
Research Forum Abstracts technician-basics. The questionnaire surveyed emergency medical technicians’ knowledge of normal vital signs (blood pressure, pulse rate, respiratory rate, temperature, and oxygen saturation) and their attitudes regarding the importance of checking vital signs in injured patients. Descriptive statistics were used to characterize questionnaire responses. Each respondent’s skills at obtaining vital signs were also tested using a clinically standardized patient-simulation. Emergency medical technicians’ clinical practice of documenting out-of-hospital vital signs was measured by retrospectively auditing respondents’ out-of-hospital patient care reports in the 6 months preceding the study. Results: Forty-one (93%) emergency medical technicians completed the questionnaire. Fifty-one percent of emergency medical technicians recalled at least 3 vital sign values correctly, 17% recalled at least 4, and 2% recalled all 5 correctly. The vital signs for which emergency medical technicians most frequently recalled normal values were temperature (80%), pulse rate (68%) respiratory rate (63%) and blood pressure (50%). One hundred percent of emergency medical technicians felt checking vital signs was important in trauma cases. Eighty-seven percent felt confident with their skills. One hundred percent appropriately checked the 5 vital signs when tested. Of the 153 trauma-related patient care reports reviewed, 36% had at least blood pressure and pulse rate documented. Twenty-eight percent of patient care reports had 1 complete set of vital signs, and 26% had none documented. Conclusion: Ghana Ambulance Service emergency medical technicians felt confident, were skillful and regarded checking vital signs in trauma patients as important. However, a marked discrepancy existed when compared to their knowledge of vital sign values and their actual out-of-hospital clinical practice of checking these vital signs. These results have guided emergency medical technician continuing medical education, quality assurance and quality improvement initiatives within this young and growing emergency medical services service functioning in a challenging low-resource setting.
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Bedside Ultrasonography Training and Barriers to Utilization in Chiapas, Mexico
Miss J, Noble J, Reynolds T, Stein J/University of California San Francisco and San Francisco General Hospital, San Francisco, CA; University of California San Francisco, San Francisco, CA
Study Objectives: Bedside ultrasonography has the potential to provide crucial rapid diagnostic information in resource scarce settings where access to other imaging modalities is limited. In 2011, a bedside ultrasonography training course was conducted at Hospital San Carlos (HSC) in Chiapas, which serves many of the poorest citizens in the most impoverished state in Mexico. The objective of this study was to assess the reported utilization and barriers to the utilization of ultrasonography at the hospital several months after the initial training. Methods: We conducted an anonymous, written survey of physicians practicing at Hospital San Carlos in Altamirano, Mexico, examining ultrasonography training, utilization of ultrasonography clinically and any barriers to its use. In Spring 2011 a Sonosite ® Nanomaxx (Bothell, WA) was purchased through a grant for use at Hospital San Carlos and an intensive 2-week ultrasonography training course was taught for all physicians at the hospital, including didactic coursework, image review, bedside teaching and practice and final written examinations. In February 2012 a refresher ultrasonography course was conducted for the physicians in the hospital, after which they were given the survey. The committee on human research at the Univ. of Calif. SF approved this study. Results: Nine out of 10 physicians completed the survey; 5 were generalists and 1 each was trained in internal medicine, family medicine and tropical medicine. Six of the 9 respondents participated in the ultrasonography course in 2011 and 4 of those felt capable of conducting bedside ultrasonography exams without supervision. Two of the respondents had previous ultrasonography training at other institutions. Among the types of training they had experienced, participating physicians preferred supervised ultrasonography of patients, followed by review of images and hands on review of the previously trained skills. All of the respondents reported that it was useful to train the physicians to use ultrasonography, citing the utility to support diagnoses and to improve the quality of care provided. During the month prior to the refresher training course, most practitioners had conducted 1 to 5 ultrasonography exams, with the majority of exams being right upper quadrant, gestational age measures, echocardiography and Focused Assessment of Trauma with Sonography (FAST) exam, respectively. After ultrasonography training, physicians felt most confident performing right upper quadrant exams, Renal, FAST and gestational age measures and least confident performing transvaginal exams to rule out ectopic pregnancy, echocardiography, and vena cava/
S40 Annals of Emergency Medicine
aortic exams. Eight of 9 respondents reported having all of the equipment necessary to use ultrasonography clinically and 56% felt they possessed the appropriate skills to utilize ultrasonography. Seven of the 9 physicians felt that there were times when they would have used ultrasonography but reported that the cost to the patient as well as the lack of confidence in their own ability to perform and interpret the ultrasonography exams lead them to perform fewer ultrasonography exams. Seventy-eight percent reported that they did not always have access to the ultrasonography machine, stating that the machine was often locked away. Conclusions: Donation of a portable ultrasonography machine and training of physicians in bedside ultrasonography is a meaningful addition to clinical care in a small rural hospital in Mexico. Right upper quadrant and gestational age measures were the most commonly performed exams. Significant barriers to utilization of ultrasonography were access to the ultrasonography machine, physician confidence in ability to conduct and interpret ultrasonography exams, and physician concern for the cost of the exam to the patient.
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Operative and Burn Surge Capacity in a Major Metropolitan Area as Demonstrated By a Large Regional Disaster Exercise
Jasper E, White M, Martin N, Grace T/Thomas Jefferson University, Philadelphia, PA; Delaware Valley Health Care Council, Philadelphia, PA
Study Objectives: Treatment of patients following a mass casualty incident presents a complex and unique set of challenges for hospitals. Physicians and other hospital personnel must quickly mobilize to care for an influx of patients, often presenting with major injury patterns. Care for a surge of pediatric surgical and burn patients is made more difficult by the lack of large numbers of pediatric and burn care specialty centers. Non-specialty centers would likely need to manage these types of patients initially, until transfer could be arranged. We set out to characterize the surgical and burn surge capacity of a major U.S. metropolitan area, specifically assessing both regional trauma centers and community hospitals during an annual regional disaster exercise. Methods: Questionnaires were distributed to participating hospitals prior to and following the annual regional disaster exercise. The scenario was modeled after the Mumbai attacks of 2007, with terrorists spreading out across the region and attacking various targets with gunfire and explosives. These questionnaires queried the number of trauma patients hospitals estimated they could treat, number of operating rooms (ORs) and respective staff available, blood supplies on hand, as well as number and types of available surgical instruments. Results: There are a total of 62 acute care hospitals in Philadelphia, Pennsylvania, and the 4 surrounding counties, including 7 level 1 trauma centers, 2 pediatric hospitals and 1 burn center. Fifty-one of these hospitals participated in the regional exercise. There were 34 pre-exercise surveys and 26 post-exercise surveys received for analysis. On average, hospitals reported the capability to manage 4.9 adult major trauma cases acutely. However, this average number fell to less than 1 for children under the age of 8. The average was 3.8 for adult acute second and third degree burn victims, but again, the number averaged less than 1 for children under the age of 8. Thirty-five percent of participating hospitals reported inadequate blood bank surge capacity for this scenario, and 19 percent reported inadequate amounts of surgical supplies. During weekdays, hospitals were able to make an average of 12 operating rooms (ORs) available within 60 minutes of the event, but would have staffing available for an average of only 8 ORs for each hospital. During nights, weekends and holidays, those average numbers were 23 available ORs, but additional staffing for only 4 of these at 60 minutes post event. Extrapolating the average numbers to all 61 hospitals in the region yielded a total regional surge capacity of about 304 major adult trauma victims, 52 major pediatric trauma victims, 226 significant adult burn victims and 40 significant pediatric burn victims. Conclusion: While there was significant regional capacity for managing mass casualty trauma victims, staffing was a limiting factor in the number of patients who could be treated surgically within 60 minutes. Blood product shortages would also likely have an impact on mass casualty care. In addition, pediatric trauma and burn surge capacity was limited. Nights, holidays and weekend shortfalls in staffing availability also presented a challenge, given that holiday special events, sporting events and other mass gatherings occur during these times, and are potential terrorist targets.
Volume , . : October
