Survey of shift and work tolerance of City of Houston emergency medical service personnel

This study of ambulance workers for the emergency medical services of the City of Houston studied the factors related to shiftwork tolerance and intolerance. The EMS personnel work a 24-hour shift with rotating days of the week. Workers are assigned to A, B, C, D shift, each of which rotate 24-hours on, 24-hours off, 24-hours on and 4 days off. One-hundred and seventy-six male EMTs, paramedics and chauffeurs from stations of varying levels of activity were surveyed. The sample group ranged in age from 20 to 45. The average tenure on the job was 8.2 years. Over 68% of the workers held a second job, the majority of which worked over 20 hours a week at the second position.^ The survey instrument was a 20-page questionnaire modeled after the Folkard Standardized Shiftwork Index. In addition to demographic data, the survey tool provided measurements of general job satisfaction, sleep quality, general health complaints, morningness/eveningness, cognitive and somatic anxiety, depression, and circadian types. The survey questionnaire included an EMS-specific scaler of stress.^ A conceptual model of Shiftwork Tolerance was presented to identify the key factors examined in the study. An extensive list of 265 variables was reduced to 36 key variables that related to: (1) shift schedule and demographic/lifestyle factors, (2) individual differences related to traits and characteristics, and (3) tolerance/intolerance effects. Using the general job satisfaction scaler as the key measurement of shift tolerance/intolerance, it was shown that a significant relationship existed between this dependent variable and stress, number of years working a 24-hour shift, sleep quality, languidness/vigorousness. The usual amount of sleep received during the shift, general health complaints and flexibility/rigidity (R$\sp2$ =.5073).^ The sample consisted of a majority of morningness-types or extreme-morningness types, few evening-types and no extreme-evening types, duplicating the findings of Motohashi's previous study of ambulance workers. The level of activity by station was not significant on any of the dependent variables examined. However, the shift worked had a relationship with sleep quality, despite the fact that all shifts work the same hours and participate in the same rotation schedule. ^

The response of Texas public health agencies and workers to the emergency preparedness initiatives after 9/11

The purpose of this research was to better understand the impact of the terrorist attacks in 2001 on public health, particularly for Texas public health. This study employed mixed methods to examine changes to public health culture within Texas local public health agencies, important attitudes of public health workers toward responding to a disaster, and the funding policies that might ensure our investment in public health emergency preparedness is protected. ^ A qualitative analysis of interviews conducted with a large sample of public health officials in Texas found that all the constituent parts of a peculiar culture for public health preparedness existed that spanned the state's local health departments regardless of size, or funding level. The new preparedness culture in Texas had the hallmarks necessary for a robust public health preparedness and emergency response system. ^ The willingness of public health workers, necessary to make these kinds of changes and mount a disaster response was examined in one of Texas' most experienced disaster response teams—the public health workers for the City of Houston. A hypothesized latent variable model showed that willingness mediated all other factors in the model (self-efficacy, knowledge, barriers, and risk perception) for self-reported likelihood of reporting to work for a disaster. The RMSEA for the final model was 0.042 with a confidence interval of 0.036—0.049 and the chi-squared difference test was P=0.08, indicating a well-fitted model that suggests willingness is an important factor for consideration by preparedness planners and researchers alike. ^ Finally, with disasters on the rise and federal funding for preparedness dwindling, a review of states' policies for the distribution of these funds and their advantages and disadvantages were examined through a review of current literature and public documents, and a survey of state-level public health officials, emergency management professionals and researchers. Although the base plus per-capita method is the most common, it is not necessarily perceived to be the most effective. No clear "optimal" method emerged from the study, but recommendations for a strategic combination of three methods were made that has the potential to maximize the benefits of each method, while minimizing the weaknesses.^

Empowering Medical Professionals to Help Victims of Trafficking

Purpose: to provide commentary of two review articles that discuss the role of medical professionals in combating human trafficking: “Health Care Providers' Training Needs Related to Human Trafficking: Maximizing the Opportunity to Effectively Screen and Intervene” by Isaac, Solak, and Giardino, and “Human Trafficking: What is the Role of the Health Care Provider?” by Crane and Moreno. Findings: Both articles provide a good introduction and explanation of the psychosocial and medical issues faced by many trafficking victims; however, they succeed only to varying degrees in describing all the gaps in the medical system and the vital next steps forward. Conclusion: The key next steps in the fight against human trafficking include: multidisciplinary teams need to improve coordination on all forms of human maltreatment; schools for all medical professions and social work need to significantly strengthen their curriculum on diagnosing and treating human maltreatment; and groups that provide training on human trafficking should partner with other agencies and organizations that provide training on child maltreatment and domestic violence.

Assessing the need and options available for trauma physician funding in Texas

Efforts have been made to provide supplemental funding to emergency departments to offset the costs of uncompensated medical care. But a problem exists within the trauma system in Texas that has largely been overlooked by the state. This project will focus on the lack of funding available to physicians and on-call specialists who contract with hospitals to provide emergency care. ^ A lack of funding and reimbursement for emergency care is directly influencing the number of medical specialists willing to provide emergency treatment in hospitals on a contractual basis. A shortage of emergency physicians has an impact on the public health of all Texans who may need trauma care in a hospital. Specifically, a shortage of emergency physicians can lead to a complete denial of specialty emergency health care, a delay in patient treatment, and increased ambulance diversions. Quality and access barriers to emergency services undoubtedly threaten the stability of the trauma care system in Texas and the health status of its citizens. ^ In 2003, Texas took a significant step towards addressing the issue of uncompensated care provided by the trauma system and passed House Bill 3588, creating the Trauma Facilities and Emergency Medical Services Fund (“the Trauma Fund”). However, the primary shortfall to this legislation is that the Trauma Fund is only available to emergency medical service providers and hospitals. The Trauma Fund does little to help offset the cost incurred by contracting physicians and on-call specialists who provide emergency services to the uninsured. ^ This paper addresses how funding shortages for emergency department physicians negatively impact the trauma care system in Texas and the policy options available to create physician funding to offset the cost of uncompensated trauma care. Ultimately this paper concludes that although creating a new funding stream similar to the actions taken in other states would be a dramatic step towards addressing the problem, the political process in Texas may slow implementation of this option. Consequently, modifying existing legislation, although the weaker of the options, may be more attractive to those looking for immediate action. ^

THE DECLINE OF ISCHEMIC HEART DISEASE MORTALITY IN TEXAS: HEALTH PLANNING IMPLICATIONS

This is a report on an empirical study of the decline of ischemic heart disease mortality in the State of Texas. The study period was from 1970 to 1977. The data was collected and analyzed at three different levels of analysis: state, health service area (HSA), and county. The study was designed to test five main hypotheses. They serve to test the role of the medical care system as a possible factor associated with the changing ischemic heart disease mortality trends.^ The principal findings of the study were that a reasonable relationship could be found between the number of emergency medical care personnel, the number of icu-ccu beds, the number of medical specialists and the percent of hospitals with icu-ccu and the decline in ischemic heart disease mortality for the State of Texas. However, non significant relationships were found between variables in the medical care system and ischemic heart disease mortality trends, at the health service area level of analysis. More specifically, the number of coronary care unit beds was found to be negatively correlated with the decline in ischemic heart disease mortality at the county level.^ While being limited in its scope, the study suggests that certain factors (emergency medical service, icu-ccu beds, percent of icu-ccu units, and medical specialists) have been shown to be associated with the observed decline in ischemic heart disease mortality. The study also suggests many avenues of future research that need to be explored. ^

The Houston Academy of Medicine--Texas Medical Center Library management information system.

A management information system (MIS) provides a means for collecting, reporting, and analyzing data from all segments of an organization. Such systems are common in business but rare in libraries. The Houston Academy of Medicine-Texas Medical Center Library developed an MIS that operates on a system of networked IBM PCs and Paradox, a commercial database software package. The data collected in the system include monthly reports, client profile information, and data collected at the time of service requests. The MIS assists with enforcement of library policies, ensures that correct information is recorded, and provides reports for library managers. It also can be used to help answer a variety of ad hoc questions. Future plans call for the development of an MIS that could be adapted to other libraries' needs, and a decision-support interface that would facilitate access to the data contained in the MIS databases.

Design and implementation of a multicriteria medical decision support system for diagnosis and treatment

Health care providers face the problem of trying to make decisions with inadequate information and also with an overload of (often contradictory) information. Physicians often choose treatment long before they know which disease is present. Indeed, uncertainty is intrinsic to the practice of medicine. Decision analysis can help physicians structure and work through a medical decision problem, and can provide reassurance that decisions are rational and consistent with the beliefs and preferences of other physicians and patients. ^ The primary purpose of this research project is to develop the theory, methods, techniques and tools necessary for designing and implementing a system to support solving medical decision problems. A case study involving “abdominal pain” serves as a prototype for implementing the system. The research, however, focuses on a generic class of problems and aims at covering theoretical as well as practical aspects of the system developed. ^ The main contributions of this research are: (1) bridging the gap between the statistical approach and the knowledge-based (expert) approach to medical decision making; (2) linking a collection of methods, techniques and tools together to allow for the design of a medical decision support system, based on a framework that involves the Analytic Network Process (ANP), the generalization of the Analytic Hierarchy Process (AHP) to dependence and feedback, for problems involving diagnosis and treatment; (3) enhancing the representation and manipulation of uncertainty in the ANP framework by incorporating group consensus weights; and (4) developing a computer program to assist in the implementation of the system. ^

An evaluation of the personal response system program for the elderly in Harris County, Texas

The Personal Response System Program at Huffington Center on Aging, Baylor College of Medicine, provides emergency call systems for elderly people living independently in Houston, Texas. The goal of the project was to complete a formative evaluation of the Personal Response System Program. The specific aims of the evaluation were three-fold. One aim was to evaluate participant health status and level of disability. The second aim was to develop a health care cost estimation strategy. Finally, a preliminary cost-effectiveness analysis was completed to evaluate the program's impact on health care costs and health status among the elderly target population. ^ The evaluation was a longitudinal, randomized experimental design. After the screening of 120 volunteers for eligibility, clients were asked to complete a written questionnaire and a monthly health service contact diary. Volunteers were contacted by telephone interviewers to collect health status information from 100 eligible clients (83%) on three occasions during the six months of follow-up. ^ Initially, volunteers were randomized to two experimental groups. The two groups were found to be comparable at the beginning of the study. No significant differences were detected related to health status, level of disability, or history of physician visits at baseline. However, the group with the Personal Response System (PRS) device had more adverse health events, higher IADL scores, more frequent use of walkers, lower average health status scores, and fewer community volunteers hours than the usual care comparison group. ^ The health care costs were estimated based on an algorithm adapted from the American Medical Association guidelines. Average total health care costs for the group with the PRS device ($912) were greater than the usual care group ($464). However, median health care values for the PRS group ($263) were similar to the usual care comparison group ($234). The preliminary findings indicated that the use of the PRS device was not associated with health care cost savings. ^ In the preliminary cost-effectiveness analysis, use of the personal response system was found to be associated with increased mental health status among elderly clients. The cost-effectiveness evaluation indicated that the associated cost for six months was $710 per unit increase in mental component score when the $150 PRS subscription was included. However, clients with the PRS device were found to have a greater decline in physical health status during the six-month follow-up. The beneficial effect on mental health status was found to be in contrast to negative findings associated with changes in physical health status. The implications for future research relate to the need to identify risk factors among geriatric populations to better target groups that would most likely benefit from PRS Program enrollment. ^

The role of STAT3 in the emergency neutrophil response

Neutrophils are an essential component of innate immunity, serving to provide an immediate response to microbial invasion. In response to emergency situations such as an infection, serum levels of granulocyte colony-stimulating factor (G-CSF) are induced, causing a boost in neutrophil production and a rapid mobilization of bone marrow neutrophils to the blood, where they can circulate to clear foreign pathogens. Signal transducer and activator of transcription 3 (STAT3) is a principal downstream signaling intermediate of the G-CSF receptor. Mice null for STAT3 are embryonic lethal; therefore, to examine the role that STAT3 has in granulocytic development and function in vivo, we utilized a conditional knockout mouse that deletes functional STAT3 in the hematopoietic system (referred to herein as STAT3-deficient). Using this model, we show that STAT3 is required for G-CSF-induced expansion of granulocytic progenitor cells within the bone marrow and for acute G-CSF-dependent neutrophil mobilization into the blood. Thus, STAT3 has a critical role in the immediate G-CSF-response in vivo. Sustained G-CSF exposure causes skewed granulocytic production and mobilization in STAT3-deficient mice, suggesting an atypical granulocytic developmental pathway. To determine if STAT3-deficient neutrophils were functional, we examined neutrophil chemotaxis, since neutrophil function relies on proper chemoattractant-induced migration to infected tissue sites. STAT3-deficient neutrophils have impaired chemotaxis in response to the potent neutrophil chemoattractants MIP-2 and KC, both ligands for the chemokine receptor CXCR2. Additionally, STAT3-deficient mice have a defect in NIIP-2-induced acute neutrophil mobilization in vivo. Chemotaxis in response to fMLP and SDF-1, which utilize distinct seven-transmembrane chemokine receptors, was similar between wild type and STAT3-deficient neutrophils, suggesting that STAT3 specifically regulates CXCR2-mediated migration. MIP-2-induced activation of the Raf/MEK/ERK signaling cascade, which we show is required for MIP-2-dependent neutrophil chemotaxis, was impaired in STAT3-deficient neutrophils. Interestingly, acute G-CSF administration induced CXCR2 expression and Raf/MEK/ERK activation in neutrophils from wild type mice, whereas these responses were abrogated in neutrophils from STAT3-deficient mice. Thus, STAT3 regulation of CXCR2 functions may also contribute to STAT3's control of the acute G-CSF mobilization response. These combined results place STAT3 as a critical intermediate in neutrophil migration and G-CSF-induced neutrophil production responses required for emergency granulopoiesis. ^

Introduction to public health preparedness for disaster and emergency response

The unprecedented attacks of September 11, 2001, and the subsequent anthrax-related events thrust our nation's often forgotten public health system into the forefront of public attention. A strong public health system with a well-prepared workforce plays a critical role in preparing for and responding to the threat of bioterrorism and other disasters and emergencies. Technical expertise is critical as is a basic awareness and understanding of core public health competencies especially as they relate to disaster and emergency response is also imperative for a public health agency to function as a vital Emergency Response team member. Ideally this training should begin at the Public Health graduate level so as to provide the baseline core tools to be able to function as a vital team member when they are practicing out in the real world. Online learning is an efficient and effective method for providing public health education to in a flexible format to meet the needs of busy student-professions. This Public Health Disaster Preparedness online course developed during an Emergency Response state program practicum is a practical and proficient approach to accomplish this endeavor. ^

Emergency health care assessment in the Houston-Galveston region 2002--2006

Background. Previous studies show emergency rooms to be over crowded nation wide. With growing attention to this problem, the Houston-Galveston Area Council (H-GAC) initiated a study in 2005 to assess their region's emergency health care system, and continued this effort in 2007. The purpose of this study was to examine recent changes in volume, capacity and performance in the Houston-Galveston region's emergency health care system and determine whether the system has been able to effectively respond to the residents' demands. Methods. Data were collected by the Houston-Galveston Area Council and The Abaris Group using a self-administered 2002-2006 survey completed by administrators of the region's hospitals, EMS providers, and select fire departments that provide EMS services. Data from both studies were combined and matched to examine trends. Results. Volume increased among the reporting hospitals within the Houston-Galveston region from 2002 to 2006; however, capacity remained relatively unchanged. EMS providers reported higher average off load times in 2007 compared to 2005, but the increases were not statistically significant. Hospitals reported transferring a statistically significant greater percentage of patients in 2006 than 2004. There was no statistically significant change in any of the other measures. Conclusion. These findings indicate an increase in demand for the Houston-Galveston region's emergency healthcare services with no change in supply. Additional studies within the area are needed to fully assess and evaluate the impact of these changes on system performance. ^

Analysis of a disaster medical track for the Certificate in Emergency Management and Preparedness Program at the University of Texas at Dallas

Since the tragic events of September 11, 2001, the United States has engaged in building the infrastructure and developing the expertise necessary to protect its borders and its citizens from further attacks against its homeland. One approach has been the development of academic courses to educate individuals on the nature and dangers of subversive attacks and to prepare them to respond to attacks and other large-scale emergencies in their roles as working professionals, participating members of their communities, and collaborators with first responders. An initial review of the literature failed to reveal any university-based emergency management courses or programs with a disaster medical component, despite the public health significance and need for such programs. In the Fall of 2003, The School of Management at The University of Texas at Dallas introduced a continuing education Certificate in Emergency Management and Preparedness Program. This thesis will (1) describe the development and implementation of a new Disaster Medical Track as a component of this Certificate in Emergency Management and Preparedness Program, (2) analyze the need for and effectiveness of this Disaster Medical Track, and (3) propose improvements in the track based on this analysis. ^

Emergency department usage patterns among residents of Hardin, Jefferson, and Orange Counties in southeast Texas

Emergency departments (EDs) have been called the net below the safety net due to their long history of providing care to the uninsured and others lacking access to the healthcare system. In past years, those with Medicaid and, more recently, those with Medicare, are also utilizing the ED as a medical home for routine primary care. There are many reasons for this but the costs to the community have become increasingly burdensome. ^ To evaluate how often the ED is being utilized for primary care, we applied a standardized tool, the New York University Algorithm, to over 43,000 ED visits when no hospitalization was required made by Hardin, Jefferson, and Orange County residents over a 12 month period. We compared our results to Harris County, where studies using the same framework have been performed, and found that sizeable segments of the population in both areas are utilizing the ED for non-emergent primary care that could be treated in a more cost-effective community setting. ^ We also analyzed our dataset for visit-specific characteristics. We found evidence of two possible health care disparities: (1) Blacks had a higher rate of primary care-related ED visits in relation to their percentage of the population when compared to other racial/ethnic groups; and (2) when form of payment is considered, the uninsured were more likely to have a primary care-related ED visit than any other group. These findings suggest a lack of community-based primary care services for the medically needy in Southeast Texas. ^ We believe that studies such as this are warranted elsewhere in Texas as well. We plan to present our findings to local policy makers, who should find this information helpful in identifying gaps in the safety net and assist them in better allocating scarce community resources. ^

The Emergency Department: Rising wait times, costs, and possible remedies

Emergency Departments (EDs) and Emergency Rooms (ERs) are designed to manage trauma, respond to disasters, and serve as the initial care for those with serious illnesses. However, because of many factors, the ED has become the doorway to the hospital and a “catch-all net” for patients including those with non-urgent needs. This increase in the population in the ED has lead to an increase in wait times for patients. It has been well documented that there has been a constant and consistent rise in the number of patients that frequent the ED (National Center for Health Statistics, 2002); the wait time for patients in the ED has increased (Pitts, Niska, Xu, & Burt, 2008); and the cost of the treatment in the ER has risen (Everett Clinic, 2008). Because the ED was designed to treat patients who need quick diagnoses and may be in potential life-threatening circumstances, management of time can be the ultimate enemy. If a system was implemented to decrease wait times in the ED, decrease the use of ED resources, and decrease costs endured by patients seeking care, better outcomes for patients and patient satisfaction could be achieved. The goal of this research was to explore potential changes and/or alternatives to relieve the burden endured by the ED. In order to explore these options, data was collected by conducting one-on-one interviews with seven physicians closely tied to a Level 1 ED (Emergency Room physicians, Trauma Surgeons and Primary Care physicians). A qualitative analysis was performed on the responses of one-on-one interviews with the aforementioned physicians. The interviews were standardized, open-ended questions that probe what makes an effective ED, possible solutions to improving patient care in the ED, potential remedies for the mounting problems that plague the ED, and the feasibility of bringing Primary Care Physicians to the ED to decrease the wait times experienced by the patient. From the responses, it is clear that there needs to be more research in this area, several areas need to be addressed, and a variety of solutions could be implemented. The most viable option seems to be making the ED its own entity (similar to the clinic or hospital) that includes urgent clinics as a part of the system, in which triage and better staffing would be the most integral part of its success.^

Workers and respirators: What factors influence medical clearance? Experience in the petrochemical industry 2004--2008

This retrospective cohort study analyzed data from more than 2200 OSHA-mandated respirator medical evaluations performed between 2004 and 2008, with information initially obtained using an online questionnaire, to determine what factors influence medical clearance and the ability to safely wear respiratory protection in a large petrochemical company.^ The employees were mostly white males with a high school education, ranging in age from 25 to 60 years of age, who had been employed with the company an average of eight years. Their work was typically performed outdoors in a rural or offshore setting. Respirators were typically required for emergency response – escape or rescue only – and/or limited to less than four hours per month.^ Approximately 90% of the population achieved medical clearance by utilizing the online questionnaire. Of the remaining 10%, 66% were cleared after additional "hands-on" medical examination exam; 28% of the individuals' jobs were modified by their supervisor in order to not use a respirator, and 6% of the individuals (n=13) were excluded from wearing a respirator on the basis of the medical examination. The primary causes for exclusion from respirator use were cardiovascular (37.5%) and respiratory (31.3%) issues, followed by psychological (18.8%) and musculoskeletal (12.5%) concerns. Ultimately, over 99% of workers evaluated under this system were found capable of using respiratory protection safely. This questionnaire has proven to be an excellent health screening tool capable of initiating early detection and further investigation of potentially serious medical conditions within a large and diverse population in multiple locations. ^