Helitransporte medicalizado: Situaci��n actual en Espa��a y an��lisis de los ��ltimos doce a��os de actividad en Andaluc��a

INTRODUCCI��N ��� Los servicios de emergencia m��dica con helic��pteros, en adelante HEMS (Helicopter Emergency Medical Service) son una herramienta consolidada en la asistencia sanitaria extra-hospitalaria y un componente esencial dentro de un sistema integral de emergencias. ��� Deben ser dise��ados para mejorar la accesibilidad al diagn��stico y el tratamiento especializado en procesos severos y de r��pido deterioro. ��� Deber��an aportar el mejor tratamiento in situ con un elevado nivel de competencia y proporcionar una reducci��n del tiempo de traslado al centro de referencia. OBJETIVOS: ��� Describir las caracter��sticas y actividad global en 2014 de los helic��pteros medicalizados de Espa��a. ��� Analizar la evoluci��n de la actividad de los helic��pteros de emergencias m��dicas (HEMS) en Andaluc��a entre 2003 y 2014. ��� Analizar las caracter��sticas as�� como el abordaje terap��utico de los traumatismos graves atendidos por los HEMS en Andaluc��a en 2013 y 2014. METODOLOG��A: ��� Estudio descriptivo transversal mediante cuestionario semiestructurado a un profesional de cada helic��ptero medicalizado de Espa��a: Se incluyen 31 helic��pteros de emergencia m��dica, 4 de rescate medicalizado y 6 multi-prop��sito. ��� Estudio descriptivo retrospectivo de los registros de las demandas asistenciales asignadas a los HEMS en Andaluc��a entre 2003 y 2014. ��� Estudio descriptivo retrospectivo de las historias cl��nicas realizadas por los HEMS en Andaluc��a en 2013-14 a traumatismos graves, definido por la escala de trauma score revisada. RESULTADOS: ��� Se obtienen datos de actividad sanitaria de 35 helic��pteros. En 2014 recibieron 10.824 activaciones y completaron 8.893 asistencias, el 79% primarias. Trasladaron 7.056 pacientes. Las facilidades HEMS de 65 hospitales de referencia fueron: 69% con helipuerto propio, 38% transferencia directa y el 45% homologados para operaci��n nocturna. ��� En Andaluc��a en el periodo 2003-14 los HEMS recibieron 19.793 activaciones y completaron 14.646 asistencias, el 82% primarias. 8.792 pacientes fueron trasladados en helic��ptero. Hay una reducci��n de la actividad desde 2007 paralela a la disminuci��n de los accidentes de tr��ficos. ��� En 2013 y 2014 los helic��pteros andaluces atendieron 700 pacientes con traumatismos. En 565 registros pudo calcularse el trauma score (RTS-T) que fue menor de 12 en 112 casos que consideramos graves. De ellos, el 47% fue ocasionado por accidente de transporte, el traumatismo craneal fue el m��s frecuente alcanzando el 67%. El 68% de los pacientes graves precis�� una intubaci��n orotraqueal en la escena. La mortalidad durante la asistencia fue del 9���8% para los pacientes graves frente al 0���4% de aquellos que consideramos no graves. CONCLUSIONES: ��� Los HEMS en Espa��a han tenido un notable desarrollo en los ��ltimos 16. A��os aunque la disponibilidad de HEMS nocturno es aun baja. Existe gran variabilidad entre los sistemas adoptados en cada comunidad aut��noma. El equipamiento de seguridad del personal sanitario de muchas bases no alcanza est��ndares internacionales. ��� El rescate medicalizado est�� disponible s��lo en 5 comunidades aut��nomas cuya gran experiencia puede guiar la introducci��n en otras. ��� Los HEMS de Andaluc��a tienen una elevada actividad global, con un notable incremento en el periodo 2003-2014. La misiones m��s frecuentes fueron la asistencia primaria a traumatismos, especialmente cr��neo-encef��licos. La actividad a primarios alcanz�� el m��ximo en 2007 y descendi�� en paralelo a los accidentes de trafico. En el periodo se triplicaron las cancelaciones a misiones primarias y se duplicaron los traslados interhospitalarios. ��� Existe gran variabilidad en la especializaci��n del personal sanitario as�� como en el volumen y tipo de demandas realizadas en las diferentes bases HEMS de Andaluc��a. ��� Es necesario incrementar la cantidad y la calidad de helisuperficies de los hospitales de referencia en Andaluc��a para que permitan la transferencia sin ambulancia. ��� Son necesarios nuevos estudios que comparen la morbi-mortalidad y los tiempos de las asistencias realizadas por HEMS y por ambulancias terrestres.

Satisfa����o/motiva����o dos enfermeiros profiss��o, servi��o e hierarquia

Apesar de d��cadas de estudos, as opini��es s��o controversas. N��o existe uma opini��o comum entre os pesquisadores sobre o que �� e como ocorre a motiva����o, a satisfa����o e a insatisfa����o no trabalho. As condi����es f��sicas dos servi��os s��o um factor primordial para a motiva����o, satisfa����o ou insatisfa����o do trabalhador, assim como o tipo de lideran��a existente no mesmo. Ao longo da nossa hist��ria tem-se assistido a muitos exemplos de lideran��a, uns mais, outros menos eficazes. A satisfa����o no trabalho �� um estado afectivo resultante da aprecia����o das caracter��sticas percebidas do trabalho e da organiza����o. Neste contexto de mudan��as na administra����o p��blica em geral e na ��rea da sa��de em particular, surge este estudo em contexto hospitalar, motivado pela necessidade de conhecer a satisfa����o dos enfermeiros de um Centro Hospitalar de Lisboa e a rela����o com algumas vari��veis s��cio demogr��ficas. Optou-se pelo paradigma quantitativo, numa amostra de 122 inquiridos pertencentes a um grupo de profissionais de enfermagem de um Hospital Central de Lisboa. Para a elabora����o da parte emp��rica utilizou-se o m��todo por question��rio de escolha m��ltipla. Os objectivos definidos: Objectivo Geral: perceber o n��vel de motiva����o/ satisfa����o dos enfermeiros relativamente �� profiss��o ao servi��o e �� hierarquia. Objectivos espec��ficos: Identificar o n��vel de satisfa����o/motiva����o dos enfermeiros dos servi��os estudados relativamente �� profiss��o, em fun����o das vari��veis sociodemogr��ficas. - Caracterizar os aspectos com os quais os enfermeiros t��m maior e menor satisfa����o relacionados com a profiss��o, servi��o e hierarquia. - Identificar se existe rela����o entre o n��vel de motiva����o/satisfa����o e os sintomas f��sicos sentidos. Os participantes da amostra s��o, maioritariamente do sexo feminino, a m��dia de idades �� de 32 anos, grande percentagem j�� tem como habilita����es profissionais a licenciatura, t��m entre 1 e 28 anos de profiss��o e 1 e 28 anos no servi��o actual, 17,2% exercem fun����es de chefia. Grande percentagem da amostra tem como hor��rio semanal de trabalho 35 horas e trabalham em hor��rio rotativo. Os enfermeiros s��o profissionais que mostram insatisfa����o relativamente �� profiss��o e hierarquia e moderada satisfa����o relativamente aos servi��os. A satisfa����o dos enfermeiros quanto �� profiss��o altera-se de acordo com o hor��rio de trabalho, v��nculo �� institui����o e os sentimentos que os mesmos t��m relativamente ao trabalho. A satisfa����o dos enfermeiros relativamente ao servi��o altera-se consoante o tempo de profiss��o e com os sentimentos que os profissionais apresentam relativamente ao trabalho. Quanto �� satisfa����o dos enfermeiros relativamente �� hierarquia altera-se dependendo da idade dos profissionais, do tempo de profiss��o e do servi��o onde desempenham. Relativamente �� satisfa����o geral com o trabalho, esta pode alterar dependendo da idade, do tempo de profiss��o, do servi��o onde desempenham fun����es e dos sentimentos dos profissionais relativamente ao trabalho. De salientar que ao analisarmos os servi��os estudados separadamente conclu��mos que os enfermeiros do servi��o de urg��ncia s��o profissionais muito insatisfeitos com a hierarquia e os enfermeiros da Unidade de Urg��ncia M��dica s��o profissionais pouco satisfeitos, mas apesar de tudo satisfeitos com a hierarquia. ABSTRACT; Behind decades of studies, the opinions are controversial. There is a common opinion among researchers about what is and how is the motivation, satisfaction and dissatisfaction at work. The physical conditions of services are a major factor in motivation, satisfaction or dissatisfaction of the worker and the type of leadership exists in it. Throughout our history have seen many examples of leadership, some more, some less effective. Job satisfaction is an affective state resulting from the assessment of the perceived characteristics of work and organization. ln this context of changes in public administration in general and in health in particular, this study appears in the hospital setting, motivated by the need to know the satisfaction of nurses in a Hospital in Lisbon and the relationship with sociodemographic variables. We chose the quantitative paradigm in a sample of 122 respondents belonging to a group of nursing professionals in a central hospital in Lisbon. ln developing the empirical part we used the method for multiple-choice test. The objectives: General Objective: To understand the level of motivation I satisfaction of nurses for the profession and the service hierarchy. Specific objectives: To identify the level of satisfaction I motivation of nursing service studied for the profession, according to the socio-demographic variables. - Characterize the points with which nurses have the highest and lowest satisfaction related to the profession, service and hierarchy. - To identify if there is a relationship between the level of motivation I satisfaction and physical symptoms felt. The sample participants are mostly female, average age is 32 years, a large percentage already has the professional qualifications of the degree, are between and 28 years of occupation and 1 and 28 in the current service, 17.2 % hold positions of leadership. A great percentage of the sample has the working week and working 35 hours on rotating schedule. Nurses are professionals who show dissatisfaction with the profession and the hierarchy and moderately satisfied for the services, the latter fact can be justified by what is possible when the organization professionals are available and perform functions in service to their liking and they like to work. The satisfaction of nurses as the profession changes according to working hours, commitment to the institution and the feelings they have for the work. The satisfaction of nurses for the service changes depending on the length of service and with the feelings that professionals are on the job. The satisfaction of nurses from the hierarchy will change depending on the age of professionals, time and professional service where they play. For the overall satisfaction with the work, this may change depending on age, length of employment, where the service functions and the feelings of the professionals for the job. Note that when analyzing the services studied separately concluded that the nurses in the emergency department professionals are very unhappy with the hierarchy and the nurses of the Unit of Emergency Medical professionals are somewhat satisfied but still happy

Efficacy and safety of out-of-hospital intravenous metoprolol administration in anterior ST-segment elevation acute myocardial infarction: insights from the METOCARD-CNIC trial

We seek to examine the efficacy and safety of prereperfusion emergency medical services (EMS)���administered intravenous metoprolol in anterior ST-segment elevation myocardial infarction patients undergoing eventual primary angioplasty. This is a prespecified subgroup analysis of the Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction trial population, who all eventually received oral metoprolol within 12 to 24 hours. We studied patients receiving intravenous metoprolol by EMS and compared them with others treated by EMS but not receiving intravenous metoprolol. Outcomes included infarct size and left ventricular ejection fraction on cardiac magnetic resonance imaging at 1 week, and safety by measuring the incidence of the predefined combined endpoint (composite of death, malignant ventricular arrhythmias, advanced atrioventricular block, cardiogenic shock, or reinfarction) within the first 24 hours. From the total population of the trial (N=270), 147 patients (54%) were recruited during out-of-hospital assistance and transferred to the primary angioplasty center (74 intravenous metoprolol and 73 controls). Infarct size was smaller in patients receiving intravenous metoprolol compared with controls (23.4 [SD 15.0] versus 34.0 [SD 23.7] g; adjusted difference ���11.4; 95% confidence interval [CI] ���18.6 to ���4.3). Left ventricular ejection fraction was higher in the intravenous metoprolol group (48.1% [SD 8.4%] versus 43.1% [SD 10.2%]; adjusted difference 5.0; 95% CI 1.6 to 8.4). Metoprolol administration did not increase the incidence of the prespecified safety combined endpoint: 6.8% versus 17.8% in controls (risk difference ���11.1; 95% CI ���21.5 to ���0.6). Out-of-hospital administration of intravenous metoprolol by EMS within 4.5 hours of symptom onset in our subjects reduced infarct size and improved left ventricular ejection fraction with no excess of adverse events during the first 24 hours.

Evaluation of the Medical Care of Patients with Hypertension in an Emergency Department and in Ambulatory Hypertension Unit

OBJECTIVE: To evaluate the characteristics of the patients receiving medical care in the Ambulatory of Hypertension of the Emergency Department, Division of Cardiology, and in the Emergency Unit of the Clinical Hospital of the Ribeir��o Preto Medical School. METHODS: Using a protocol, we compared the care of the same hypertensive patients in on different occasions in the 2 different places. The characteristics of 62 patients, 29 men with a mean age of 57 years, were analyzed between January 1996 and December 1997. RESULTS: The care of these patients resulted in different medical treatment regardless of their clinical features and blood pressure levels. Thus, in the Emergency Unit, 97% presented with symptoms, and 64.5% received medication to rapidly reduce blood pressure. In 50% of the cases, nifedipine SL was the elected medication. Patients who applied to the Ambulatory of Hypertension presenting with similar features, or, in some cases, presenting with similar clinically higher levels of blood pressure, were not prescribed medication for a rapid reduction of blood pressure at any of the appointments. CONCLUSION: The therapeutic approach to patients with high blood pressure levels, symptomatic or asymptomatic, was dependent on the place of treatment. In the Emergency Unit, the conduct was, in the majority of cases, to decrease blood pressure immediately, whereas in the Ambulatory of Hypertension, the same levels of blood pressure, in the same individuals, resulted in therapeutic adjustment with nonpharmacological management. These results show the need to reconsider the concept of hypertensive crises and their therapeutical implications.

Missed Opportunities: Evolution of Patients Leaving without Being Seen or against Medical Advice during a Six-Year Period in a Swiss Tertiary Hospital Emergency Department.

Aim. The study aimed at describing the evolution over a 6-year period of patients leaving the emergency department (ED) before being seen ("left without being seen" or LWBS) or against medical advice ("left against medical advice" or LAMA) and at describing their characteristics. Methods. A retrospective database analysis of all adult patients who are admitted to the ED, between 2005 and 2010, and who left before being evaluated or against medical advice, in a tertiary university hospital. Results. During the study period, among the 307,716 patients who were registered in the ED, 1,157 LWBS (0.4%) and 1,853 LAMA (0.9%) patients were identified. These proportions remained stable over the period. The patients had an average age of 38.5 �� 15.9 years for LWBS and 41.9 �� 17.4 years for LAMA. The median time spent in the ED before leaving was 102.4 minutes for the LWBS patients and 226 minutes for LAMA patients. The most frequent reason for LAMA was related to the excessive length of stay. Conclusion. The rates of LWBS and LAMA patients were low and remained stable. The patients shared similar characteristics and reasons for leaving were largely related to the length of stay or waiting time.

Delay for admission of unstable hospitalized patients to intensive care unit: a need for a medical emergency team?

INTRODUCTION. Patients admitted in Intensive Care Unit (ICU) from general wards are more severe and have a higher mortality than those admitted from emergency department as reported [1]. The majority of them develop signs of instability (e.g. tachypnea, tachycardia, hypotension, decreased oxygen saturation and change in conscious state) several hours before ICU admission. Considering this fact and that in-hospital cardiac arrests and unexpected deaths are usually preceded by warning signs, immediate on site intervention by specialists may be effective. This gave an impulse to medical emergency team (MET) implementation, which has been shown to decrease cardiac arrest, morbidity and mortality in several hospitals. OBJECTIVES AND METHODS. In order to verify if the same was true in our hospital and to determine if there was a need for MET, we prospectively collected all non elective ICU admissions of already hospitalized patients (general wards) and of patients remaining more than 3 h in emergency department (considered hospitalized). Instability criteria leading to MET call correspond to those described in the literature. The delay between the development of one criterion and ICU admission was registered. RESULTS. During an observation period of 12 months, 321 patients with our MET criteria were admitted to ICU. 88 patients came from the emergency department, 115 from the surgical and 113 from the medical ward. 65% were male. The median age was 65 years (range 17-89). The delay fromMETcriteria development to ICU admission was higher than 8 h in 155 patients, with a median delay of 32 h and a range of 8.4 h to 10 days. For the remaining 166 patients, an early MET criterion was present up to 8 h (median delay 3 h) before ICU admission. These results are quite concordant with the data reported in the literature (ref 1-8). 122 patients presented signs of sepsis or septic shock, 70 patients a respiratory failure, 58 patients a cardiac emergency. Cardiac arrest represent 5% of our collective of patients. CONCLUSIONS.Similar to others observations, the majority of hospitalized patients admitted on emergency basis in our ICU have warning signs lasting for several hours. More than half of them were unstable for more than 8 h. This shows there is plenty of time for early acute management by dedicated and specialized team such as MET. However, further studies are required to determine if MET implementation can reduce in-hospital cardiac arrests and influence the morbidity, the length of stay and the mortality.

Social and medical vulnerability factors of emergency department frequent users in a universal health insurance system.

OBJECTIVES: The objectives were to identify the social and medical factors associated with emergency department (ED) frequent use and to determine if frequent users were more likely to have a combination of these factors in a universal health insurance system. METHODS: This was a retrospective chart review case-control study comparing randomized samples of frequent users and nonfrequent users at the Lausanne University Hospital, Switzerland. The authors defined frequent users as patients with four or more ED visits within the previous 12 months. Adult patients who visited the ED between April 2008 and March 2009 (study period) were included, and patients leaving the ED without medical discharge were excluded. For each patient, the first ED electronic record within the study period was considered for data extraction. Along with basic demographics, variables of interest included social (employment or housing status) and medical (ED primary diagnosis) characteristics. Significant social and medical factors were used to construct a logistic regression model, to determine factors associated with frequent ED use. In addition, comparison of the combination of social and medical factors was examined. RESULTS: A total of 359 of 1,591 frequent and 360 of 34,263 nonfrequent users were selected. Frequent users accounted for less than a 20th of all ED patients (4.4%), but for 12.1% of all visits (5,813 of 48,117), with a maximum of 73 ED visits. No difference in terms of age or sex occurred, but more frequent users had a nationality other than Swiss or European (n = 117 [32.6%] vs. n = 83 [23.1%], p = 0.003). Adjusted multivariate analysis showed that social and specific medical vulnerability factors most increased the risk of frequent ED use: being under guardianship (adjusted odds ratio [OR] = 15.8; 95% confidence interval [CI] = 1.7 to 147.3), living closer to the ED (adjusted OR = 4.6; 95% CI = 2.8 to 7.6), being uninsured (adjusted OR = 2.5; 95% CI = 1.1 to 5.8), being unemployed or dependent on government welfare (adjusted OR = 2.1; 95% CI = 1.3 to 3.4), the number of psychiatric hospitalizations (adjusted OR = 4.6; 95% CI = 1.5 to 14.1), and the use of five or more clinical departments over 12 months (adjusted OR = 4.5; 95% CI = 2.5 to 8.1). Having two of four social factors increased the odds of frequent ED use (adjusted = OR 5.4; 95% CI = 2.9 to 9.9), and similar results were found for medical factors (adjusted OR = 7.9; 95% CI = 4.6 to 13.4). A combination of social and medical factors was markedly associated with ED frequent use, as frequent users were 10 times more likely to have three of them (on a total of eight factors; 95% CI = 5.1 to 19.6). CONCLUSIONS: Frequent users accounted for a moderate proportion of visits at the Lausanne ED. Social and medical vulnerability factors were associated with frequent ED use. In addition, frequent users were more likely to have both social and medical vulnerabilities than were other patients. Case management strategies might address the vulnerability factors of frequent users to prevent inequities in health care and related costs.

Social and medical vulnerability factors of emergency department frequent users in a universal health insurance system

Objectifs - Identifier les facteurs de vuln��rabilit�� sociaux et m��dicaux associ��s au recours multiple aux consultations des urgences. - D��terminer si les patients �� recours multiple sont plus �� m��me de combiner ces facteurs dans un syst��me d'assurance universelle. M��thode Il s'agit d'une ��tude cas-contr��le r��trospective bas��e sur l'��tude de dossiers m��dico-administratifs comparant des ��chantillons randomis��s de patients �� recours multiple �� des patients n'appartenant pas �� cette cat��gorie, au sein des urgences du Centre Hospitalier Universitaire Vaudois et de la Policlinique M��dicale Universitaire de Lausanne. Les auteurs ont d��fini les patients �� recours multiple comme comptabilisant au moins quatre consultations aux urgences durant les douze mois pr��c��dents. Les patients adultes (>18 ans) ayant consult�� les urgences entre avril 2008 et mars 2009 (p��riode d'��tude) ��taient inclus ; ceux quittant les urgences sans d��charge m��dicale ��taient exclus. Pour chaque patient, le premier dossier d'urgence informatis�� inclus dans la p��riode d'��tude ��tait s��lectionn�� pour l'extraction des donn��es. Outre les variables d��mographiques de base, les variables d'int��r��t comprennent des caract��ristiques sociales (emploi, type de r��sidence) et m��dicales (diagnostic principal aux urgences). Les facteurs sociaux et m��dicaux significatifs ont ��t�� utilis��s dans la construction d'un mod��le de r��gression logistique, afin de d��terminer les facteurs associ��s avec le recours multiple aux urgences. De plus, la combinaison des facteurs sociaux et m��dicaux a ��t�� ��tudi��e. R��sultats Au total, 359/Γ591 patients �� recours multiple et 360/34'263 contr��les ont ��t�� s��lectionn��s. Les patients �� recours multiple repr��sentaient moins d'un vingti��me de tous les patients des urgences (4.4%), mais engendraient 12.1% de toutes les consultations (5'813/48'117), avec un record de 73 consultations. Aucune diff��rence en termes d'��ge ou de genre n'est apparue, mais davantage de patients �� recours multiples ��taient d'une nationalit�� autre que suisse ou europ��enne (n=117 [32.6%] vs n=83 [23.1%], p=0.003). L'analyse multivari��e a montr�� que les facteurs de vuln��rabilit�� sociaux et m��dicaux les plus fortement associ��s au recours multiple aux urgences ��taient : ��tre sous tutelle (Odds ratio [OR] ajust�� = 15.8; intervalle de confiance [IC] �� 95% = 1.7 �� 147.3), habiter plus proche des urgences (OR ajust�� = 4.6; IC95% = 2.8 �� 7.6), ��tre non assur�� (OR ajust�� = 2.5; IC95% = 1.1 �� 5.8), ��tre sans emploi ou d��pendant de l'aide sociale (OR ajust�� = 2.1; IC95% = 1.3 �� 3.4), le nombre d'hospitalisations psychiatriques (OR ajust�� = 4.6; IC95% = 1.5 �� 14.1), ainsi que le recours �� au moins cinq d��partements cliniques diff��rents durant une p��riode de douze mois (OR ajust�� = 4.5; IC95% = 2.5 �� 8.1). Le fait de comptabiliser deux sur quatre facteurs sociaux augmente la vraisemblance du recours multiple aux urgences (OR ajust�� = 5.4; IC95% = 2.9 �� 9.9) ; des r��sultats similaires ont ��t�� trouv��s pour les facteurs m��dicaux (OR ajust�� = 7.9; IC95% = 4.6 �� 13.4). La combinaison de facteurs sociaux et m��dicaux est fortement associ��e au recours multiple aux urgences, puisque les patients �� recours multiple ��taient dix fois plus �� m��me d'en comptabiliser trois d'entre eux (sur un total de huit facteurs, IC95% = 5.1 �� 19.6). Conclusion Les patients �� recours multiple aux urgences repr��sentent une proportion mod��r��e des consultations aux urgences du Centre Hospitalier Universitaire Vaudois et de la Policlinique M��dicale Universitaire de Lausanne. Les facteurs de vuln��rabilit�� sociaux et m��dicaux sont associ��s au recours multiple aux urgences. En outre, les patients �� recours multiple sont plus �� m��me de combiner les vuln��rabilit��s sociale et m��dicale que les autres. Des strat��gies bas��es sur le case management pourraient am��liorer la prise en charge des patients �� recours multiple avec leurs vuln��rabilit��s afin de pr��venir les in��galit��s dans le syst��me de soins ainsi que les co��ts relatifs.

Social and medical vulnerability factors of frequent users at the emergency department: a case-control study

BACKGROUND: Up to 5% of patients presenting to the emergency department (ED) four or more times within a 12 month period represent 21% of total ED visits. In this study we sought to characterize social and medical vulnerability factors of ED frequent users (FUs) and to explore if these factors hold simultaneously. METHODS: We performed a case-control study at Lausanne University Hospital, Switzerland. Patients over 18 years presenting to the ED at least once within the study period (April 2008 toMarch 2009) were included. FUs were defined as patients with four or more ED visits within the previous 12 months. Outcome data were extracted from medical records of the first ED attendance within the study period. Outcomes included basic demographics and social variables, ED admission diagnosis, somatic and psychiatric days hospitalized over 12 months, and having a primary care physician.We calculated the percentage of FUs and non-FUs having at least one social and one medical vulnerability factor. The four chosen social factors included: unemployed and/or dependence on government welfare, institutionalized and/or without fixed residence, either separated, divorced or widowed, and under guardianship. The fourmedical vulnerability factors were: &#8805;6 somatic days hospitalized, &#8805;1 psychiatric days hospitalized, &#8805;5 clinical departments used (all three factors measured over 12 months), and ED admission diagnosis of alcohol and/or drug abuse. Univariate and multivariate logistical regression analyses allowed comparison of two JGIM ABSTRACTS S391 random samples of 354 FUs and 354 non-FUs (statistical power 0.9, alpha 0.05 for all outcomes except gender, country of birth, and insurance type). RESULTS: FUs accounted for 7.7% of ED patients and 24.9% of ED visits. Univariate logistic regression showed that FUs were older (mean age 49.8 vs. 45.2 yrs, p=0.003),more often separated and/or divorced (17.5%vs. 13.9%, p=0.029) or widowed (13.8% vs. 8.8%, p=0.029), and either unemployed or dependent on government welfare (31.3% vs. 13.3%, p<0.001), compared to non-FUs. FUs cumulated more days hospitalized over 12 months (mean number of somatic days per patient 1.0 vs. 0.3, p<0.001; mean number of psychiatric days per patient 0.12 vs. 0.03, p<0.001). The two groups were similar regarding gender distribution (females 51.7% vs. 48.3%). The multivariate linear regression model was based on the six most significant factors identified by univariate analysis The model showed that FUs had more social problems, as they were more likely to be institutionalized or not have a fixed residence (OR 4.62; 95% CI, 1.65 to 12.93), and to be unemployed or dependent on government welfare (OR 2.03; 95% CI, 1.31 to 3.14) compared to non-FUs. FUs were more likely to need medical care, as indicated by involvement of&#8805;5 clinical departments over 12 months (OR 6.2; 95%CI, 3.74 to 10.15), having an ED admission diagnosis of substance abuse (OR 3.23; 95% CI, 1.23 to 8.46) and having a primary care physician (OR 1.70;95%CI, 1.13 to 2.56); however, they were less likely to present with an admission diagnosis of injury (OR 0.64; 95% CI, 0.40 to 1.00) compared to non-FUs. FUs were more likely to combine at least one social with one medical vulnerability factor (38.4% vs. 12.1%, OR 7.74; 95% CI 5.03 to 11.93). CONCLUSIONS: FUs were more likely than non-FUs to have social and medical vulnerability factors and to have multiple factors in combination.

The knowledge about diagnostic imaging methods among primary care and medical emergency physicians

Objective To evaluate the knowledge about diagnostic imaging methods among primary care and medical emergency physicians. Materials and Methods Study developed with 119 primary care and medical emergency physicians in Montes Claros, MG, Brazil, by means of a structured questionnaire about general knowledge and indications of imaging methods in common clinical settings. A rate of correct responses corresponding to &#8805; 80% was considered as satisfactory. The Poisson regression (PR) model was utilized in the data analysis. Results Among the 81 individuals who responded the questionnaire, 65% (n = 53) demonstrated to have satisfactory general knowledge and 44% (n = 36) gave correct responses regarding indications of imaging methods. Respectively, 65% (n = 53) and 51% (n = 41) of the respondents consider that radiography and computed tomography do not use ionizing radiation. The prevalence of a satisfactory general knowledge about imaging methods was associated with medical residency in the respondents' work field (PR = 4.55; IC 95%: 1.18-16.67; p-value: 0.03), while the prevalence of correct responses regarding indication of imaging methods was associated with the professional practice in primary health care (PR = 1.79; IC 95%: 1.16-2.70; p-value: 0.01). Conclusion Major deficiencies were observed as regards the knowledge about imaging methods among physicians, with better results obtained by those involved in primary health care and by residents.

The implementation of the Medical Regulation Office and Mobile Emergency Attendance System and its impact on the gravity profile of non-traumatic afflictions treated in a University Hospital: a research study

Abstract Background The public health system of Brazil is structured by a network of increasing complexity, but the low resolution of emergency care at pre-hospital units and the lack of organization of patient flow overloaded the hospitals, mainly the ones of higher complexity. The knowledge of this phenomenon induced Ribeir��o Preto to implement the Medical Regulation Office and the Mobile Emergency Attendance System. The objective of this study was to analyze the impact of these services on the gravity profile of non-traumatic afflictions in a University Hospital. Methods The study conducted a retrospective analysis of the medical records of 906 patients older than 13 years of age who entered the Emergency Care Unit of the Hospital of the University of S��o Paulo School of Medicine at Ribeir��o Preto. All presented acute non-traumatic afflictions and were admitted to the Internal Medicine, Surgery or Neurology Departments during two study periods: May 1996 (prior to) and May 2001 (after the implementation of the Medical Regulation Office and Mobile Emergency Attendance System). Demographics and mortality risk levels calculated by Acute Physiology and Chronic Health Evaluation II (APACHE II) were determined. Results From 1996 to 2001, the mean age increased from 49 �� 0.9 to 52 �� 0.9 (P = 0.021), as did the percentage of co-morbidities, from 66.6 to 77.0 (P = 0.0001), the number of in-hospital complications from 260 to 284 (P = 0.0001), the mean calculated APACHE II mortality risk increased from 12.0 �� 0.5 to 14.8 �� 0.6 (P = 0.0008) and mortality rate from 6.1 to 12.2 (P = 0.002). The differences were more significant for patients admitted to the Internal Medicine Department. Conclusion The implementation of the Medical Regulation and Mobile Emergency Attendance System contributed to directing patients with higher gravity scores to the Emergency Care Unit, demonstrating the potential of these services for hierarchical structuring of pre-hospital networks and referrals.