Impact of community based, specialist palliative care teams on hospitalisations and emergency department visits late in life and hospital deaths: a pooled analysis

Objective: To determine the pooled effect of exposure to one of 11 specialist palliative care teams providing services in patients’ homes.Design: Pooled analysis of a retrospective cohort study.Setting: Ontario, Canada.Participants: 3109 patients who received care from specialist palliative care teams in 2009-11 (exposed) matched by propensity score to 3109 patients who received usual care (unexposed).Intervention: The palliative care teams studied served different geographies and varied in team composition and size but had the same core team members and role: a core group of palliative care physicians, nurses, and family physicians who provide integrated palliative care to patients in their homes. The teams’ role was to manage symptoms, provide education and care, coordinate services, and be available without interruption regardless of time or day.Main outcome measures: Patients (a) being in hospital in the last two weeks of life; (b) having an emergency department visit in the last two weeks of life; or (c) dying in hospital.Results: In both exposed and unexposed groups, about 80% had cancer and 78% received end of life homecare services for the same average duration. Across all palliative care teams, 970 (31.2%) of the exposed group were in hospital and 896 (28.9%) had an emergency department visit in the last two weeks of life respectively, compared with 1219 (39.3%) and 1070 (34.5%) of the unexposed group (P<0.001). The pooled relative risks of being in hospital and having an emergency department visit in late life comparing exposed versus unexposed were 0.68 (95% confidence interval 0.61 to 0.76) and 0.77 (0.69 to 0.86) respectively. Fewer exposed than unexposed patients died in hospital (503 (16.2%) v 887 (28.6%), P<0.001), and the pooled relative risk of dying in hospital was 0.46 (0.40 to 0.52).Conclusions: Community based specialist palliative care teams, despite variation in team composition and geographies, were effective at reducing acute care use and hospital deaths at the end of life.

Physical education undergraduates and dental trauma knowledge

The aim of the present study was to assess the level of knowledge of undergraduates from the College of Physical Education (Toledo, Aracatuba) concerning dental avulsion injuries. Data showed that 95% of the respondents did not know what dental avulsion is, 73.5% said they know how to define dental replantation, however, only 26% were able to do it correctly. When asked about first emergency measures after an avulsion, 50% of the respondents said they know what they should do, and the most cited measure was to seek a dentist. When asked about optimal storage media, 45.5% would keep it in a favorable one, and 28% did not know where to keep the tooth until treatment. Only 25.6% indicated a suitable extra-oral time for replantation; 90.3% of the respondents had received no advice about the emergency management of dental avulsion; 90% said they consider this an important and necessary subject. The results indicated that educational campaigns are necessary to improve the emergency management of dental injuries by those future P.E. professors for a better prognosis of dental replantation.

Drug dependence, mental impairment and education

This study aimed to evaluate the mental conditions of cocaine-dependent individuals and school commitment/attachment. We evaluated 50 patients referred to the psychiatry emergency room due to mental disorders from chemical dependence. After clinical diagnosis, clinical interview, Hospital Anxiety and Depression Scale, Hamilton Scale for Depression and Brief Psychiatric Rating Scale were applied. The Spearman and Mann-Whitney nonparametric tests, as well as the t-Student test were utilized for statistical analysis.. The accepted significance value was 0.05. All subjects had used cocaine or crack and other substances. Only 13 (26%) did not drop out of school (group 1). Regarding the other 37 (74%), irregular class attendance , successive failures and definitive school drop out rates (group 2) were verified. These subjects presented an early substance use when compared with those which did not drop out of school (p=0.0001). Patients with an early substance use presented higher school dropout rates than those with a later initiation to substance use. Psychopathological phenomena were frequent in both groups.

Current practices in the management of patients with ureteral calculi in the emergency room of a university hospital

OBJECTIVE: Urinary lithiasis is a common disease. The aim of the present study is to assess the knowledge regarding the diagnosis, treatment and recommendations given to patients with ureteral colic by professionals of an academic hospital. MATERIALS AND METHODS: Sixty-five physicians were interviewed about previous experience with guidelines regarding ureteral colic and how they manage patients with ureteral colic in regards to diagnosis, treatment and the information provided to the patients. RESULTS: Thirty-six percent of the interviewed physicians were surgeons, and 64% were clinicians. Forty-one percent of the physicians reported experience with ureterolithiasis guidelines. Seventy-two percent indicated that they use noncontrast CT scans for the diagnosis of lithiasis. All of the respondents prescribe hydration, primarily for the improvement of stone elimination (39.3%). The average number of drugs used was 3.5. The combination of nonsteroidal anti-inflammatory drugs and opioids was reported by 54% of the physicians (i. e., 59% of surgeons and 25.6% of clinicians used this combination of drugs) (p = 0.014). Only 21.3% prescribe alpha blockers. CONCLUSION: Reported experience with guidelines had little impact on several habitual practices. For example, only 21.3% of the respondents indicated that they prescribed alpha blockers; however, alpha blockers may increase stone elimination by up to 54%. Furthermore, although a meta-analysis demonstrated that hydration had no effect on the transit time of the stone or on the pain, the majority of the physicians reported that they prescribed more than 500 ml of fluid. Dipyrone, hyoscine, nonsteroidal anti-inflammatory drugs, and opioids were identified as the most frequently prescribed drug combination. The information regarding the time for the passage of urinary stones was inconsistent. The development of continuing education programs regarding ureteral colic in the emergency room is necessary.

Prevalence and associated factors of viral hepatitis and transferrin elevations in 5036 patients admitted to the emergency room of a Swiss university hospital: cross-sectional study

BACKGROUND: The epidemiology of liver disease in patients admitted to emergency rooms is largely unknown. The current study aimed to measure the prevalence of viral hepatitis B and C infection and pathological laboratory values of liver disease in such a population, and to study factors associated with these measurements. METHODS: Cross-sectional study in patients admitted to the emergency room of a university hospital. No formal exclusion criteria. Determination of anti-HBs, anti-HCV, transferrin saturation, alanine aminotransferase, and obtaining answers from a study-specific questionnaire. RESULTS: The study included 5'036 patients, representing a 14.9% sample of the target population during the study period. Prevalence of anti-HBc and anti-HCV was 6.7% (95%CI 6.0% to 7.4%) and 2.7% (2.3% to 3.2%), respectively. Factors independently associated with positive anti-HBc were intravenous drug abuse (OR 18.3; 11.3 to 29.7), foreign country of birth (3.4; 2.6 to 4.4), non-white ethnicity (2.7; 1.9 to 3.8) and age > or =60 (2.0; 1.5 to 2.8). Positive anti-HCV was associated with intravenous drug abuse (78.9; 43.4 to 143.6), blood transfusion (1.7; 1.1 to 2.8) and abdominal pain (2.7; 1.5 to 4.8). 75% of all participants were not vaccinated against hepatitis B or did not know their vaccination status. Among anti-HCV positive patients only 49% knew about their infection and 51% reported regular alcohol consumption. Transferrin saturation was elevated in 3.3% and was associated with fatigue (prevalence ratio 1.9; 1.2 to 2.8). CONCLUSION: Emergency rooms should be considered as targets for public health programs that encourage vaccination, patient education and screening of high-risk patients for liver disease with subsequent referral for treatment if indicated.

Consequences of insecurity in emergency telephone consultations: an experimental study in medical students.

QUESTION UNDER STUDY Handling emergency telephone consultations (ETCs) is a challenging and very important task for doctors. The aims of the study were to document insecurity in medical students during ETCs and to identify the reasons for that insecurity. We hypothesised that insecurity is associated with advising more urgent action (e.g. advice to call for an ambulance) in ETCs. METHODS We used ETCs with simulated patients (SPs), with each student randomly allocated two of four possible cases. After the training, 137 students reported on any insecurity that they had in the various ETC phases. We analysed the reasons for insecurity using descriptive statistics. The association between the students' advice that urgent action was needed and their insecurity was analysed with Spearman rank correlation. RESULTS Overall, 95% of the students felt insecure in at least one phase of their ETC. History taking was the phase in which students felt most insecure (63.1%), followed by the phase of analysing the information given by the patient (44.9%). Perceived insecurity was associated with more urgent advice in one case scenario (abdominal pain; correlation r = 0.46; p <0.01). The other two cases (child with fever; chest pain) also had a positive, but not statistically significant, correlation trend (p <0.12; p <0.08). CONCLUSIONS Insecurity is highly prevalent among medical students in their ETC decision-making. ETC training in medical schools, with a focus on structured history taking and formulating discriminating questions, might help decrease insecurity in ETCs. Medical education should also teach management of insecurity.

Health, education and community: Assets and needs of a small urban community in north east Tamaulipas, Mexico: A community based participatory research assessment

This study explored the health, education, social assets, needs, attitudes, and behaviors of residents of Ferrocarril #4, a small urban community in Tamaulipas, Mexico. A collaborative Participatory Action Research approach was used to emphasize community involvement. Using Triangulation to ensure validity, qualitative methods included key informant in depth interviews, participant observation and participatory discussion groups with women and men. A personal interview with a probability sample of women was done. The median age of interviewees was 37 years. The majority was married or had a partner. Over half of respondents completed grades 6-9. Employed women (25%) earned a median weekly salary equivalent to ∼56 USD. Women with health insurance (67.7%) were covered mainly through Social Security and Seguro Popular. One in 5 reported bad health. Barriers to care were primarily money and transportation. To improve health care, women wanted a full service clinic in or close to the community and affordable health care. Socially, 28% of respondents had no close friends in the community and most did not participate in beneficial community activities. Many women did not socialize with others and help from neighbors was situational. Primary school teachers lacked parental support and it interfered with classroom efforts. Healthy community discussion groups focused on personal and environmental hygiene and safety. Valuable assets exist in the community. To date, collaborative efforts resulted in a school First Aid station, a school nurse visit weekly, posting of emergency contact phone numbers in the school and community center, and development of a student health information form. ^

Minority preferences and disease types for non-emergent emergency department usage in a CHIP population

Background. Of the over five million annual pediatric visits to U.S. emergency departments, one-third to one-half are for non-emergent conditions. Minorities are more likely to utilize the emergency department (ED) for non-emergent conditions. Very little research has analyzed the role of illness type, perceived need, or family preferences in explaining this disparity. ^ Objectives. This study examined racial-ethnic differences in preferences for care among non-emergent users of the ED. ^ Research design. A random selection of pediatric non-emergent ED users within a single CHIP managed care plan were surveyed regarding attitudes and health care preferences. Preferences for ED utilization were analyzed by racial-ethnic category, controlling for illness type, child and guardian age, education level, language, and perceived need. ^ Results. A total of 250 families were surveyed. Most respondents reported having a regular doctor, satisfaction with their physician, and ready access to their physician. Fifteen percent of White, 39% of Hispanic, and 38% of Black families reported they preferred the emergency department for ill care. In multivariate analysis, Whites families were significantly less likely to prefer the emergency department for ill visits (odds ratio, 0.12; 95% confidence interval 0.03-0.55) compared to Blacks and Hispanics. ^ Conclusions. Racial-ethnic disparities in non-emergent ED utilization may be partially explained by different preferences for care. ^ Key words: children, emergency department, preferences for care, disparities ^

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. ^

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. ^

AN ECONOMIC ANALYSIS OF THE DEMAND FOR CARE IN A FREE-STANDING EMERGENCY CENTER

Free-standing emergency centers (FECs) represent a new approach to the delivery of health care which are competing for patients with more conventional forms of ambulatory care in many parts of the U.S. Currently, little is known about these centers and their patient populations. The purpose of this study, therefore, was to describe the patients who visited two commonly-owned FECs, and determine the reasons for their visits. An economic model of the demand for FEC care was developed to test its ability to predict the economic and sociodemographic factors of use. Demand analysis of other forms of ambulatory services, such as a regular source of care (RSOC), was also conducted to examine the issues of substitution and complementarity.^ A systematic random sample was chosen from all private patients who used the clinics between July 1 and December 31, 1981. Data were obtained by means of a telephone interview and from clinic records. Five hundred fifty-one patients participated in the study.^ The typical FEC patient was a 26 year old white male with a minimum of a high school education, and a family income exceeding $25,000 a year. He had lived in the area for at least twenty years, and was a professional or a clerical worker. The patients made an average of 1.26 visits to the FECs in 1981. The majority of the visits involved a medical complaint; injuries and preventive care were the next most common reasons for visits.^ The analytic results revealed that time played a relatively important role in the demand for FEC care. As waiting time at the patients' regular source of care increased, the demand for FEC care increased, indicating that the clinic serves as a substitute for the patients' usual means of care. Age and education were inversely related to the demand for FEC care, while those with a RSOC frequented the clinics less than those lacking such a source.^ The patients used the familiar forms of ambulatory care, such as a private physician or an emergency room in a more typical fashion. These visits were directly related to the age and education of the patients, existence of a regular source of care, and disability days, which is a measure of health status. ^

An assessment of post-disaster psychological stress in hazardous waste operations and emergency response (HAZWOPER) workers

Personnel involved in natural or man-made disaster response and recovery efforts may be exposed to a wide variety of physical and mental stressors that can exhibit long-lasting and detrimental psychopathological outcomes. In a disaster situation, huge numbers of "secondary" responders can be involved in contaminant clean-up and debris removal and can be at risk of developing stress-related mental health outcomes. The Occupational Safety and Health Administration (OSHA) worker training hierarchy typically required for response workers, known as "Hazardous Waste Operations and Emergency Response" (HAZWOPER), does not address the mental health and safety concerns of workers. This study focused on the prevalence of traumatic stress experienced by secondary responders that had received or expressed interest in receiving HAZWOPER training through the National Institute of Environmental Health Sciences Worker Education and Training Program (NIEHS WETP). ^ The study involved the modification of two preexisting and validated survey tools to assess secondary responder awareness of physical, mental, and traumatic stressors on mental health and sought to determine if a need existed to include traumatic stress-related mental health education in the current HAZWOPER training regimen. The study evaluated post-traumatic stress disorder (PTSD), resiliency, mental distress, and negative effects within a secondary responder population of 176 respondents. Elevated PTSD levels were seen in the study population as compared to a general responder population (32.9% positive vs. 8%-22.5% positive). Results indicated that HAZWOPER-trained disaster responders were likely to test positive for PTSD, whereas, untrained responders with no disaster experience and responders who possessed either training or disaster experience only were likely to test PTSD negative. A majority (68.75%) of the population tested below the mean resiliency to cope score (80.4) of the average worker population. Results indicated that those who were trained only or who possessed both training and disaster work experience were more likely to have lower resiliency scores than those with no training or experience. There were direct correlations between being PTSD positive and having worked at a disaster site and experiencing mental distress and negative effects. However, HAZWOPER training status does not significantly correlate with mental distress or negative effect. ^ The survey indicated clear support (91% of respondents) for mental health education. The development of a pre- and post-deployment training module is recommended. Such training could provide responders with the necessary knowledge and skills to recognize the symptomology of PTSD, mental stressors, and physical and traumatic stressors, thus empowering them to employ protective strategies or seek professional help if needed. It is further recommended that pre-deployment mental health education be included in the current HAZWOPER 24- and 40-hour course curriculums, as well as, consideration be given towards integrating a stand-alone post-deployment mental health education training course into the current HAZWOPER hierarchy.^

Debriefing after resuscitations in a pediatric emergency department

Multiple guidelines recommend debriefing of actual resuscitations to improve clinical performance. We implemented a novel standardized debriefing program using a Debriefing In Situ Conversation after Emergent Resuscitations Now (DISCERN) tool. Following the development of the evidence-based DISCERN tool, we conducted an observational study of all resuscitations (intubation, CPR, and/or defibrillation) at a pediatric emergency department (ED) over one year. Resuscitation interventions, patient survival, and physician team leader characteristics were analyzed as predictors for debriefing. Each debriefing's participants, time duration, and content were recorded. Thematic content of debriefings was categorized by framework approach into Team Emergency Assessment Measure (TEAM) elements. There were 241 resuscitations and 63 (26%) debriefings. A higher proportion of debriefings occurred after CPR (p<0.001) or ED death (p<0.001). Debriefing participants always included an attending and nurse; the median number of staff roles present was six. Median interval (from resuscitation end to start of debriefing) & debriefing durations were 33 (IQR 15,67) and 10 minutes (IQR 5,12), respectively. Common TEAM themes included co-operation/coordination (30%), communication (22%), and situational awareness (15%). Stated reasons for not debriefing included: unnecessary (78%), time constraints (19%), or other reasons (3%). Debriefings with the DISCERN tool usually involved higher acuity resuscitations, involved most of the indicated personnel, and lasted less than 10 minutes. This qualitative tool could be adapted to other settings. Future studies are needed to evaluate for potential impacts on education, quality improvement programming, and staff emotional well-being.^

Interactive Graphic Simulation: An Advanced Methodology to Improve the Teaching-Learning Process in Nuclear Engineering Education and Training

Nowadays, computer simulators are becoming basic tools for education and training in many engineering fields. In the nuclear industry, the role of simulation for training of operators of nuclear power plants is also recognized of the utmost relevance. As an example, the International Atomic Energy Agency sponsors the development of nuclear reactor simulators for education, and arranges the supply of such simulation programs. Aware of this, in 2008 Gas Natural Fenosa, a Spanish gas and electric utility that owns and operate nuclear power plants and promotes university education in the nuclear technology field, provided the Department of Nuclear Engineering of Universidad Politécnica de Madrid with the Interactive Graphic Simulator (IGS) of “José Cabrera” (Zorita) nuclear power plant, an industrial facility whose commercial operation ceased definitively in April 2006. It is a state-of-the-art full-scope real-time simulator that was used for training and qualification of the operators of the plant control room, as well as to understand and analyses the plant dynamics, and to develop, qualify and validate its emergency operating procedures.

Seismic Risk Scenarios in Puerto Principe (Haiti). A Tool for Reconstruction and Emergency Planning

The 12 January 2010, an earthquake hit the city of Port-au-Prince, capital of Haiti. The earthquake reached a magnitude Mw 7.0 and the epicenter was located near the town of Léogâne, approximately 25 km west of the capital. The earthquake occurred in the boundary region separating the Caribbean plate and the North American plate. This plate boundary is dominated by left-lateral strike slip motion and compression, and accommodates about 20 mm/y slip, with the Caribbean plate moving eastward with respect to the North American plate (DeMets et al., 2000). Initially the location and focal mechanism of the earthquake seemed to involve straightforward accommodation of oblique relative motion between the Caribbean and North American plates along the Enriquillo-Plantain Garden fault system (EPGFZ), however Hayes et al., (2010) combined seismological observations, geologic field data and space geodetic measurements to show that, instead, the rupture process involved slip on multiple faults. Besides, the authors showed that remaining shallow shear strain will be released in future surface-rupturing earthquakes on the EPGFZ. In December 2010, a Spanish cooperation project financed by the Politechnical University of Madrid started with a clear objective: Evaluation of seismic hazard and risk in Haiti and its application to the seismic design, urban planning, emergency and resource management. One of the tasks of the project was devoted to vulnerability assessment of the current building stock and the estimation of seismic risk scenarios. The study was carried out by following the capacity spectrum method as implemented in the software SELENA (Molina et al., 2010). The method requires a detailed classification of the building stock in predominant building typologies (according to the materials in the structure and walls, number of stories and age of construction) and the use of the building (residential, commercial, etc.). Later, the knowledge of the soil characteristics of the city and the simulation of a scenario earthquake will provide the seismic risk scenarios (damaged buildings). The initial results of the study show that one of the highest sources of uncertainties comes from the difficulty of achieving a precise building typologies classification due to the craft construction without any regulations. Also it is observed that although the occurrence of big earthquakes usually helps to decrease the vulnerability of the cities due to the collapse of low quality buildings and the reconstruction of seismically designed buildings, in the case of Port-au-Prince the seismic risk in most of the districts remains high, showing very vulnerable areas. Therefore the local authorities have to drive their efforts towards the quality control of the new buildings, the reinforcement of the existing building stock, the establishment of seismic normatives and the development of emergency planning also through the education of the population.