(1/818) Use of PRISM scores in triage of pediatric patients with diabetic ketoacidosis.
Triage guidelines are needed to help in the decision process of intensive care unit (ICU) versus non-ICU admission for patients with diabetic ketoacidosis (DKA). Pediatric risk of mortality (PRISM) scores have long been used to assess mortality risk. This study assess the usefulness of the traditional PRISM score and adaptation of that score (PRISM-ED, which uses presentation data only) in predicting hospital stay in pediatric patients with DKA. PRISM and PRISM-ED were tested for correlation with length of stay and length of ICU stay. A medical record review was conducted for patients admitted to The Children's Hospital of Alabama with DKA during an 18-month period (n = 79). Two scores were calculated for each study entrant: PRISM using the worst recorded values over the first 24 hours and PRISM-ED using arrival values. Median scores, median test, and Spearman rank correlations were determined for both tests. Median PRISM scores were PRISM = 11 and PRISM-ED = 12; Median PRISM and PRISM-ED scores for patients admitted to the ICU were less than median scores among floor-admitted patients: [table: see text] Spearman rank correlations were significant for both scores versus total stay: PRISM, rs = 0.29; P = 0.009; PRISM-ED, rs = 0.60, P < 0.001. Also, correlations were significant for both scores versus ICU stay: PRISM rs = 0.22, P = 0.05; PRISM-ED, rs = 0.41, P < 0.001. Triage guidelines for ICU versus floor admission for DKA patients could have significant economic impact (mean ICU charge = $11,417; mean charge for floor admission = $4,447). PRISM scores may be an important variable to include in a multiple regression model used to predict the need for ICU monitoring. (+info)
(2/818) Satisfaction with telephone advice from an accident and emergency department: identifying areas for service improvement.
OBJECTIVES: Members of the public often telephone general practice, accident and emergency departments, and other health services for advice. However, satisfaction related to telephone consultation has received relatively little attention. This study aimed to describe the views of callers to an accident and emergency department who expressed any element of dissatisfaction about their telephone consultation. This was part of a larger study intended to help identify areas for service improvement. METHODS: A telephone consultation record form was used to document details of advice calls made to the accident and emergency department over a three month period. Callers who provided a telephone number were followed up within 72 hours. The interviews were tape recorded, transcribed, and explored using content analysis for emerging themes related to dissatisfaction. RESULTS: 203 callers were contacted within 72 hours of their call, of which 197 (97%) agreed to participate. 11 (5.6%) expressed global dissatisfaction, and a further 34 (17%) callers expressed at least one element of dissatisfaction at some point during the interview. Sources of dissatisfaction fell into four broad categories, each of which included more specific aspects of dissatisfaction: 36 (80%) callers were dissatisfied with advice issues, 31 (69%) with process aspects, such as the interpersonal skills of the staff member who took the call, 23 (51%) due to lack of acknowledgement of physical or emotional needs, and 11 (24%) due to access problems. CONCLUSIONS: This study supports the findings of other work and identifies three issues for particular consideration in improving the practice of telephone consultation: (a) training of health professionals at both undergraduate and specialist levels should cover telephone communication skills, (b) specific attention needs to be given to ensuring that the information and advice given over the phone is reliable and consistent, and (c) organisational change is required, including the introduction of departmental policies for telephone advice which should become the subject of regular audit. (+info)
(3/818) The myths of emergency medical care access in the managed care era.
In this paper, we examine the perception that emergency care is unusually expensive. We discuss the myths that have fueled the ineffective and sometimes deleterious efforts to limit access to emergency care. We demonstrate the reasons why these efforts are seriously flawed and propose alternate strategies that aim to improve outcomes, including cooperative ventures between hospitals and managed care organizations. We challenge managed care organizations and healthcare providers to collaborate and lead the drive to improve the cost and clinical effectiveness of emergency care. (+info)
(4/818) Referral centers and specialized care. Based on a presentation by Ronald P. Lesser, MD.
Appropriate diagnosis and treatment and the correct use of specialized services at epilepsy referral centers make it possible to control seizures relatively quickly in a large number of patients. Timeliness is extremely important, however, because delaying treatment decreases the likelihood of achieving complete remission from seizures. Epilepsy has a tremendous impact on quality of life. Concerns about concomitant illnesses, seizure-related injuries, and the psychosocial effects of seizures and anticonvulsants on patients are very real and should be addressed. An accurate diagnosis is the first step in effective seizure control, because not every patient with a seizure disorder has epilepsy. The second step is choosing an antiepileptic drug (AED) that is appropriate for the patient and using the correct dose and dosing schedule. When seizures remain uncontrolled or are poorly controlled despite medical therapy, the patient should be reevaluated to ascertain why the drug or drug combination is not working. The reason may be the wrong diagnosis, the wrong drug, or the wrong dose. If the seizures remain uncontrolled, the patient should be evaluated as a possible candidate for epilepsy surgery. If the patient is a good candidate, a presurgical work-up that includes monitoring and imaging studies should be performed, ideally at an epilepsy referral center. Quality care depends on access, communication, and knowledge, which involves patients who know how to achieve the best possible seizure control, doctors who are well informed and know what to do to ensure that their patients are receiving the best care, and mechanisms that permit consultation among everyone involved in caring for patients with epilepsy. Developing a system of quality, cost-effective care for the management of epilepsy also offers an excellent opportunity to apply such a system to the larger arena of medical care in general. (+info)
(5/818) Barriers between guidelines and improved patient care: an analysis of AHCPR's Unstable Angina Clinical Practice Guideline. Agency for Health Care Policy and Research.
OBJECTIVES: To describe common barriers that limit the effect of guidelines on patient care, with emphasis on recommendations for triage in the Agency for Health Care Policy and Research (AHCPR) Unstable Angina Clinical Practice Guideline. DATA SOURCES: Previously reported results from a prospective clinical study of 10,785 patients presenting to the emergency department (ED) with symptoms suggestive of acute cardiac ischemia. STUDY DESIGN: Design is an analysis of the AHCPR guideline with regard to recognized barriers in guideline implementation. Presentation of hypothetical scenarios to ED physicians was used to determine interrater reliability in applying the guideline to assess risk and to make triage decisions. PRINCIPAL FINDINGS: The AHCPR guideline's triage recommendations demonstrate (1) poor interobserver reliability in interpretation by ED physicians; (2) limited applicability of recommendations for outpatient management (applies to 6 percent of patients presenting to the ED with unstable angina); (3) incomplete specifications of exceptions that may require deviation from guideline recommendations; (4) unexpected effects on medical care by significantly increasing the demand for limited intensive care beds; and (5) unknown effects on patient outcomes. In addition, analysis of the guideline highlights the need to address organizational barriers, such as administrative policies that conflict with guideline recommendations and the need to adapt the guideline to conform to local systems of care. CONCLUSIONS: Careful analysis of guideline attributes, projected effect on medical care, and organizational factors reveal several barriers to successful guideline implementation that should be addressed in the design of future guideline-based interventions. (+info)
(6/818) Planning for major incidents involving children by implementing a Delphi study.
This paper provides a practical approach to the difficult problem of planning for a major incident involving children. It offers guidance on how general principles resulting from an expert Delphi study can be implemented regionally and locally. All phases of the response are covered including preparation, management of the incident, delivery of medical support during the incident, and recovery and support. A check list for regional planners is provided. Supplementary equipment is discussed and action cards for key roles in the paediatric hospital response are shown. Particular emphasis is placed on management of the secondary-tertiary interface including the special roles of paediatric assessment teams and paediatric transfer teams. A paediatric primary triage algorithm is provided. The important role of local interpretation of guidance is emphasised. (+info)
(7/818) Interpretation of the electronic fetal heart rate during labor.
Electronic fetal heart rate monitoring is commonly used to assess fetal well-being during labor. Although detection of fetal compromise is one benefit of fetal monitoring, there are also risks, including false-positive tests that may result in unnecessary surgical intervention. Since variable and inconsistent interpretation of fetal heart rate tracings may affect management, a systematic approach to interpreting the patterns is important. The fetal heart rate undergoes constant and minute adjustments in response to the fetal environment and stimuli. Fetal heart rate patterns are classified as reassuring, nonreassuring or ominous. Nonreassuring patterns such as fetal tachycardia, bradycardia and late decelerations with good short-term variability require intervention to rule out fetal acidosis. Ominous patterns require emergency intrauterine fetal resuscitation and immediate delivery. Differentiating between a reassuring and nonreassuring fetal heart rate pattern is the essence of accurate interpretation, which is essential to guide appropriate triage decisions. (+info)
(8/818) Amputation prevention by vascular surgery and podiatry collaboration in high-risk diabetic and nondiabetic patients. The Operation Desert Foot experience.
OBJECTIVE: To describe a unique multidisciplinary outpatient intervention for patients at high risk for lower-extremity amputation. RESEARCH DESIGN AND METHODS: Patients with foot ulcers and considered to be high risk for lower-extremity amputation were referred to the High Risk Foot Clinic of Operation Desert Foot at the Carl T. Hayden Veterans Affairs' Medical Center in Phoenix, Arizona, where patients received simultaneous vascular surgery and podiatric triage and treatment. Some 124 patients, consisting of 90 diabetic patients and 34 nondiabetic patients, were initially seen between 1 October 1991 and 30 September 1992 and followed for subsequent rate of lower-extremity amputation. RESULTS: In a mean follow-up period of 55 months (range 3-77), only 18 of 124 patients (15%) required amputation at the level of the thigh or leg. Of the 18 amputees, 17 (94%) had type 2 diabetes. The rate of avoiding limb loss was 86.5% after 3 years and 83% after 5 years or more. Furthermore, of the 15 amputees surviving longer than 2 months, only one (7%) had to undergo amputation of the contralateral limb over the following 12-65 months (mean 35 months). Compared with nondiabetic patients, patients with diabetes had a 7.68 odds ratio for amputation (95% CI 5.63-9.74) (P < 0.01). CONCLUSIONS: A specialized clinic for prevention of lower-extremity amputation is described. Initial and contralateral amputation rates appear to be far lower in this population than in previously published reports for similar populations. Relative to patients without diabetes, patients with diabetes were more than seven times as likely to have a lower-extremity amputation. These data suggest that aggressive collaboration of vascular surgery and podiatry can be effective in preventing lower-extremity amputation in the high-risk population. (+info)