Categorization, Designation, and Regionalization of Emergency Care: Definitions, a Conceptual Framework, and Future Challenges

This article reflects the proceedings of a breakout session, “Beyond ED Categorization—Matching Networks to Patient Needs,” at the 2010 Academic Emergency Medicine consensus conference, “Beyond Regionalization: Integrated Networks of Emergency Care.” It is based on concepts and areas of priority identified and developed by the authors and participants at the conference. The paper first describes definitions fundamental to understanding the categorization, designation, and regionalization of emergency care and then considers a conceptual framework for this process. It also provides a justification for a categorization system being integrated into a regionalized emergency care system. Finally, it discusses potential challenges and barriers to the adoption of a categorization and designation system for emergency care and the opportunities for researchers to study the many issues associated with the implementation of such a system.ACADEMIC EMERGENCY MEDICINE 2010; 17:1306–1311 © 2010 by the Society for Academic Emergency MedicinePeer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79324/1/j.1553-2712.2010.00932.x.pd

Pain Intervention for Infant Lumbar Puncture in the Emergency Department: Physician Practice and Beliefs

Objectives:  The objectives were to characterize physician beliefs and practice of analgesia and anesthesia use for infant lumbar puncture (LP) in the emergency department (ED) and to determine if provider training type, experience, and beliefs are associated with reported pain intervention use. Methods:  An anonymous survey was distributed to ED faculty and pediatric emergency medicine (PEM) fellows at five Midwestern hospitals. Questions consisted of categorical, yes/no, descriptive, and incremental responses. Data were analyzed using descriptive statistics with confidence intervals (CIs) and odds ratios (ORs). Results:  A total of 156 of 164 surveys (95%) distributed were completed and analyzed. Training background of respondents was 52% emergency medicine (EM), 30% PEM, and 18% pediatrics. Across training types, there was no difference in the belief that pain treatment was worthwhile (overall 78%) or in the likelihood of using at least one pain intervention. Pharmacologic pain interventions (sucrose, injectable lidocaine, and topical anesthetic) were used in the majority of LPs by 20, 29, and 27% of respondents, respectively. Nonpharmacologic pain intervention (pacifier/nonnutritive sucking) was used in the majority of LPs by 67% of respondents. Many respondents indicated that they never used sucrose (53%), lidocaine (41%), or anesthetic cream (49%). Physicians who thought pain treatment was worthwhile were more likely to use both pharmacologic and nonpharmacologic pain interventions than those who did not (93% vs. 53%, OR = 10.98, 95% CI = 4.16 to 29.00). The number of LPs performed or supervised per year was not associated with pain intervention use. Other than pacifiers, injectable lidocaine was the most frequently reported pain intervention. Conclusions:  Provider beliefs regarding infant pain are associated with variation in anesthesia and analgesia use during infant LP in the ED. Although the majority of physicians hold the belief that pain intervention is worthwhile in this patient group, self‐reported pharmacologic interventions to reduce pain associated with infant LP are used regularly by less than one‐third. Strategies targeting physician beliefs on infant pain should be developed to improve pain intervention use in the ED for infant LPs.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/98758/1/j.1553-2712.2010.00970.x.pd

Advanced medical life support procedures in vitally compromised children by a helicopter emergency medical service

<p>Abstract</p> <p>Background</p> <p>To determine the advanced life support procedures provided by an Emergency Medical Service (EMS) and a Helicopter Emergency Medical Service (HEMS) for vitally compromised children. Incidence and success rate of several procedures were studied, with a distinction made between procedures restricted to the HEMS-physician and procedures for which the HEMS is more experienced than the EMS.</p> <p>Methods</p> <p>Prospective study of a consecutive group of children examined and treated by the HEMS of the eastern region of the Netherlands. Data regarding type of emergency, physiological parameters, NACA scores, treatment, and 24-hour survival were collected and subsequently analysed.</p> <p>Results</p> <p>Of the 558 children examined and treated by the HEMS on scene, 79% had a NACA score of IV-VII. 65% of the children had one or more advanced life support procedures restricted to the HEMS and 78% of the children had one or more procedures for which the HEMS is more experienced than the EMS. The HEMS intubated 38% of all children, and 23% of the children intubated and ventilated by the EMS needed emergency correction because of potentially lethal complications. The HEMS provided the greater part of intraosseous access, as the EMS paramedics almost exclusively reserved this procedure for children in cardiopulmonary resuscitation. The EMS provided pain management only to children older than four years of age, but a larger group was in need of analgesia upon arrival of the HEMS, and was subsequently treated by the HEMS.</p> <p>Conclusions</p> <p>The Helicopter Emergency Medical Service of the eastern region of the Netherlands brings essential medical expertise in the field not provided by the emergency medical service. The Emergency Medical Service does not provide a significant quantity of procedures obviously needed by the paediatric patient.</p

Prepared to react? Assessing the functional capacity of the primary health care system in rural Orissa, India to respond to the devastating flood of September 2008

Background: Early detection of an impending flood and the availability of countermeasures to deal with it can significantly reduce its health impacts. In developing countries like India, public primary health care facilities are frontline organizations that deal with disasters particularly in rural settings. For developing robust counter reacting systems evaluating preparedness capacities within existing systems becomes necessary. Objective: The objective of the study is to assess the functional capacity of the primary health care system in Jagatsinghpur district of rural Orissa in India to respond to the devastating flood of September 2008. Methods: An onsite survey was conducted in all 29 primary and secondary facilities in five rural blocks (administrative units) of Jagatsinghpur district in Orissa state. A pre-tested structured questionnaire was administered face to face in the facilities. The data was entered, processed and analyzed using STATA&#x00AE; 10. Results: Data from our primary survey clearly shows that the healthcare facilities are ill prepared to handle the flood despite being faced by them annually. Basic utilities like electricity backup and essential medical supplies are lacking during floods. Lack of human resources along with missing standard operating procedures; pre-identified communication and incident command systems; effective leadership; and weak financial structures are the main hindering factors in mounting an adequate response to the floods. Conclusion: The 2008 flood challenged the primary curative and preventive health care services in Jagatsinghpur. Simple steps like developing facility specific preparedness plans which detail out standard operating procedures during floods and identify clear lines of command will go a long way in strengthening the response to future floods. Performance critiques provided by the grass roots workers, like this one, should be used for institutional learning and effective preparedness planning. Additionally each facility should maintain contingency funds for emergency response along with local vendor agreements to ensure stock supplies during floods. The facilities should ensure that baseline public health standards for health care delivery identified by the Government are met in non-flood periods in order to improve the response during floods. Building strong public primary health care systems is a development challenge. The recovery phases of disasters should be seen as an opportunity to expand and improve services and facilities

Reasons for (Non)Participating in a Telephone-Based Intervention Program for Families with Overweight Children

Willingness to participate in obesity prevention programs is low; underlying reasons are poorly understood. We evaluated reasons for (non)participating in a novel telephone-based obesity prevention program for overweight children and their families. percentile) aged 3.5–17.4 years were screened via the CrescNet database, a representative cohort of German children, and program participation (repetitive computer aided telephone counseling) was offered by their local pediatrician. Identical questionnaires to collect baseline data on anthropometrics, lifestyle, eating habits, sociodemographic and psychosocial parameters were analyzed from 433 families (241 participants, 192 nonparticipants). Univariate analyses and binary logistic regression were used to identify factors associated with nonparticipation. percentile) was higher in participants (58.9% vs.38%,p<0.001). Participating girls were younger than boys (8.8 vs.10.4 years, p<0.001). 87.3% and 40% of participants, but only 72.2% and 24.7% of nonparticipants, respectively, reported to have regular breakfasts (p = 0.008) and 5 regular daily meals (p = 0.003). Nonparticipants had a lower household-net-income (p<0.001), but higher subjective physical wellbeing than participants (p = 0.018) and believed that changes in lifestyle can be made easily (p = 0.05).An important reason for nonparticipation was non-awareness of their child's weight status by parents. Nonparticipants, who were often low-income families, believed that they already perform a healthy lifestyle and had a higher subjective wellbeing. We hypothesize that even a low-threshold intervention program does not reach the families who really need it

Cancer risks in patients treated with growth hormone in childhood: the SAGhE European cohort study.

Context: Growth hormone (GH) is prescribed for an increasing range of indications, but there has been concern that it might raise cancer risk. Published data are limited. Objective: To examine cancer risks in relation to GH treatment. Design: Cohort study. Setting: Population-based. Patients: Cohort of 23,984 patients treated with recombinant human GH (r-hGH) in eight European countries since this treatment was first used in 1984. Cancer expectations from country-specific national population statistics. Main Outcome Measures: Cancer incidence and cancer mortality. Results: Incidence and mortality risks in the cohort were raised for several cancer sites, largely consequent on second primary malignancies in patients given r-hGH after cancer treatment. There was no clear raised risk in patients with growth failure without other major disease. Only for bone and bladder cancers was incidence significantly raised in GH-treated patients without previous cancer. Cancer risk was unrelated to duration or cumulative dose of r-hGH treatment, but for patients treated after previous cancer, cancer mortality risk increased significantly with increasing daily r-hGH dose (P trend < 0.001). Hodgkin lymphoma (HL) incidence increased significantly with longer follow-up (P trend = 0.001 for patients overall and 0.002 for patients without previous cancer). Conclusions: Our results do not generally support a carcinogenic effect of r-hGH, but the unexplained trend in cancer mortality risk in relation to GH dose in patients with previous cancer, and the indication of possible effects on bone cancer, bladder cancer, and HL risks, need further investigation