TRIAD VIII: Nationwide Multicenter Evaluation to Determine Whether Patient Video Testimonials Can Safely Help Ensure Appropriate Critical Versus End-of-Life Care.
Journal of patient safety
Characteristics of Pediatric Trauma Transfers to a Level I Trauma Center: Implications for Developing a Regionalized Pediatric Trauma System in California
ACADEMIC EMERGENCY MEDICINE
2010; 17 (12): 1364-1373
End-of-life interventions should be predicated on consensus understanding of patient wishes. Written documents are not always understood; adding a video testimonial/message (VM) might improve clarity. Goals of this study were to (1) determine baseline rates of consensus in assigning code status and resuscitation decisions in critically ill scenarios and (2) determine whether adding a VM increases consensus.We randomly assigned 2 web-based survey links to 1366 faculty and resident physicians at institutions with graduate medical education programs in emergency medicine, family practice, and internal medicine. Each survey asked for code status interpretation of stand-alone Physician Orders for Life-Sustaining Treatment (POLST) and living will (LW) documents in 9 scenarios. Respondents assigned code status and resuscitation decisions to each scenario. For 1 of 2 surveys, a VM was included to help clarify patient wishes.Response rate was 54%, and most were male emergency physicians who lacked formal advanced planning document interpretation training. Consensus was not achievable for stand-alone POLST or LW documents (68%-78% noted "DNR"). Two of 9 scenarios attained consensus for code status (97%-98% responses) and treatment decisions (96%-99%). Adding a VM significantly changed code status responses by 9% to 62% (P ≤ 0.026) in 7 of 9 scenarios with 4 achieving consensus. Resuscitation responses changed by 7% to 57% (P ≤ 0.005) with 4 of 9 achieving consensus with VMs.For most scenarios, consensus was not attained for code status and resuscitation decisions with stand-alone LW and POLST documents. Adding VMs produced significant impacts toward achieving interpretive consensus.
View details for DOI 10.1097/PTS.0000000000000357
View details for PubMedID 28198722
Characteristics of pediatric patients at risk of poor emergency department aftercare
ACADEMIC EMERGENCY MEDICINE
2006; 13 (8): 840-847
since California lacks a statewide trauma system, there are no uniform interfacility pediatric trauma transfer guidelines across local emergency medical services (EMS) agencies in California. This may result in delays in obtaining optimal care for injured children.this study sought to understand patterns of pediatric trauma patient transfers to the study trauma center as a first step in assessing the quality and efficiency of pediatric transfer within the current trauma system model. Outcome measures included clinical and demographic characteristics, distances traveled, and centers bypassed. The hypothesis was that transferred patients would be more severely injured than directly admitted patients, primary catchment transfers would be few, and out-of-catchment transfers would come from hospitals in close geographic proximity to the study center.this was a retrospective observational analysis of trauma patients ≤ 18 years of age in the institutional trauma database (2000-2007). All patients with a trauma International Classification of Diseases, 9th revision (ICD-9) code and trauma mechanism who were identified as a trauma patient by EMS or emergency physicians were recorded in the trauma database, including those patients who were discharged home. Trauma patients brought directly to the emergency department (ED) and patients transferred from other facilities to the center were compared. A geographic information system (GIS) was used to calculate the straight-line distances from the referring hospitals to the study center and to all closer centers potentially capable of accepting interfacility pediatric trauma transfers.of 2,798 total subjects, 16.2% were transferred from other facilities within California; 69.8% of transfers were from the catchment area, with 23.0% transferred from facilities ≤ 10 miles from the center. This transfer pattern was positively associated with private insurance (risk ratio [RR] = 2.05; p < 0.001) and negatively associated with age 15-18 years (RR = 0.23; p = 0.01) and Injury Severity Score (ISS) > 18 (RR = 0.26; p < 0.01). The out-of-catchment transfers accounted for 30.2% of the patients, and 75.9% of these noncatchment transfers were in closer proximity to another facility potentially capable of accepting pediatric interfacility transfers. The overall median straight-line distance from noncatchment referring hospitals to the study center was 61.2 miles (IQR = 19.0-136.4), compared to 33.6 miles (IQR = 13.9-61.5) to the closest center. Transfer patients were more severely injured than directly admitted patients (p < 0.001). Out-of-catchment transfers were older than catchment patients (p < 0.001); ISS > 18 (RR = 2.06; p < 0.001) and age 15-18 (RR = 1.28; p < 0.001) were predictive of out-of-catchment patients bypassing other pediatric-capable centers. Finally, 23.7% of pediatric trauma transfer requests to the study institution were denied due to lack of bed capacity.from the perspective an adult Level I trauma center with a certified pediatric intensive care unit (PICU), delays in definitive pediatric trauma care appear to be present secondary to initial transport to nontrauma community hospitals within close proximity of a trauma hospital, long transfer distances to accepting facilities, and lack of capacity at the study center. Given the absence of uniform trauma triage and transfer guidelines across state EMS systems, there appears to be a role for quality monitoring and improvement of the current interfacility pediatric trauma transfer system, including defined triage, transfer, and data collection protocols.
View details for DOI 10.1111/j.1553-2712.2010.00926.x
View details for Web of Science ID 000284848100018
View details for PubMedID 21122022
Emergency department orientation utilizing web-based streaming video
ACADEMIC EMERGENCY MEDICINE
2004; 11 (8): 848-852
To identify and characterize subgroups of a pediatric population at risk of poor emergency department (ED) aftercare compliance.This was a prospective, cohort study conducted at a university hospital ED with a 2003 pediatric census of 11,040 patients. A convenience sample of 461 children was enrolled. The study follow-up rate was 97%. The primary outcomes were guardian compliance with instructions for physician follow-up appointment and with obtaining prescribed medications. Predictors of compliance outcomes were analyzed by using recursive partitioning to describe population subgroups at risk of poor compliance.Only 60.4% of patient guardians followed up with instructions to see a physician. Children with private insurance were more likely to follow up than were children without private insurance (76.8% vs. 46.5%, p < 0.001). Of children with private insurance, those with high-acuity diagnoses were more likely to follow up than were patients with low-acuity diagnoses (80.0% vs. 38.5%, p < 0.001). Of children who were considered underinsured (defined as publicly insured or uninsured), those with English-speaking guardians were more likely to follow up than were those with non-English-speaking guardians (58.0% vs. 40.0%, p < 0.05). Only 63.3% of patient guardians obtained prescribed medications. Privately insured children were more likely to obtain medications than were underinsured children (71.0% vs. 58.0%, p < 0.05). Descriptive profiles of the subgroups revealed that those with lower socioeconomic status were at greatest risk of poor aftercare compliance.Compliance with ED aftercare instructions remains a challenge. Health insurance disparities are associated with poor ED aftercare compliance in our pediatric population. Interventions aimed at improving compliance could be targeted to specific subgroups on the basis of their descriptive profiles.
View details for DOI 10.1197/j.aem.2006.04.021
View details for Web of Science ID 000242967300005
View details for PubMedID 16880500
Socioeconomic disparities are negatively associated with pediatric emergency department aftercare compliance
ACADEMIC EMERGENCY MEDICINE
2003; 10 (11): 1278-1284
To assure a smooth transition to their new work environment, rotating students and housestaff require detailed orientations to the physical layout and operations of the emergency department. Although such orientations are useful for new staff members, they represent a significant time commitment for the faculty members charged with this task. To address this issue, the authors developed a series of short instructional videos that provide a comprehensive and consistent method of emergency department orientation. The videos are viewed through Web-based streaming technology that allows learners to complete the orientation process from any computer with Internet access before their first shift. This report describes the stepwise process used to produce these videos and discusses the potential benefits of converting to an Internet-based orientation system.
View details for DOI 10.1197/j.aem.2003.10.032
View details for Web of Science ID 000223090900006
View details for PubMedID 15289191
This study sought to identify demographic, socioeconomic, and clinical predictors of aftercare noncompliance by pediatric emergency department (ED) patients.The authors conducted a prospective, observational study of pediatric patients presenting to a university teaching hospital ED from July 1, 2002, through August 31, 2002. Demographic and clinical information was obtained from guardians during the ED visit. Guardians were contacted after discharge to determine compliance with ED aftercare instructions. Subjects were excluded if they were admitted or if guardians were unavailable or unwilling to consent. Data were analyzed using multivariable logistic regression to identify predictors of noncompliance from a list of predetermined variables.Of the 409 patients enrolled in the study, 111 were prescribed medications and 364 were given specific follow-up instructions. Subtypes of the variable "insurance status" were significantly associated with medication noncompliance in multivariable regression analysis. "Insurance status" and "low-acuity discharge diagnoses" were significantly associated with follow-up noncompliance.Disparity in health insurance has been shown to be a predictor of poor aftercare compliance for pediatric ED patients within the patient population.
View details for DOI 10.1197/S1069-6563(03)00499-8
View details for Web of Science ID 000186426300019
View details for PubMedID 14597505