The role of emergency physicians in the care of the child in school

Emergency physicians may contribute significantly to the health of children in the school setting. Because children spend the majority of their waking hours in school, they and their adult caretakers experience medical and surgical emergencies on a regular basis. These emergencies include a wide range of problems, such as asthma, seizures, firearms violence, and mass disasters. Additionally, many children in school have limited access to primary care, which increases their risk for medical emergencies. Recent reports from the National Academy of Sciences Institute of Medicine and the Maternal and Child Health Bureau's Emergency Medical Services for Children Program have described the challenges in improving the medical care of children in both the emergency and school settings. The prevalence of school health emergencies provides an opportunity for use of the expertise of emergency physicians. Emergency physicians have an important role in ensuring the proper treatment of emergency medical problems that occur in school. They need to be integrally involved in the development and organization of systems for prevention, initial stabilization, definitive management, and responsible follow-up of medical problems and injuries.     

Community perceptions of appropriate sources of emergency care

Two hundred eighteen residents in a suburban community northwest of Chicago were interviewed using standard telephone survey techniques. Respondents lived in an area served by two hospitals and two freestanding emergency centers (FECs) that had been in operation for three years prior to the survey. Those surveyed were asked to react to three common medical emergencies of graded levels of severity, small laceration, injured ankle, and myocardial infarction, to identify self-referral patterns of this community. Respondents were questioned about their knowledge and perception of the FECs and their hours of operation. Approximately 66.5% of the sample population was aware of the existence of these two centers. Fifty-four percent to 85.5% of respondents did not view these facilities as appropriate centers for the treatment of major emergencies. Only 58.3% (at 6:00 PM) and 63.3% (at 3:00 AM) of those surveyed would activate the emergency medical services system for a suspected myocardial infarction. Respondents made choices that would have delayed definitive care, including going to an FEC. Of those who thought they knew the hours of operation of the FECs, 65% believed these facilities were open 24 hours a day when, in fact, they were not.     

Health systems organization for emergency care

The increasing number of acute and severe digestive diseases presenting to hospital emergency departments, mainly related with an ageing population, demands an appropriate answer from health systems organization, taking into account the escalating pressure on cost reduction. However, patients expect and deserve a response that is appropriate, effective, efficient and safe. The huge variety of variables which can influence the evolution of such cases warranting intensive monitoring, and the coordination and optimization of a range of human and technical resources involved in the care of these high-risk patients, requires their admission in hospital units with conveniently equipped facilities, as is done for heart attack and stroke patients. Little information of gastroenterology emergencies as a function of structure, processes and outcome is available at the organizational level. Surveys that have been conducted in different countries just assess local treatment outcome and question the organizational structure and existing resources but its impact on the outcome is not clear. Most studies address the problem of upper gastrointestinal bleeding and the out-of-hours endoscopy services in the hospital setting. The demands placed on emergency (part of the overall continuum of care) are obvious, as are the needs for the efficient use of resources and processes to improve the quality of care, meaning data must cover the full care cycle. Gastrointestinal emergencies, namely gastrointestinal bleeding, must be incorporated into the overall emergency response as is done for heart attack and stroke. This chapter aims to provide a review of current literature/evidence on organizational health system models towards a better management of gastroenterology emergencies and proposes a research agenda.     

Recipients in need of ancillary services and their receipt of HIV medical care in California

For many individuals with access to quality medical care, HIV disease is no longer a critical short term illness but a chronic condition giving rise to more clients requiring ongoing medical care. Programs funded by the federal Ryan White Comprehensive AIDS Resources Emergency Act not only provide essential medical care for these individuals but also facilitate access to medical care services. These programmes fund services, including case management, transportation, and translation assistance, that feature ongoing assistance and enable individuals to remain in the health care system. Because of the importance of maintaining the strict drug regimen, retention in care is also an important part of the overall HIV care component. This study analyzed the relationship of ancillary services and a federal health programme client's receipt of medical care and retention in the health care system. We defined a cohort in need of ancillary services in part by a questionnaire designed to identify factors relating to need. These factors included education, language, and substance use. By merging client level data files we were able to identify medical service utilization trends among the individuals in the cohort who received a high number of ancillary services (more than 11 ancillary service visits in the two-year study period, n = 138) and those who received few services (fewer than six ancillary service visits in the two-year study period, n = 132). Results suggest that the receipt of ancillary services is associated with receipt of and retention in primary medical care. We found that for federal health programme clients in need of ancillary services, a positive relationship existed between their receipt of ancillary services and their access to primary medical care (p 相似文献   

Latino children with asthma: rates and risks for medical care utilization.

Latino families have been reported to underutilize health care services compared with families from other ethnic backgrounds. As part of a community trial in a low income Latino population designed to decrease environmental tobacco smoke (ETS) exposure in children with asthma in San Diego, we examined unscheduled medical care for asthma. Latino families (N = 193) reported information about medical care use for their children during the past 12 months. About 23% were hospitalized, 45% used the emergency department, and 60% used urgent care services. About 8.5% of families had two or more hospitalizations in 12 months. Most families were insured by Medicaid or had no insurance. Significant risk factors for a child's hospitalization were age (under age six), failure to use a controller medication, and a parental report of the child's health status as being poor. Risk factors for emergency department use were age (under age six) and male gender. These findings indicate that low-income Latino families with young children with asthma lack the medical resources necessary for good asthma control. Quality and monitored health care with optimization of asthma management could reduce costly acute care services.     

Rheumatology care: Involvement in medical decisions, received information, satisfaction with care, and unmet health care needs in patients with rheumatoid arthritis and ankylosing spondylitis

OBJECTIVE: To examine levels of received information, involvement in medical decisions, and satisfaction with care, to explore factors related to current involvement in medical decisions, and to assess patients' unmet health care needs related to their disease. METHODS: A total of 1,193 patients with rheumatoid arthritis and ankylosing spondylitis completed self-reported health status questionnaires, including registration of sociodemographic data and questions about rheumatology care. Separate questions addressed information received, involvement in decisions, and satisfaction with care. Aspects of unmet health were assessed by an open-ended question. RESULTS: The majority of patients reported medium to high levels of received information, involvement in medical decisions, and satisfaction with care. High involvement in medical decisions was univariately associated with high levels of perceived information and satisfaction, as well as with lower age and a good health status. In the multivariate analyses, patient satisfaction (odds ratio [OR] 4.21) and a high level of received information (OR 7.85), age (OR 0.99), and >12 years of formal education (OR 1.46) remained as significant predictors to current involvement. Nearly one-third reported a variety of unmet health care needs, and this report was associated with poor health. CONCLUSION: The results indicate a need for a more flexible and patient centered care model, in which patients to a larger degree can decide which services they need and how these services should be delivered.     

Epidemiology of pediatric prehospital care

Very few studies about prehospital care of pediatric emergencies have been published. With new interest in emergency care of the pediatric population demonstrated by the development of Pediatric Advanced Life Support and Advanced Pediatric Life Support, it is imperative to have data that define the different types of problems encountered in the prehospital care setting and their outcomes. Prehospital assessment forms were reviewed retrospectively over a consecutive 12-month period beginning August 1, 1983. Patients under 19 years of age were studied in a service area with a population of 557,700. A total of 3,184 forms were analyzed, representing approximately 10% of all ambulance runs. This contrasts sharply with the fact that the pediatric age group represents 32% of the population. The major users were the youngest and the oldest of the pediatric population. Of the cases, 54.4% were in the trauma category. The largest trauma group was motor vehicle accidents in the adolescent age group. Male patients predominated in the trauma cases. Medical disorders were the major reason for prehospital care in the very young. The demand for emergency medical services (EMS) occurred mainly during the summer months and on weekends. More than 50 percent of all EMS pediatric cases occurred during the hours of 1:00 PM to 9:00 PM. Advanced life support was associated with prolonged on-scene time and had a relatively low use and success rate in the younger pediatric population. Resuscitation of 23 cases of pediatric prehospital arrest resulted in no survivors to hospital discharge. The appropriateness of prolonged time spent on scene (mean of 18.3 minutes in 1,196 cases) for prehospital pediatric emergencies requires further evaluation.     

The effect of health care provider consultation on acute coronary syndrome care-seeking delay

PROBLEM: The time required for health care provider (HCP) consultation during acute coronary syndrome (ACS) has not been systematically studied. This study seeks to understand who calls an HCP and the duration of HCP evaluation during ACS. METHODS: Interviews were conducted with 1102 hospitalized patients with ACS in Columbus, Ohio. At discharge, diagnoses were acute myocardial infarction (560), unstable angina (214), cardiac disease (122), and noncardiac emergencies (206). RESULTS: Among the 1102 patients studied, 40.9% (451) contacted an HCP. Situational factors were more important than demographic factors in accounting for medical evaluation phase incidence and duration. Advice from HCPs to call the emergency medical services or travel to the emergency department reduced medical evaluation phase duration. The median total time duration was 6 hours for HCP consulters and 1 hour 30 minutes for nonconsulters (P < .001). Patients foregoing HCP consultation experienced significantly greater hemodynamic instability than patients contacting an HCP. Calling an HCP significantly (P < .001) reduced emergency medical services use. CONCLUSIONS: Consulting an HCP during ACS extended total time duration from symptom onset to emergency department arrival. In general, patients calling an HCP experienced a less severe ACS event than patients not contacting an HCP. There is a need for an epidemiologic study of calls to HCPs to develop a protocol for ACS call management.     

Pressure on the emergency department: the expanding right to medical care.

Lack of a comprehensive health care system in the United States has resulted in a series of legal cases that have expanded the common-law right to care in the hospital emergency department, thereby bringing increased pressure on hospitals to provide care under an ever-widening variety of nonemergency conditions. Health care legislation at the state and federal level during the 1980s expanded the concept of physician duty to include women in labor as well as any condition that could reasonably be expected to lead to serious impairment to bodily functions or serious dysfunction of any bodily organ or part. Presently, any patient presenting to a hospital ED must be examined to determine whether an emergency exists. The expanding definition of an emergency and mandated patient examination requirements have hit urban hospitals particularly hard, as the uninsured and disenfranchised increasingly find the ED their only source of medical care. The United States needs a national health care solution that does not rely on the ED as the locus of care for general medical practice. Failure to act will jeopardize the ability of hospital EDs to provide the highly specialized care that only they can provide and will put more hospitals at financial risk as they struggle to comply with state and federal law while serving a growing population of uninsured and underinsured patients.     

Emergency medicine in Southern Brazil

Emergency medicine is developing rapidly in southern Brazil, where elements of both the Franco-German and the Anglo-American models of emergency care are in place, creating a uniquely Brazilian approach to emergency care. Although emergency medical services (EMS) in Brazil have been directly influenced by the French mobile EMS (SAMU) system, with physicians dispatched by ambulances to the scenes of medical emergencies, the first American-style emergency medicine residency training program in Brazil was recently established at the Hospital de Pronto Socorro (HPS) in Porto Alegre. Emergency trauma care appears to be particularly developed in southern Brazil, where advanced trauma life support is widely taught and SAMU delivers sophisticated trauma care en route to trauma centers designated by the state.     

Quality and accountability: Children's emergency services in a managed care environment

The fast pace of change in the health care system has sparked growing interest among purchasers, consumers, providers, health plans, and others in evaluating and improving the quality of health services. The Emergency Medical Services for Children Program's Managed Care Task Force recommended the development of a white paper to focus on issues related to quality and accountability in children's emergency medical services in a managed care environment. A literature review was conducted, and a panel reviewed and discussed relevant materials. The panelists then developed recommendations as a resource for managed care organizations, providers of care, professional associations, and federal, state, and local policymakers.     

Health and functional status and utilization of health care services among holocaust survivors and their counterparts in Israel

To examine differences in health and functional status and in utilization of health services between holocaust survivors and their counterparts; and (b) to investigate if holocaust survivor status is a significant predictor of health status, functional status, and utilization of health services. The study included 1255 respondents of whom 272 were holocaust survivors. Interviews were conducted face-to-face at the respondents’ homes. Participants were asked about their health (self-rated health and comorbidity) and functional (ADL and IADL) status, utilization of inpatient and outpatient health care services, age, gender, education, marital status, length of residence in Israel, and if they were holocaust survivors. Holocaust survivors, who were frailer and more chronically ill compared to their counterparts, visited their family physician and the nurse at the health care clinic more often than their counterparts did, and received more homecare services. Yet, there were no differences between them in the utilization of other health care services such as visits to specialists, emergency department, and hospitalizations. Holocaust survivors are more homebound due to more morbidity and functional limitations and therefore receive more health home care services that offset the utilization of other health services.     

Predictors of medical service utilization among individuals with co-occurring HIV infection and substance abuse disorders

This study examined factors affecting medical service use among HIV-infected persons with a substance abuse disorder. The sample comprised 190 participants enrolled in a randomized trial of a case management intervention. Participants were interviewed about their backgrounds, housing status, income, alcohol and drug use problems, health status and depressive symptoms at study entry. Electronic medical records were used to assess medical service use. Poisson regression models were tested to determine the effects of need, enabling and predisposing factors on the dependent variables of emergency department visits, inpatient admissions and ambulatory care visits. During a two-year period, 71% were treated in the emergency department, 64% had been hospitalized and the sample averaged 12.9 ambulatory care visits. Homelessness was associated with higher utilization of emergency department and inpatient services; drug use severity was associated with higher inpatient and ambulatory care service use; and alcohol use severity was associated with greater use of emergency medical services. Homelessness and substance abuse exacerbate the health care needs of HIV-infected persons and result in increased use of emergency department and inpatient services. Interventions are needed that target HIV-infected persons with substance abuse disorders, particularly those that increase entry and retention in outpatient health care and thus decrease reliance on acute hospital-based services.     

Use of health care services among diabetic Spanish adults: related factors and trends, 1993–2006

ObjectiveWe examined time trends in the use of health care services between diabetic and nondiabetic adults in Spain and their associations with sociodemographics variables.Research Design and MethodsUsing data from two national health surveys, we estimated use of health care services, including hospital days per person-year, in the diabetic and nondiabetic populations in 1993 (n=20,880) and 2006 (n=29,478) in Spain.As the dependent variable, we took the answer to the questions, “Has used emergency medical services in the preceding year?” and/or “Have you been admitted to hospital in the preceding year?” Independent variables were age group, gender, educational level, and coexistence of chronic conditions.ResultsUse of emergency medical services has been significantly incremented between 1993 and 2006—from 19.6% to 36.6% for the diabetic population and from 13.8% to 29.0% for the nondiabetics. In the diabetic population, with respect to hospital admission, 13.2% of diabetics said that they had been hospitalized in 1993 compared with 18.0% in 2006 (P<.05). The results of multivariate analysis, after controlling for confounders, indicated that diabetics used significantly more health care resources in 2006 than in 1993 [odds ratio (OR)=1.34, 95% confidential interval (CI)=1.01–1.79 for admission in hospital and OR=2.03 95% CI=1.58–2.62]. Also, the length of hospital stay for diabetics increased significantly in 2006 with respect to 1993 (1.38 relative hospital days).ConclusionsSpanish diabetic individuals used health care services (emergency room, admission to hospital) more often than nondiabetics. Furthermore, the length of hospital stay increased among the diabetics surveyed in 2006 compared with that in 1993.     

Assessing use of primary health care services by very low-income adults in a managed care program

OBJECTIVE: To assess the effect of providing free health care services to low-income adults. METHODS: We measured access to primary care services by enrollees with 4 chronic medical conditions in the General Relief Health Care Program (GRHCP), a program designed for adults receiving General Relief (GR). Implemented by the Los Angeles County Health Department in October 1995, the GRHCP is composed of private and public health care facilities. As adults registered for GR, they were asked to complete a baseline health survey, were enrolled in the GRHCP, and assigned a health care provider. A total of 8520 surveys were completed between September and November 1996 (98% response rate). The analyses of this article are limited to individuals (N = 2164) who reported a history of hypertension, diabetes mellitus, a nonresolving cough, or substance dependence. We reviewed medical records to determine whether new GR recipients had visited their designated GRHCP provider within 4 months of enrollment and used multivariate logistic regression to assess the effect of individual patient factors on the use of free health care. RESULTS: A total of 17% of individuals visited their assigned GRHCP provider within 4 months of enrollment. In multivariate analysis, patients were more likely to have made a visit if they were younger than 50 years, were female, were Asian/Pacific Islander, reported needing to see a physician, or had seen a physician within 12 months. CONCLUSIONS: It is not sufficient to merely supply the name and address of a health care provider to this population. More aggressive efforts should be attempted to increase utilization of services for patients with medical conditions responsive to ambulatory care.     

The burden of behavioral emergencies: need for specialist emergency services

Behavioral emergencies constitute an important component of medical emergencies. Psychiatric emergency services, which handle the bulk of behavioral emergencies, are inadequate to meet the burden. Strategies to deal with them are also hampered by the lack of adequate research and availability of data. Since behavioral emergencies may present differently in different groups, requiring differing management, consensus guidelines need to be arrived at for tackling behavioral emergencies. In addition, training professionals for psychiatric emergency services should form a part and parcel of emergency management services.     

Resource utilization among intensive care patients. Managed care vs traditional insurance.

BACKGROUND--There is considerable evidence that members of managed care organizations use fewer hospital resources than patients covered by traditional health insurance. While intensive care might seem to be an unlikely setting for such differences to exist, the relationship between health coverage and use of intensive care has not been examined. METHODS--We conducted a cross-sectional analysis of consecutive intensive care unit admissions at a regional tertiary care teaching hospital. Patients in managed care plans (n = 159) and with traditional insurance (n = 389) were compared with respect to length of stay, hospital charges, charges for specific services, and use of mechanical ventilation. The analysis controlled for severity of illness, as measured by the Mortality Probability Model, case mix, and mortality. The whole sample as well as subsamples representing medical, emergency surgery, and elective surgery patients were examined. RESULTS--The managed care group, on average, had short stays (both hospital and intensive care unit), lower charges, and less use of mechanical ventilation than the traditionally insured group. Average differences of about 30% to 40% were observed. The finding held for the whole sample as well as the medical and emergency surgery subsamples. The differences were more pronounced in the patients with lowest severity of illness. CONCLUSION--Even in a setting where there would appear to be relatively little room for discretion in treatment decisions, incentives associated with type of health insurance seemed to affect resource use.     

Direct costs of emergency medical care: a diagnosis-based case-mix classification system

STUDY OBJECTIVE: To develop a diagnosis-based case mix classification system for emergency department patient visits based on direct costs of care designed for an outpatient setting. DESIGN: Prospective provider time study with collection of financial data from each hospital's accounts receivable system and medical information, including discharge diagnosis, from hospital medical records. SETTING: Three community hospital EDs in Los Angeles County during selected times in 1984. MEASUREMENTS AND MAIN RESULTS: Only direct costs of care were included: health care provider time, ED management and clerical personnel excluding registration, nonlabor ED expense including supplies, and ancillary hospital services. Indirect costs for hospitals and physicians, including depreciation and amortization, debt service, utilities, malpractice insurance, administration, billing, registration, and medical records were not included. Costs were derived by valuing provider time based on a formula using annual income or salary and fringe benefits, productivity and direct care factors, and using hospital direct cost to charge ratios. Physician costs were based on a national study of emergency physician income and excluded practice costs. Patients were classified into one of 216 emergency department groups (EDGs) on the basis of the discharge diagnosis, patient disposition, age, and the presence of a limited number of physician procedures. Total mean direct costs ranged from $23 for follow-up visit to $936 for trauma, admitted, with critical care procedure. The mean total direct costs for the 16,771 nonadmitted patients was $69. Of this, 34% was for ED costs, 45% was for ancillary service costs, and 21% was for physician costs. The mean total direct costs for the 1,955 admitted patients was $259. Of this, 23% was for ED costs, 63% was for ancillary service costs, and 14% was for physician costs. Laboratory and radiographic services accounted for approximately 85% of all ancillary service costs and 38% of total direct costs for nonadmitted patients versus 80% of ancillary service costs and 51% of total direct costs for admitted patients. CONCLUSION: We have developed a diagnosis-based case mix classification system for ED patient visits based on direct costs of care designed for an outpatient setting which, unlike diagnosis-related groups, includes the measurement of time-based cost for physician and nonphysician services. This classification system helps to define direct costs of hospital and physician emergency services by type of patient.     

Transition of adolescents with cystic fibrosis from paediatric to adult care

Transition to adult health care for adolescents with complex chronic illness such as cystic fibrosis (CF) is a challenge for the health care system with increasing numbers of young people requiring lifelong adult health care due to improvements in early diagnosis, treatment and survival. The changing face of CF and current guidelines for transition to adult care will be reviewed with a discussion and case study illustrating effective transition. Key features include (i) early preparation, planning and facilitating self-management skills; (ii) engaging all involved by a coordinated approach, including young people with CF, their families and the paediatric and adult teams; (iii) detailed communication, including comprehensive written referral report and documentation of prior complications of CF; (iv) feedback between the paediatric and the adult health care teams; and (v) ongoing audit of the transition process. The barriers to effective transition will be examined in the context of challenges faced by the paediatric centres, the development and resourcing of appropriate adult services, difficulties for the young person and their family as well as integrating the health care system overall. While acknowledging the development and evaluation of models of care for transition services with CF, continued evaluation of transition services can provide an evidence base to ensure effective systems with allocation of resources, inform training of health professionals and meet the needs of young people with CF and other chronic illnesses as they navigate the health care system.     

上海某医科院校突发公共卫生事件认知现况分析

目的调查并分析上海某医科院校大学生对突发公共卫生事件的认知情况及影响因素。方法采用随机抽样方法,2020年7月抽取上海某医科院校在校大学生508人开展问卷调查。结果大学生应急意识有提升空间,了解突发公共卫生事件程度不一,正确认知率有待提高;应急态度不积极,12.20%的学生态度消极;大学生应急知识和技能掌握情况不乐观,掌握程度低和基本掌握的高分人数高达44.98%,应急能力需加强并提高,20.47%的学生获取应急自救知识较被动。结论上海某医科院校大学生突发公共卫生事件认知水平有待提高,高校应尽可能增加实际演练次数,扩大应急知识宣讲范围及次数,全面提升大学生应急能力并丰富应急知识。