The epidemiology and presence of pediatric medical emergencies and injury prevention practices in Kenya and resource-limited settings are not well understood. This is a barrier to planning and ...providing quality emergency care within the local health systems. We performed a prospective, cross-sectional study to describe the epidemiology of case encounters to the pediatric emergency unit (PEU) at Kenyatta National Hospital in Nairobi, Kenya; and to explore injury prevention measures used in the population.
Patients were enrolled prospectively using systematic sampling over four weeks in the Kenyatta National Hospital PEU. Demographic data, PEU visit data and lifestyle practices associated with pediatric injury prevention were collected directly from patients or guardians and through chart review. Data were analyzed with descriptive statistics with stratification based on pediatric age groups.
Of the 332 patients included, the majority were female (56%) and 76% were under 5 years of age. The most common presenting complaints were cough (40%) fever (34%), and nausea/vomiting (19%). The most common PEU diagnoses were upper respiratory tract infections (27%), gastroenteritis (11%), and pneumonia (8%). The majority of patients (77%) were discharged from the PEU, while 22% were admitted. Regarding injury prevention practices, the majority (68%) of guardians reported their child never used seatbelts or car seats. Of 68 patients that rode bicycles/motorbikes, one reported helmet use. More than half of caregivers cook at potentially dangerous heights; 59% use ground/low level stoves.
Chief complaints and diagnoses in the PEU population were congruent with communicable disease burdens seen globally. Measures for primary injury prevention were reported as rarely used in the sample studied. The epidemiology described by this study provides a framework for improving public health education and provider training in resource-limited settings.
Background
Women comprise 28% of faculty in academic departments of emergency medicine (EM) and 11% of academic chairs. Professional development programs for women are key to career success and to ...prevent pipeline attrition. Within emergency medicine, there is a paucity of outcomes‐level data for such programs.
Objectives
We aim to measure the impact of a novel structured professional development curriculum and mentorship group (Resident and Faculty Female Tribe, or RAFFT) within an academic department of EM.
Methods
This prospective single‐center curriculum implementation and evaluation was conducted in the academic year 2020–2021. A planning group identified potential curricular topics using an iterative Delphi process. We developed a 10‐session longitudinal curriculum; a postcurriculum survey was conducted to assess the perceived benefit of the program in four domains.
Results
A total of 76% of 51 eligible women attended at least one session; for this project we analyzed the 24 participants (47%) who attended at least one session and completed both the pre‐ and the postsurvey. The majority of participants reported a positive benefit, which aligned with their expectations in the following areas: professional development (79.2%), job satisfaction (83.3%), professional well‐being (70.8%), and personal well‐being (79.2%). Resident physicians more often reported less benefit than expected compared to fellow/faculty physicians. Median perceived impact on career choice and trajectory was positive for all respondents.
Conclusions
Success of this professional development program was measured through a perceived benefit aligning with participant expectations, a positive impact on career choice and career trajectory for participants in each career stage, and a high level of engagement in this voluntary program. Recommendations for the successful implementation of professional development programs include early engagement of stakeholders, the application of data from a program‐specific needs assessment, early dissemination of session dates to allow for protected time off, and structured discussions with appropriate identification of presession resources.
BackgroundResource-limited settings are increasingly experiencing a ‘triple burden’ of disease, composed of trauma, non-communicable diseases (NCDs) and known communicable disease patterns. However, ...the epidemiology of acute and emergency care is not well characterised and this limits efforts to further develop emergency care capacity.ObjectiveTo define the burden of disease by describing the patient population presenting to the Accident and Emergency Department (A&E) at Kenyatta National Hospital (KNH) in Kenya.MethodsWe completed a prospective descriptive assessment of patients in KNH’s A&E obtained via systematic sampling over 3 months. Research assistants collected data directly from patients and their charts. Chief complaint and diagnosis codes were grouped for analysis. Patient demographic characteristics were described using the mean and SD for age and n and percentages for categorical variables. International Classification of Disease 10 codes were categorised by 2013 Global Burden of Disease Study methods.ResultsData were collected prospectively on 402 patients with an average age of 36 years (SD 19), and of whom, 50% were female. Patients were most likely to arrive by taxi or bus (39%), walking (28%) or ambulance (17%). Thirty-five per cent of patients were diagnosed with NCDs, 24% with injuries and 16% with communicable diseases, maternal and neonatal conditions. Overall, head injury was the single most common final diagnosis and occurred in 32 (8%) patients. The most common patient-reported mechanism for head injury was road traffic accident (39%).ConclusionThis study estimates the characteristics of the A&E population at a tertiary centre in Kenya and highlights the triple burden of disease. Our findings emphasise the need for further development of emergency care resources and training to better address patient needs in resource-limited settings, such as KNH.
Older adults are less likely than younger adults to receive analgesic treatment during emergency department visits. Whether older adults are less likely to receive analgesics during protocolized ...prehospital care is unknown. We analyzed all ambulance transports in 2011 in the state of North Carolina and compared the administration of any analgesic or an opioid among older adults (aged 65 and older) versus adults aged 18 to 64. Complete data were available for 407,763 transports. Older men were less likely than younger men to receive an analgesic or an opioid regardless of pain severity. Among women with mild or moderate pain, older women were less likely than younger women to receive either form of pain treatment, but among women with more severe pain (pain score 8 or more), older women were more likely than younger women to receive pain treatment. Further, among women with mild or moderate pain, the oldest patients (aged 85 and older) were the least likely to receive any analgesic or an opioid, but among women with severe pain the oldest patients were the most likely to receive treatment. Further research is needed to assess the generalizability of this interaction between age, gender, and pain severity on pain treatment.
During prehospital care in North Carolina in 2011, older adults were generally less likely to receive pain treatment. However, older women with severe pain were more likely to receive treatment than younger women with severe pain. These results suggest an interaction between age, gender, and pain severity on pain treatment.
Objectives
Constipation is a common and potentially serious side effect of oral opioids. Accordingly, most clinical guidelines suggest routine use of laxatives to prevent opioid‐induced constipation. ...The objective was to characterize emergency provider prescribing of laxatives to prevent constipation among adults initiating outpatient opioid treatment.
Methods
National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2010 were analyzed. Among visits by individuals aged 18 years and older discharged from the emergency department (ED) with opioid prescriptions, the authors estimated the survey‐weighted proportion of visits in which laxatives were also prescribed. A subgroup analysis was conducted for individuals aged 65 years and older, as the potential risks associated with opioid‐induced constipation are greater among older individuals. To examine a group expected to be prescribed laxative medication and confirm that NHAMCS captures prescriptions for these medications, the authors estimated the proportion of visits by individuals discharged with prescriptions for laxatives among those who presented with constipation.
Results
Among visits in 2010 by adults aged 18 years and older discharged from the ED with opioid prescriptions, 0.9% (95% confidence interval CI = 0.7% to 1.3%, estimated total n = 191,203 out of 21,075,050) received prescriptions for laxatives. Among the subset of visits by adults aged 65 years and older, 1.0% (95% CI = 0.5% to 2.0%, estimated total n = 18,681 out of 1,904,411) received prescriptions for laxatives. In comparison, among visits by individuals aged 18 years and older with constipation as a reason for visit, 42% received prescriptions for laxatives.
Conclusions
In this nationally representative sample, laxatives were not routinely prescribed to adults discharged from the ED with prescriptions for opioid pain medications. Routine prescribing of laxatives for ED visits may improve the safety and effectiveness of outpatient opioid pain management.
Resumen
La Profilaxis del Estreñimiento es Rara en los Adultos que Recibieron Tratamiento Domiciliario con Opiáceos en los Servicios de Urgencias de Estados Unidos
Objetivos
El estreñimiento es un efecto secundario frecuente y potencialmente grave de los opiáceos orales. La mayoría de las guías clínicas proponen el uso rutinario de laxantes para prevenir el estreñimiento inducido por opiáceos. El objetivo fue caracterizar la prescripción por parte del profesional de urgencias de laxantes para prevenir el estreñimiento en los adultos que iniciaron un tratamiento ambulatorio con opiáceos.
Metodologia
Se analizaron los datos de la National Hospital Ambulatory Medical Care Survey (NHAMCS) desde 2010. Entre las visitas en individuos de 18 años o más dados de alta desde el servicio de urgencias (SU) con una prescripción de opiáceos, los autores estimaron la proporción de visitas ponderadas por la muestra en las que un laxante fue también prescrito. Se llevó a cabo un análisis de subgrupo en los individuos de 65 años o más, ya que los potenciales riesgos asociados con el estreñimiento provocado por opiáceos son mayores entre los individuos de mayor edad. Para examinar un grupo en el que se espera se prescriba una medicación laxante y confirmar que las prescripciones de estas medicaciones son capturadas por la NHAMCS, los autores estimaron la proporción de visitas en individuos dados de alta con una prescripción de laxante entre aquellos que acudieron por estreñimiento.
Resultados
En 2010, entre la visitas de adultos de 18 años o más dados de alta desde el SU con una prescripción de opiáceos, un 0,9% (Intervalo Confianza IC 95% = 0,7% a 1,3%, total estimado n = 191.203 de 21.075.050) recibió una prescripción para un laxante. Entre el subgrupo de visitas por adultos de 65 años o más, un 1,0% (IC95% = 0,5% a 2,0%, total estimado n = 18.681 de 1.904.411) recibió una prescripción para un laxante. En comparación, entre las visitas por individuos de 18 años o más con estreñimiento como causa de la visita, un 42% recibió una prescripción para un laxante.
Conclusiones
En esta muestra representativa de ámbito nacional, los laxantes no se prescribieron de forma rutinaria para los adultos dados de alta del SU con una prescripción de medicación con opiáceos para el dolor. La prescripción rutinaria de laxantes en las visitas al SU puede mejorar la seguridad y la efectividad del manejo domiciliario del dolor con opiáceos.
Objectives
To assess the relationship between older adults' perceptions of shared decision‐making in the selection of an analgesic to take at home for acute musculoskeletal pain and (1) patient ...satisfaction with the analgesic and (2) changes in pain scores at 1 week.
Design
Cross‐sectional study.
Setting
Single academic emergency department.
Participants
Individuals aged 65 and older with acute musculoskeletal pain.
Measurements
Two components of shared decision‐making were assessed: information provided to the patient about the medication choice and patient participation in the selection of the analgesic. Optimal satisfaction with the analgesic was defined as being “a lot” satisfied. Pain scores were assessed in the ED and at 1 week using a 0‐to‐10 scale.
Results
Of 159 individuals reached by telephone, 111 met all eligibility criteria and completed the survey. Fifty‐two percent of participants reported receiving information about pain medication options, and 31% reported participating in analgesic selection. Participants who received information were more likely to report optimal satisfaction with the pain medication than those who did not (67% vs 34%; P < .001). Participants who participated in the decision were also more likely to report optimal satisfaction with the analgesic (71% vs 43%; P = .008) and had a greater average decrease in pain score (4.1 vs 2.9; P = .05). After adjusting for measured confounders, participants who reported receiving information remained more likely to report optimal satisfaction with the analgesic (63% vs 38%; P = .04).
Conclusion
Shared decision‐making in analgesic selection for older adults with acute musculoskeletal pain may improve outcomes.
Objectives
To assess the relationship between the number of primary care providers (PCPs) in an area and emergency department (ED) visits by older adults.
Design
Population‐based cross‐sectional ...observational study.
Setting
Nonfederal EDs in North Carolina in 2010.
Participants
All older adults (n = 640,086) presenting to a nonfederal ED in North Carolina in 2010.
Measurements
The primary outcome was the number of ED visits by older adults in each ZIP code per 100 adults aged 65 and older living in that ZIP code. A secondary outcome was the number of ED visits not resulting in hospital admission per 100 older adults. The primary predictor variable was the number of PCPs per 100 older residents for each ZIP code. Covariates included those representing healthcare need (Medicare hospitalizations, nursing home beds), predisposing factors for healthcare use (race, education, population density of older adults), and enabling factors (distance to the nearest ED).
Results
In a multivariable regression model corrected for spatial clustering, ZIP code characteristics associated with ED visits included more hospitalizations by Medicare beneficiaries, more nursing home beds, and closer proximity to an ED. Number of PCPs per 100 older adult residents in each ZIP code was not associated with ED use, and the 95% confidence limit indicates at most a small effect of PCP availability on ED use.
Conclusion
These findings suggest that primary care availability has at most a limited effect on ED use by older adults in North Carolina.
•We examined ambulance transport rates after motor vehicle collision.•Of 484,310 adults seen by EMS, 36% were transported to emergency departments.•Raw transport rates were only 2% higher for older ...vs. younger adults.•Adjusted transport rates were also only 2% higher for older adults.•Age-specific guidelines may improve the triage of older adults after MVC.
Older adults are at greater risk than younger adults for life-threatening injury after motor vehicle collision (MVC). Among those with life-threatening injury, older adults are also at greater risk of not being transported by emergency medical services (EMS) to an emergency department. Despite the greater risk of serious injury and non-transportation among older adults, little is known about the relationship between patient age and EMS transportation rates for individuals experiencing MVC. We describe transport rates across the age-span for adults seen by EMS after experiencing MVC using data reported to the North Carolina Department of Motor Vehicles between 2008 and 2011. Of all adults aged 18 years and older experiencing MVC and seen by EMS (n=484,310), 36.3% (n=175,768) were transported to an emergency department. Rates of transport for individuals seen by EMS after MVC increased only a small amount with increasing patient age. After adjusting for potential confounders of the relationship between patient age and the decision to transport (patient gender, patient race, air bag deployment, patient trapped or ejected, and injury severity), transport rates were: age 18–64=36.0% (95% confidence interval CI, 35.9–36.2%); age 65–74=36.6% (95% CI, 36.0–37.1%); age 75–84=37.3% (95% CI, 36.5–38.1%), and age 85–94=38.2% (95% CI, 36.7–39.8%). In North Carolina between 2008 and 2011, the transportation rate was only slightly higher for older adults than for younger adults, and most older adults experiencing MVC and seen by EMS were not transported to the emergency department. These findings have implications for efforts to improve the sensitivity of criteria used by EMS to determine the need for transport for older adults experiencing MVC.
Objectives
Emergency medicine (EM) residents take the In‐Training Examination (ITE) annually to assess medical knowledge. Question content is derived from the Model of Clinical Practice of Emergency ...Medicine (EM Model), but it is unknown how well clinical encounters reflect the EM Model. The objective of this study was to compare the content of resident patient encounters from 2016–2018 to the content of the EM Model represented by the ITE Blueprint.
Methods
This was a retrospective cross‐sectional study utilizing the National Hospital Ambulatory Medical Care Survey (NHAMCS). Reason for visit (RFV) codes were matched to the 20 categories of the American Board of Emergency Medicine (ABEM) ITE Blueprint. All analyses were done with weighted methodology. The proportion of visits in each of the 20 content categories and 5 acuity levels were compared to the proportion in the ITE Blueprint using 95% confidence intervals (CIs).
Results
Both resident and nonresident patient visits demonstrated content differences from the ITE Blueprint. The most common EM Model category were visits with only RFV codes related to signs, symptoms, and presentations regardless of resident involvement. Musculoskeletal disorders (nontraumatic), psychobehavioral disorders, and traumatic disorders categories were overrepresented in resident encounters. Cardiovascular disorders and systemic infectious diseases were underrepresented. When residents were involved with patient care, visits had a higher proportion of RFV codes in the emergent and urgent acuity categories compared to those without a resident.
Conclusions
Resident physicians see higher acuity patients with varied patient presentations, but the distribution of encounters differ in content category than those represented by the ITE Blueprint.