Search

Objectives: There is controversy over who should serve as the Trauma Team Leader (TTL) at trauma-receiving centres. This study compared survival and emergency department (ED) length-of-stay between patients cared for by 3 different groups of TTLs: surgeons, emergency physicians (EPs) on call for trauma cases and EPs on shift in the ED.Methods: We performed a retrospective cohort study involving all adult major blunt trauma patients (aged 17 and older) who were admitted to 2 level I trauma centres and who were entered into a provincial Trauma Registry between March 2000 and April 2002. The study was designed to compare the effect of TTL-type on survival and ED length-of-stay, while controlling for sex, age, and trauma severity as defined by the Injury Severity Score (ISS) and the Revised Trauma Score (RTS). Analysis was performed using linear regression modeling (for the ED lenght-of-stay outcome variable), and logistic regression modeling (for the surivial outcome variable).Results: There were 1412 patients enrolled in the study. The study population comprised 74% men and 26% women, with a mean age of 44.7 years (43.1, 46.6 and 42.8 years for surgeons, on-call EPs and on-shift EPs, respectively). The overall mean ISS was 23.2 (23.7 for surgeons, 22.9 for on-call EPs and 23.3 for on-shift EPs) and the overall average RTS was 7.6 (7.6 for surgeons, 7.6 for on-call EPs and 7.5 for on-shift EPs). The overall median ED length-of-stay was 5.3 hours (4.5, 5.3 and 5.6 hours for surgeons, on-call EPs and on-shift EPs, respectively; p = 0.07) and the overall survival was 87% (86% surgeon, 88% on-call EP, 87% on-shift EP; p = 0.08). No statistically significant relationship was found between TTL-type and ED length-of-stay (p = 0.42) or survival (p = 0.43) using multivariate modeling.Conclusion: Our results suggest that surgeons, on-call EPs, or on-shift EPs can act as the TTL without a negative impact on patient survival or ED length-of-stay. [ABSTRACT FROM AUTHOR]

BACKGROUND: Health promotion and disease prevention have been increasingly recognized as activities that may be within the scope of emergency medicine. The purpose of this feasibility study was to identify health risks and offer immediate interventions to adult patients who have drug and/or alcohol problems, incomplete immunization, are overdue for a Pap (Papanicolaou) smear, and/or are smokers. METHODS: The study took place in a busy tertiary Emergency Department (ED) serving an inner-city population with a significant proportion of patients who are homeless, substance abusers, working poor, and/or recent immigrants. A convenience sample of patients completed a computer-based health-risk survey. Trained health promotion nurses offered appropriate interventions to patients following review and discussion of their self-reported data. Interventions included counseling for problem drinking, substance abuse, and smoking cessation, screening for cervical cancer, and immunization. RESULTS: From October 20, 2000 to June 30, 2003, we enrolled 2366 patients. One thousand and eleven subjects (43%) reported substance abuse and 1095 (46%) were smokers. Of the 158 smokers contacted in follow-up, 19 (12%) had quit, 63 (40%) had reduced the number of cigarettes/day and 76 (48%) reported no change. Of 1248 women surveyed, 307 (25%) were overdue for a Pap smear and 54 (18%) received this intervention. Forty-four percent of subjects were overdue for at least one immunization and of those, 414 (40%) were immunized in the ED. CONCLUSION: At-risk patients can be identified using a computer-based screening tool, and appropriate interventions can be given to a proportion of these patients in a busy inner city ED without increasing wait time. [ABSTRACT FROM AUTHOR]

Objective: To describe disaster medicine (DM) education in 16 Canadian medical schools before and after September 11, 2001 (9/11). Methods: Email invitations and reminders to complete an Internet-based survey were sent to 48 undergraduate and fellowship representatives. Results: A total of 24 responses were received from 15 of the 16 Canadian medical schools in operation at the time of the study, representing 10 undergraduate and 14 fellowship programs. Prior to 9/11, 22 programs at 9 schools taught DM compared with 14 programs post 9/11, a reduction of 37%. Six schools reported no DM teaching before 9/11; 7 reported no DM instruction after that date. Respondents from 12 schools felt that DM should be taught at the undergraduate level, and 9 of the 12 felt it should be included as core content. Respondents from all 15 responding schools felt that DM should be included as core content at the fellowship level. Twenty-two respondents (92%) indicated a belief that the public expects physicians to be prepared to deal with the consequences of disasters. The most frequently taught topics were emergency medical services and disasters, disaster management, hospital disaster planning, and bioterrorism. Conclusion: Despite support for DM instruction and increases in terrorism and global disasters, 46% of the responding medical schools do not teach this topic and there has been a downward trend in this regard since 9/11. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The objective of this study was to evaluate the feasibility of a school-based influenza immunization program. METHODS: Pupils and their families from 3 demographically similar elementary schools participated in this pilot, unblinded, controlled intervention study. Live attenuated influenza vaccine (FluMist) was made available to all eligible pupils in 1 target school during regular school hours. Two schools where vaccine was not offered served as control schools. All families from the 3 study schools were sent an anonymous questionnaire requesting 7-day recall data on fever or respiratory illness (FRI)-related medical visits, medications purchased, and days of school or paid work lost during the peak influenza week. Changes in weekly pupil absenteeism were also examined. RESULTS: One hundred eighty-five (40%) of the target school pupils received vaccine, of whom >50% were vaccinated < or =3 weeks before the influenza outbreak period. Questionnaires were returned by 43% to 51% of households. Significant (45-70%) relative reductions in FRI-related outcomes, including doctor visits by adults or children, prescription or other medicines purchased, and family schooldays or workdays missed, were observed for target school households, compared with control school households. The increases in absenteeism rates during the influenza outbreak period, compared with baseline rates earlier in the fall, were not significantly different between target and control schools. Within the target school, however, the increase in absenteeism rates was significantly smaller for the FluMist-vaccinated pupils, compared with the non-FluMist-vaccinated pupils. CONCLUSIONS: This school-based influenza immunization program was associated with significant reductions in FRI-related outcomes in households of pupils attending an intervention school. These results might have underestimated the potential impact of FluMist, because the majority of children received intraepidemic vaccination. [ABSTRACT FROM AUTHOR]

Objectives: To investigate which independent factor(s) have an impact on the pharmacokinetics of vancomycin in critically ill children, develop an equation to predict the 24-hour area under the concentration-time curve from a trough concentration, and evaluate dosing regimens likely to achieve a 24-hour area under the concentration-time curve to minimum inhibitory concentration ratio (AUC24/MIC) greater than or equal to 400., Design: Prospective population pharmacokinetic study of vancomycin., Setting: Critically ill patients in quaternary care PICUs., Patients: Children 90 days old or older to younger than 18 years who received IV vancomycin treatment, irrespective of the indication for use, in the ICUs at the University of Maryland Children's Hospital and Texas Children's Hospital were enrolled., Interventions: Vancomycin was prescribed at doses and intervals chosen by the treating clinicians., Measurements and Main Results: A median of four serum levels of vancomycin per patient were collected along with other variables for up to 7 days following the first administration. These data were used to characterize vancomycin pharmacokinetics and evaluate the factors affecting the variability in achieving AUC24/MIC ratio greater than or equal to 400 in PICU patients who are not on extracorporeal therapy. A total of 302 children with a median age of 6.0 years were enrolled. A two-compartment model described the pharmacokinetics of vancomycin with the clearance of 2.76 L/hr for a typical patient weighing 20 kg. The glomerular filtration rate estimated using either the bedside Schwartz equation or the chronic kidney disease in children equation was the only statistically significant predictor of clearance among the variables evaluated, exhibiting equal predictive performance. The trough levels achieving AUC24/MIC = 400 were 5.6-10.0 μg/mL when MIC = 1 μg/mL. The target of AUC24/MIC greater than or equal to 400 was achieved in 60.4% and 36.5% with the typical dosing regimens of 15 mg/kg every 6 and 8 hours (q6h and q8h), respectively., Conclusions: The pharmacokinetics of vancomycin in critically ill children were dependent on the estimated glomerular filtration rate only. Trough concentrations accurately predict AUC24. Typical pediatric vancomycin dosing regimens of 15 mg/kg q6h and q8h will often lead to AUC24/MIC under 400., Competing Interests: Dr. Gobburu is a co-founder of Pumas-AI, which commercializes Pumas and Lyv and a co-founder of Vivpro Corp, which commercializes Research and Development Intelligence Assistant software. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Background: Documentation during resident transitions from long-term care (LTC) to the emergency department (ED) can be inconsistent, leading to inappropriate care. Inconsistent documentation can lead to undertreatment, inefficiencies and adverse patient outcomes. Many individuals residing in LTC have some form of cognitive impairment and may not be able to advocate for themselves, making accurate and consistent documentation vital to ensuring they receive safe care. We examined documentation consistency related to reason for transfer across care settings during these transitions., Methods: We included residents of LTC aged 65 or over who experienced an emergency transition from LTC to the ED via emergency medical services. We used a standardized and pilot-tested tracking tool to collect resident chart/patient record data. We collected data from 38 participating LTC facilities to two participating EDs in Western Canadian provinces. Using qualitative directed content analysis, we categorized documentation from LTC to the ED by sufficiency and clinical consistency., Results: We included 591 eligible transitions in this analysis. Documentation was coded as consistent, inconsistent, or ambiguous. We identified the most common reasons for transition for consistent cases (falls), ambiguous cases (sudden change in condition) and inconsistent cases (falls). Among inconsistent cases, three subcategories were identified: insufficient reporting, potential progression of a condition during transition and unclear reasons for inconsistency., Conclusions: Shared continuing education on documentation across care settings should result in documentation supports geriatric emergency care; on-the-job training needs to support reporting of specific signs and symptoms that warrant an emergent response, and discourage the use of vague descriptors., (© 2023. The Author(s).)

We identified quality indicators (QIs) for care during transitions of older persons (≥ 65 years of age). Through systematic literature review, we catalogued QIs related to older persons' transitions in care among continuing care settings and between continuing care and acute care settings and back. Through two Delphi survey rounds, experts ranked relevance, feasibility, and scientific soundness of QIs. A steering committee reviewed QIs for their feasible capture in Canadian administrative databases. Our search yielded 326 QIs from 53 sources. A final set of 38 feasible indicators to measure in current practice was included. The highest proportions of indicators were for the emergency department (47%) and the Institute of Medicine (IOM) quality domain of effectiveness (39.5%). Most feasible indicators were outcome indicators. Our work highlights a lack of standardized transition QI development in practice, and the limitations of current free-text documentation systems in capturing relevant and consistent data.

Residents of long-term care (LTC) whose deaths are imminent are likely to trigger a transfer to the emergency department (ED), which may not be appropriate. Using data from an observational study, we employed structural equation modeling to examine relationships among organizational and resident variables and death during transitions between LTC and ED. We identified 524 residents involved in 637 transfers from 38 LTC facilities and 2 EDs. Our model fit the data, (χ 2 = 72.91, df = 56, p = .064), explaining 15% variance in resident death. Sustained shortness of breath (SOB), persistent decreased level of consciousness (LOC) and high triage acuity at ED presentation were direct and significant predictors of death. The estimated model can be used as a framework for future research. Standardized reporting of SOB and changes in LOC, scoring of resident acuity in LTC and timely palliative care consultation for families in the ED, when they are present, warrant further investigation.

Objective: For long-term care (LTC) residents, transfers to emergency departments (EDs) can be associated with poor health outcomes. We aimed to describe characteristics of residents transferred, factors related to decisions during transfer, care received in emergency medical services (EMS), ED settings, outcomes on return to LTC, and times of transfer segments along the transition. Method: We prospectively followed 637 transitions to an ED in British Columbia and Alberta, Canada, over a 12-month period. Data were captured through an electronic Transition Tracking Tool and interviews with health care professionals. Results: Common events triggering transfer were falls (26.8%), sudden change in condition (23.5%), and shortness of breath (19.8%). Discrepancies existed between reason for transfer, EMS reported chief complaint, and ED diagnosis. Many transfers resulted in resident return directly to LTC (42.7%). Discussion: Avoidable transfers may put residents at risk of receiving inappropriate care. Standardized communication strategies to highlight changes in resident condition are warranted.

Background: The Zika virus epidemic and associated congenital infections have prompted rapid vaccine development. We assessed two new DNA vaccines expressing premembrane and envelope Zika virus structural proteins., Methods: We did two phase 1, randomised, open-label trials involving healthy adult volunteers. The VRC 319 trial, done in three centres, assessed plasmid VRC5288 (Zika virus and Japanese encephalitis virus chimera), and the VRC 320, done in one centre, assessed plasmid VRC5283 (wild-type Zika virus). Eligible participants were aged 18-35 years in VRC19 and 18-50 years in VRC 320. Participants were randomly assigned 1:1 by a computer-generated randomisation schedule prepared by the study statistician. All participants received intramuscular injection of 4 mg vaccine. In VRC 319 participants were assigned to receive vaccinations via needle and syringe at 0 and 8 weeks, 0 and 12 weeks, 0, 4, and 8 weeks, or 0, 4, and 20 weeks. In VRC 320 participants were assigned to receive vaccinations at 0, 4, and 8 weeks via single-dose needle and syringe injection in one deltoid or split-dose needle and syringe or needle-free injection with the Stratis device (Pharmajet, Golden, CO, USA) in each deltoid. Both trials followed up volunteers for 24 months for the primary endpoint of safety, assessed as local and systemic reactogenicity in the 7 days after each vaccination and all adverse events in the 28 days after each vaccination. The secondary endpoint in both trials was immunogenicity 4 weeks after last vaccination. These trials are registered with ClinicalTrials.gov, numbers NCT02840487 and NCT02996461., Findings: VRC 319 enrolled 80 participants (20 in each group), and VRC 320 enrolled 45 participants (15 in each group). One participant in VRC 319 and two in VRC 320 withdrew after one dose of vaccine, but were included in the safety analyses. Both vaccines were safe and well tolerated. All local and systemic symptoms were mild to moderate. In both studies, pain and tenderness at the injection site was the most frequent local symptoms (37 [46%] of 80 participants in VRC 319 and 36 [80%] of 45 in VRC 320) and malaise and headache were the most frequent systemic symptoms (22 [27%] and 18 [22%], respectively, in VRC 319 and 17 [38%] and 15 [33%], respectively, in VRC 320). For VRC5283, 14 of 14 (100%) participants who received split-dose vaccinations by needle-free injection had detectable positive antibody responses, and the geometric mean titre of 304 was the highest across all groups in both trials., Interpretation: VRC5283 was well tolerated and has advanced to phase 2 efficacy testing., Funding: Intramural Research Program of the Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: OPTIC is a mixed method Partnership for Health System Improvement (http://www.cihr-irsc.gc.ca/e/34348.html) study focused on improving care for nursing home (NH) residents who are transferred to and from emergency departments (EDs) via emergency medical services (EMS). In the pilot study we tested feasibility of concurrently collecting individual resident data during transitions across settings using the Transition Tracking Tool (T3)., Methods: The pilot study tracked 54 residents transferred from NHs to one of two EDs in two western Canadian provinces over a three month period. The T3 is an electronic data collection tool developed for this study to record data relevant to describing and determining success of transitions in care. It comprises 800+ data elements including resident characteristics, reasons and precipitating factors for transfer, advance directives, family involvement, healthcare services provided, disposition decisions, and dates/times and timing., Results: Residents were elderly (mean age = 87.1 years) and the majority were female (61.8%). Feasibility of collecting data from multiple sources across two research sites was established. We identified resources and requirements to access and retrieve specific data elements in various settings to manage data collection processes and allocate research staff resources. We present preliminary data from NH, EMS, and ED settings., Conclusions: While most research in this area has focused on a unidirectional process of patient progression from one care setting to another, this study established feasibility of collecting detailed data from beginning to end of a transition across multiple settings and in multiple directions.

Background: Changes in health status, triggered by events such as infections, falls, and geriatric syndromes, are common among nursing home (NH) residents and necessitate transitions between NHs and Emergency Departments (EDs). During transitions, residents frequently experience care that is delayed, unnecessary, not evidence-based, potentially unsafe, and fragmented. Furthermore, a high proportion of residents and their family caregivers report substantial unmet needs during transitions. This study is part of a program of research whose overall aim is to improve quality of care for frail older adults who reside in NHs. The purpose of this study is to identify successful transitions from multiple perspectives and to identify organizational and individual factors related to transition success, in order to inform improvements in care for frail elderly NH residents during transitions to and from acute care. Specific objectives are to: 1. define successful and unsuccessful elements of transitions from multiple perspectives; 2. develop and test a practical tool to assess transition success; 3. assess transition processes in a discrete set of transfers in two study sites over a one year period; 4. assess the influence of organizational factors in key practice locations, e.g., NHs, emergency medical services (EMS), and EDs, on transition success; and 5. identify opportunities for evidence-informed management and quality improvement decisions related to the management of NH - ED transitions., Methods/design: This is a mixed-methods observational study incorporating an integrated knowledge translation (IKT) approach. It uses data from multiple levels (facility, care unit, individual) and sources (healthcare providers, residents, health records, and administrative databases)., Discussion: Key to study success is operationalizing the IKT approach by using a partnership model in which the OPTIC governance structure provides for team decision-makers and researchers to participate equally in developing study goals, design, data collection, analysis and implications of findings. As preliminary and ongoing study findings are developed, their implications for practice and policy in study settings will be discussed by the research team and shared with study site administrators and staff. The study is designed to investigate the complexities of transitions and to enhance the potential for successful and sustained improvement of these transitions.

Objective: To determine the feasibility of using volunteers to assist in school-located mass vaccination clinics for influenza., Methods: A set of elementary school-based mass vaccination clinics was implemented in Carroll County, Maryland by the local health department in the 2005-2006 school year. In addition to using health department personnel, fiscal restraints necessitated using medical volunteers and lay volunteers to assist health professionals. The medical volunteers included physicians, nurses, and pharmacists, and were responsible for administering intranasal vaccine (live, attenuated influenza vaccine [LAIV]). We assessed the performance, as measured by the number of vaccinations administered, and effort expended by these volunteers., Results: A total of 5319 (44%) of the 12,090 elementary school children in the county received LAIV. Of the estimated 3547 (66%) children eligible and consenting to receive a second dose, 3124 (88%) received it. In total, 8806 doses of LAIV were administered. Health department nurses worked 42 person-days and were assisted by medical and allied health professionals volunteering 87 person-days without compensation, totaling 581 person-hours spent in this effort., Conclusions: A mass school-located influenza vaccination program using medical and lay volunteers guided by health department nurses is feasible. Several issues were identified to improve future clinics and help make the program sustainable.

Special mass influenza vaccination programs of elementary school-aged children (ESAC) in some or all Maryland Counties were conducted during the falls of 2005-2007. From 3% to 46% of ESAC received live attenuated influenza vaccine during these county programs, which were in addition to routine influenza vaccination efforts conducted in county medical offices. Anonymous, all cause public school absentee data for all grades was available from 11 of Maryland's 24 counties. Binomial regression was used to estimate associations between the percentage of children vaccinated in each county and the degree of increase in absenteeism rates during influenza outbreaks. We estimated that, for every 20% increase in vaccination rates for ESAC during these special programs, a 4% decrease in the rise in absentee rates occurred during influenza outbreak periods in both elementary and upper schools (P<0.05). These results suggest both direct and indirect benefits of influenza vaccination of young children., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Purpose: Hypertension is a highly prevalent risk factor for cardiovascular disease, and its early identification and management results in reductions in morbidity and mortality. Our objectives were to: (1) determine the extent to which the emergency department (ED) has been used to screen patients for undiagnosed hypertension; (2) estimate the incidence of undiagnosed hypertension in the ED population; (3) identify and describe the programs for ED hypertension screening; and (4) determine the feasibility of ED-based hypertension screening programs and the requirements for further study., Data Sources: An online search of databases (i.e., OVID Search, CINAHL, Scopus, Web of Science), unpublished sources (i.e., ProQuest Dissertation & Theses and Papers First), and grey literature (i.e., OpenSIGLE and the New York Academy of Grey Literature) was conducted. A manual search of the reference lists of relevant studies was also completed., Conclusion: Hypertension screening in the ED is feasible. Individuals with elevated blood pressure (BP) in the ED should be referred for follow-up. Further study is needed to develop an ED screening tool that is predictive of persistently elevated BP in undiagnosed individuals., Implications for Practice: Nurse practitioners in the ED should identify patients with elevated BP, provide hypertension education, and ensure appropriate intervention and referral., (©2011 The Author(s) Journal compilation ©2011 American Academy of Nurse Practitioners.)

Special influenza vaccination programs of elementary school-aged children (ESAC) in some or all of Maryland Counties were conducted during the falls of 2005-2007. Rates of emergency department (E.D.) visits and hospitalizations for medically attended acute respiratory illnesses (MAARI) as well as deaths due to pneumonia and influenza for county residents were determined. The degree to which these rates were modulated during intense influenza outbreak periods (IIOP) in counties who vaccinated a greater percentage of ESAC was estimated using Poisson regression. Notably, for every 20% increase in vaccination rates, MAARI related E.D. visits during IIOP decreased by 8% (95% C.I., 5-12%) in children aged 5-11 years and by 6% (95% C.I., 3-8%) in adults aged 19-49 years (p<0.001), which suggests both a direct and indirect benefit of the vaccination programs. In contrast, MAARI related hospitalizations increased during IIOP by 4% (95% C.I., 3-9%) in adults aged >50 years for every 20% increase in vaccination rates (p<0.023) for which we have no plausible biologic explanation. No significant changes in deaths were noted., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Background: Lactoferrin has an array of biological activities that include growth, immune modulation, and antimicrobial effects. The aim of this randomized, placebo-controlled, double-blind study was to examine the impact of bovine lactoferrin supplementation in infants., Patients and Methods: Healthy, formula-fed infants, > or =34 weeks' gestation and < or =4 weeks of age, enrolled in a pediatric clinic. Infants received either formula supplemented with lactoferrin (850 mg/L) or commercial cow milk-based formula (102 mg/L) for 12 months. Growth parameters and information on gastrointestinal, respiratory, and colic illnesses were collected for the infants' first year. Antibodies to immunizations and hematologic parameters were measured at 9 and 12 months., Results: The lactoferrin-enhanced formula was well tolerated. There were significantly fewer lower respiratory tract illnesses, primarily wheezing, in the 26 lactoferrin-fed (0.15 episodes/y) compared with the 26 regular formula-fed (0.5 episodes/y) infants (P < 0.05). Significantly higher hematocrit levels at 9 months (37.1% vs 35.4%; P < 0.05) occurred in the lactoferrin-supplemented group compared with the control formula group., Conclusions: Lactoferrin supplementation was associated with potentially beneficial outcomes such as significantly fewer lower respiratory tract illnesses and higher hematocrits. Larger, more focused studies in infants are warranted.

Purpose: The purpose of this paper is to report on gender differences in emergency physicians with respect to their attitudes, knowledge, and practices concerning health promotion and disease prevention., Design/methodology/approach: A mail survey of 325 male and 97 female Canadian emergency physicians., Findings: Results suggest female emergency physicians report having greater knowledge of health promotion topics, spend more time with each of their patients in the emergency setting, and engage in more health promotion counseling in the emergency setting than do their male counterparts., Originality/value: The paper argues that in the future, educating and socializing emergency physicians, both male and female, in the practice of health promotion will enhance the potential of the emergency department to be a more effective resource for their community.

Objectives: Our goal was to determine the effectiveness of an intervention aimed at improving the emergency department (ED) documentation of pediatric injuries., Methods: All physicians and nursing staff in the ED of an urban teaching hospital and trauma centre underwent focused injury surveillance training and were instructed how to document 14 injury-specific data elements. Pocket reminder cards were provided, and pediatric injury charts were flagged. Subsequently, random samples of pediatric injury charts were analyzed from a 3-month period prior to the intervention and from the corresponding months after the intervention. Post-intervention documentation was compared to pre-intervention documentation for the 14 pre-defined data elements., Results: Six of the 14 data elements were charted more frequently, and 2 less frequently during the post-intervention phase. Odds ratios ranged from 4.59 (95%CI, 3.40 to 6.19) for charting "the presence of an adult observer" to 0.09 (95%CI, 0.01 to 0.76) for charting "sports equipment related to the injury." The "flagging" of injury charts, as a visual reminder for clinicians to document injury data, seemed to be the most effective component of the intervention., Conclusion: A simple intervention, consisting of staff training, chart modification, and visual flagging of charts, can increase the amount of injury information documented by ED clinicians. Efforts to improve ED charting are most likely to succeed if they include visual prompts for clinicians.

A pilot study to survey the attitudes of emergency department (ED) personnel regarding their role in injury prevention education in children and parents was conducted at a tertiary care trauma center. The survey consisted of 14 statements, asking staff members their level of agreement (from strongly agree to strongly disagree) on a forced-choice four-point scale. These were followed by two questions asking staff members to rank schools, physician's offices, emergency departments, and public health units on their value in providing injury prevention information to children and parents. Before the intervention (an in-service training program on the importance of documenting the circumstances of injury on a patient's chart), a 50% randomly selected sample of ED staff members was asked in May 1997 to complete the survey. After the data collection prepilot (4 months later), the remaining 50% was asked in September 1997 to complete the same questionnaire. Administration of the preintervention survey resulted in 53 of 62 surveys being returned (85%). The postintervention survey was completed by 35 of the 41 staff members still eligible (85%), those who were employed in the ED during the entire pilot project. There was no statistically significant difference between the pre- and post-pilot groups on any demographic characteristics. Staff members agreed least with the statement that ED physicians and staff members could impact the severity of injuries to children by providing counseling to parents (68.1% preintervention and 64.5% postintervention agreement). Of most significance was the fact that a lower percentage of staff members agreed postintervention that almost all injuries to children were avoidable. The emergency department was the lowest ranked information dissemination venue for both parents and children.

An unusual case of an anorectal fistula presenting with hip pain and extensive lower limb muscle wasting in a patient with Crohn's disease is reported. This report emphasizes the important role of a thorough history, a complete physical examination, and a thorough search for evaluating such cases. Any progressive local irritation and pain in a Crohn's disease patient may indicate possible fistulous involvement. Nonspecific laboratory findings such as leukocytosis, anemia, decreased albumin level, and thrombocytosis may be considered as supportive indicators. Barium contrast studies and enhanced computed tomography scan may be helpful but can be falsely negative in the presence of a fistula, as in this case. These findings illustrate that the clinician must not be dissuaded from the diagnosis simply based on negative radiological findings because the presence of a fistula may be impossible to determine preoperatively.

Injuries account for more deaths and hospital admissions among children and adolescents than all diseases combined. The authors report two deaths by asphyxiation that resulted from drawstrings on the children's clothing becoming entangled on slides. Although such incidents are not common, they are preventable. The authors urge physicians to counsel parents and guardians to remove drawstrings from children's clothing, and they call upon the government and the clothing industry to work toward improving the safety standards for the design, manufacture and importation of children's clothing and banning the sale of children's clothing with drawstrings in Canada. In addition, they provide several resources for readers interested in helping reduce playground hazards in their communities.

PAM/NET is a computerized data base and conferencing system used by nine neonatal intensive care units in Michigan and Illinois. The system depends on the timesharing resource of a large university mainframe computer. The data base functions are managed by a sophisticated inverted file relational data base management system capable of mass storage and rapid and specific retrieval of individual cases or summary data. Data stored in the system are used to generate admission, discharge and developmental assessment clinic summaries that serve as such for the medical record and as letters to primary physicians. We report here the early experience in the design and dissemination of this database network to the participating hospitals. Conflicting goals of sharing and confidentiality of clinical data are addressed in the design of this system.