Search

BackgroundNational benchmarks for trauma triage sensitivity (≥95%) and specificity (≥50%) have not been rigorously evaluated across broad populations of injured patients. We evaluated the impact of different field triage schemes for identifying seriously injured patients across a range of sensitivity values. Impact metrics included specificity and number of undertriaged and overtriaged patients compared with current triage practices.MethodsThis was a retrospective cohort study of injured children and adults transported by 48 emergency medical service (EMS) agencies to 105 hospitals in 6 regions of the Western United States from 2006 through 2008. Hospital outcomes were probabilistically linked to EMS records through trauma registries, state discharge databases, and state emergency department databases. The primary outcome was an Injury Severity Score (ISS) of 16 or greater. We evaluated 40 field predictor variables, including 31 current field triage criteria, using classification and regression tree analysis and cross-validation to generate estimates for sensitivity and specificity.ResultsA total of 89,261 injured patients were evaluated and transported by EMS providers during the 3-year period, of whom 5,711 (6.4%) had ISS of 16 or greater. As the 95% sensitivity target for triage was approached (from the current value of 87.5%), decision tree complexity increased, specificity decreased (from 62.8% to 18.7%), and the number of triage-positive patients without serious injury doubled (67,927 vs. 31,104). Analyses restricted to children and older adults were similar. The most consistent modification to the current triage algorithm to increase sensitivity without a major decrease in specificity was altering the Glasgow Coma Scale (GCS) score cutoff point from 13 or less to 14 or less (sensitivity increase to 90.4%).ConclusionReaching the field triage sensitivity benchmark of 95% would require a large decrease in specificity (increase in overtriage). A 90% sensitivity target seems more realistic and may be obtainable by modest changes to the current triage algorithm.

In Oregon, only 17% of the requests for a prescription for lethal drugs have been granted by doctors under the Death With Dignity Act of 1997. This law legalized physician-assisted suicide, which means that doctors can prescribe drugs that critically ill patients can use to commit suicide. A survey of 2,649 Oregon doctors found that only 5% had received a request for a lethal drug prescription. Of 165 patients who made such a request, only 29 actually received the prescription and only 17 used the drugs to commit suicide. Forty-six percent of the patients changed their minds when they were offered palliative treatment.

Most Oregon physicians seem to support the legalization of assisted suicide, but many are unsure about the details of the practice. Researchers mailed surveys to physicians eligible to participate in assisted suicide under the Oregon Death with Dignity Act passed in 1994, and received surveys from 2,761 physicians. Sixty percent believed assisted suicide should be legal in some cases, and 46% would prescribe a lethal dose of medication if it were legal. Of those who would not prescribe a lethal dose, 31% raised moral objections. Half of the physicians were unsure about what drug to prescribe and were concerned about complications of failed suicide attempts. Half were also not confident they could predict a patient would die within six months, and a third were not convinced they could recognize depression in patients requesting a lethal dose. The law requires the physician to do both. Most physicians thought some patients would make the request because of financial considerations or concern about being a burden to others.

Objectives. High rates of family violence and low rates of detection, report, and therapeutic intervention by health professionals are well documented. This study was undertaken to determine what factors influence clinicians' decision making about identifying abuse and intervening with victims. Methods. Survey data about clinicians' experiences with and attitudes toward family violence were gathered by mailed questionnaire from a random sample of practicing clinicians in six disciplines (n = 1521). Results. Data showed similarities within and wide differences among three groups of subjects: dentists/dental hygienists, nurses/ physicians, and psychologists/social workers. Overall, a third of subjects reported having received no educational content on child, spouse, or elder abuse in their professional training programs. Subjects with education on the topic more commonly suspected abuse in their patients than those without; among all subjects, spouse abuse was suspected more often than child abuse while elder abuse was suspected infrequently. Significant numbers of subjects did not view themselves as responsible for dealing with problems of family violence. Subjects indicated low confidence in and low compliance with mandatory reporting laws. Conclusions. There is a need for educators to expand curricula on family violence and for legislators to reexamine mandatory reporting laws., Clinicians in several fields commonly do not suspect family violence, intervene when they suspect it or report it, even under mandatory reporting laws. Results of a survey completed by 1,521 practicing dentists, physicians, dental hygienists, social workers, psychologists and nurses indicate that more education does increase clinicians' awareness of and likelihood of suspecting child, spousal and elderly abuse. However, it has little effect on intervention or reporting. One-third of those surveyed indicated they received no education on domestic violence while in professional school. When such education was included in the curriculum, it was more likely to relate to child abuse, with 64% of the respondents saying they received education in this area. Nineteen percent of those who received education said they commonly suspected physical child abuse. Just under seven percent of those with no education in the area suspected such abuse. Only social workers and psychologists would report suspected abuse the majority of the time. Most dentists and dental hygienists would not report it. Education in the subject matter has little effect on these attitudes.

Dental health care workers appear to feel inadequately trained in identifying cases of domestic violence. A total of 275 dental hygienists and 251 dentists completed questionnaires about domestic violence in their practices. An additional five dentists and five hygienists were interviewed. Slightly less than half of the dentists and hygienists indicated they had received training in identifying child abuse. Education on the identification of spouse abuse was reported by 15% of the dentists and 14% of the hygienists. Education in intervention was reported by few members of either group. Six percent of the dentists and 3.7% of the hygienists commonly suspected spouse abuse. Two percent of the dentists and 0.4% of the hygienists commonly suspected child abuse. During the interviews both dentists and dental hygienists appeared to have little compassion for a battered woman or her abuser though they believed spouse abuse to be inappropriate. However, in cases of child abuse children were seen as innocent victims needing to be protected.