Chemical accidents occur often across the United States, endangering the health and safety of many people. The Super fund Amendments and Reauthorization Act of 1986 (SARA) requires that communities increase their planning for medical response to these accidents. So far, little evidence has come forth that supports the notion that environmental legislation, such as SARA, improves preparedness for such accidents.

A one-group pretest/post-test longitudinal design was used to survey the medical directors of emergency departments in all acute care hospitals in the State of New York. Data were collected by mail survey and telephone follow-up in 1986 before the passage of SARA (Timel), and in 1989 after its implementation (Time2).

Ninety-four percent of the directors responded at Timel and 72% at Time2. In New York State, hospital preparedness for chemical accidents improved significantly during the study interval. The longer a hospital had a plan for response to chemical accidents, the more elements of preparedness were in place. Further, as a group, the hospitals that were the least prepared were located in the areas at highest risk.

Environmental legislation can influence the manner by which health care organizations prepare for environmental emergencies.

Nationwide data were collected concerning serious, disabling injuries requiring hospitalization (SDIH) or deaths among urban emergency medical services (EMS) providers.

A mail survey of EMS systems was conducted among the 200 most populated U.S. cities.

Participants were training and operations officers of urban EMS systems.

Ninety forms (45%) were returned with 88 evaluable (44%). There were 81 SDIHs for a rate of one in 31,616 dispatches. No deaths were reported. Body parts most frequently injured were the hand (22%), head (19%), foot (16%), and eye (14%). Although 90% of fire-based EMS systems (fire-EMS) provided helmets, eye protection, safety shoes, and gloves, less than half (45%) of nonfire-EMS did so. Three (4%) SDIHs resulted from acts of violence.

Occupational injuries of EMS personnel are at a serious level. Fire-based EMS systems experienced a higher rate of hand SDIHs despite the provision of protective equipment. Few nonfire-EMS staff are provided with safety equipment, which may have resulted in a relatively high number of head and hand SDIHs. Fire-EMS medical directors need to take an active role in verifying that protective equipment is adequate and appropriate to allow the performance of field EMS duties without being too cumbersome. Medical directors of nonfire-EMS must be advocates for the provision of basic protective equipment aimed at mitigating SDIHs of EMS staff.

An epidemic of surgical wound infections observed at the State Hospital of Sarajevo during June-September 1992 is reported.

A cross-sectional survey of 138 surgical patients with wound infection treated by the Department of Surgery of the State Hospital of Sarajevo was performed in mid-September and again in mid-November 1992. A preliminary evaluation of the bactericidal effectiveness of a new antiseptic preparation called DI-ASEPT also was done.

The frequency of wound infection was 24.4% in September and 19.2% in November. Pseudomonas species was the primary etiologic agent in this epidemic. DI-ASEPT was as effective as povidone-iodine in producing wound asepsis.

Because of limited resources large numbers of casualties, and an extremely adverse environment as a result of war that has affected hygienic conditions at the State Hospital of Sarajevo, a high frequency of contaminated or dirty operations were performed. This was the primary reason for the observed increase in wound infections. After hygienic conditions were restored, the epidemic of wound infections was terminated.

To investigate the adequacy of hospital disaster preparedness in the Osaka, Japan area.

Questionnaires were constructed to elicit information from hospital administrators, pharmacists, and safety personnel about self-sufficiency in electrical, gas, water, food, and medical supplies in the event of a disaster. Questionnaires were mailed to 553 hospitals.

A total of 265 were completed and returned (Recovery rate; 48%). Of the respondents, 16% of hospitals that returned the completed surveys had an external disaster plan, 93% did not have back-up plans to accept casualties during a disaster if all beds were occupied, 8% had drugs and 6% had medical supplies stockpiled for disasters. In 78% of hospitals, independent electric power generating plants had been installed. However, despite a high proportion of power-plant equipment available, 57% of hospitals responding estimated that emergency power generation would not exceed six hours due to a shortage of reserve fuel. Of the hospitals responding, 71% had reserve water supply, 15% of hospitals responding had stockpiles of food for emergency use, and 83% reported that it would be impossible to provide meals for patients and staff with no main gas supply.

No hospitals fulfilled the criteria for adequate disaster preparedness based on the categories queried. Areas of greatest concern requiring improvement were: 1) lack of an external disaster plan; and 2) self-sufficiency in back-up energy, water, and food supply. It is recommended that hospitals in Japan be required to develop plans for emergency operations in case of an external disaster. This should be linked with hospital accreditation as is done for internal disaster plans.

Although emergency medical services (EMS) liability litigation is a concern of many prehospital health care providers, there have been no studies of these legal cases nationwide and no local case studies since 1987.

A retrospective case series was obtained from a computerized database of trial court cases filed against EMS agencies nation-wide. All legal cases that met the inclusion criteria were included in the study sample. These cases must have involved either ambulance collisions (AC) or patient care (PC) incidents, and they must have been closed between 1987 and 1992.

There were 76 cases that met the inclusion criteria. Half of these cases involved an AC, and the other cases alleged negligence of a PC encounter. Thirty (78.9%) of the plaintiffs in the AC cases were other motorists, and 35 (92.1%) of the plaintiffs in the PC cases were EMS patients. Almost half of the cases named an individual (usually an emergency medical technician or paramedic) as a codefendant. Thirty-one (40.8%) of the cases were closed without any payment to the plaintiff. There were five cases with plaintiffs' awards or settlements greater than [US] $1 million. Most (71.0%) ofthe ACs occurred in an intersection or when one vehicle rear-ended another vehicle. The most common negligence allegations in the PC cases were arrival delay, inadequate assessment, inadequate treatment, patient transport delay, and no patient transport.

Risk management for EMS requires specific knowledge of the common sources of EMS liability litigation. This sample of recent legal cases provides the common allegations of negligence. Recommendations to decrease the legal risk of EMS agencies and prehospital providers are suggested.

A mechanism was initiated for conveying quality improvement (QI) results to paramedics as a means of improving chart documentation in difficult-to-correct areas. This study examines the impact of this QI feedback loop on charting, resuscitation rates from cardiac arrest, endotracheal intubation (ETI) success rates, and trauma scene times.

Paramedic trip sheets were reviewed before and after the institution of the QI feedback hop in this interrupted time series design.

The New Castle County, Delaware, Paramedic Program.

All New Castle County paramedics participated in the study.

In January 1990, the medical director began to circulate a QI summary among the paramedics in an effort to improve performance and chart documentation. The summary focused on the management of respiratory distress or arrest, cardiac arrest, and major trauma. The success rate for ETI was compared with the rate of field resuscitation from cardiac arrest, the percentage of unjustified prolonged trauma scene times (longer than 10 minutes), and the percent compliance with minimum endotracheal intubation documetation (ETID) requirements from a six-month period before institution of the QI feedback mechanism with data obtained from a six-month period after the program had been operational for one year.

Comparing results from before with after the initiation of the QI program, the ETI success rate was 273 of 295 (92.5%) before and 300 of 340 (88.2%) after (X2 = 3.04, p <.1, ns); field resuscitations totaled 26 of 187 (13.9%) before and 44 of 237 (18.6) after (X2 = 1.40, p <.25, ns); ETID rate was 249 of 295 (84.4%) before and 336 of 340 (98.8%) after (X2 = 44.24, p <.001), and unjustified prolonged trauma scene times were 69 of 278 (24.8%) before and seven of 501 (1.4%) after (X2 = 320.5, p <.001).

The use of QI feedback had little effect on psychomotor skills such as the ETI success rate or resuscitation rate, but had a dramatic effect on chart documentation, as evidenced by ETID rate, and behavior, as evidenced by the reduction in prolonged trauma scene times. The use of QI feedback is recommended as a means of correcting charting deficiencies or modifying behavior.

The siege of Sarajevo is a longterm, human-made, medical disaster of international significance. The delivery of emergency health care provided to the large civilian population held captive in that war zone for an extended time was studied.

In May 1993, a humanitarian and fact-finding visit to Sarajevo was conducted. Physicians, administrators, and public health officials were interviewed; epidemiological data were acquired—the resuscitation of war casualties at the two largest hospitals were observed; and local published reports and videotaped footage on the organization and delivery of prehospital and hospital care were reviewed. The videotapes also served to document war crimes.

Daily bombardment and sniper fire directed at civilians have caused a steady stream of casualties (64,130, or an average of 119 killed or injured per day in 18 months). Eighty percent of the victims were civilian. Despite hazardous conditions from direct shelling, disruption of vital lifelines, and shortage of supplies, medicines, oxygen, and anesthetics, the physicians continue to provide at least a minimum standard of resuscitative care. Seventy percent of all war victims were transported to hospitals in private vehicles. Most casualties (93%) received some form of prehospital, basic first-aid from lay bystanders or first responders. From November 1992 to February 1993, 27,733 patients were treated in hospitals, resulting in 2,139 major surgical procedures. The primary cause of death in 71 of 273 victims was prolonged hemorrhagic, hypovolemic shock. Sixty-one percent of these victims died within 24 hours of injury.

Continuous needs assessment be accompanied by rapid delivery of outside aid. International “peacekeeping” forces should protect hospitals and their staffs, and ensure the entry of supplies and evacuation of some patients. A public trained in life-supporting first-aid, and physicians and paramedics with experience in advanced life support may have enhanced lifesaving efforts in Sarajevo.

Recent studies have documented decreased time to emergency department (ED) thrombolytic therapy with the use of prehospital electrocardiography.

Is the time to ED diagnosis and treatment of acute myocardial infarction (AMI) patients with thrombolytic agents decreased by emergency medical services (EMS) transport when compared with those transported by other means (non-EMS)?

Retrospective, case-control study

The AMI patients treated with thrombolytic agents at a 34,000-visit, community hospital ED during 1992.

Review of records of patients who received thrombolytic therapy for AMI. Statistical analysis was performed using “Student's” t-test and Yates corrected Chi-square (X2).

Eighty-seven patients received thrombolytic agents for AMI during 1992; 33 arrived by ambulance, 54 arrived by other methods. There were no differences in age, gender, or time of ED arrival among these groups. Ambulance patients received standard advanced life support (ALS) care, but not a 12-lead electrocardiogram (ECG) or thrombolytic agents. Ambulance patients experienced a significantly shorter time to first ECG (12.9 ±9.1 min. versus 20.8 ±25.3 win.; p = .028) and received thrombolytic therapy sooner than did controls (56.0 ±31.5 min. versus 78.0 ±63.4 min.; p = .018). There was no difference in time from diagnosis to treatment between these groups.

Emergency medical services transport of AMI patients in this study decreased time to diagnosis and treatment and may be a confounder in studies that assess the value of field EMS interventions. Non-EMS AMI patients did not receive as rapid diagnosis and treatment, and emergency physicians should evaluate and address this issue in their departments.

This study attempted to determine the extent of training and emergency care knowledge of public school teachers in midwestern states. A secondary purpose was to assess the frequency of injury and illness in the school setting requiring the teacher to first respond.

A questionnaire and 14-item, scenario-based, emergency medical care test was developed and pretested. A discrimination index was used for validation of the instrument and a reliability coefficient of .82 was computed using the Kuder-Richardson Formula 20. A randomly recruited group of public school nurses from Arkansas, Kansas, and Missouri administered the instrument to 334 teachers who had no prior knowledge of the test. A random telephone survey of local school patrons also was completed to determine parental assumptions and expectations for emergency care and cardiopulmonary resuscitation (CPR) training in teachers.

One-third (112 teachers) had no specific training in first-aid and 40% never had been trained in CPR. However, most (87%) of the respondents strongly agreed that emergency care training should be required in teacher preparation programs. Eighteen percent of the teachers responded to more than 20 injured or ill students annually, and 17% reported that they had encountered at least one life-threatening emergency in a student during their career. The average score for all respondents on the emergency care test was 58% (X2 = 8.12±2.42). Those with prior first-aid training averaged 60.5% (X2 = 8.47±2.32). Significant deficiencies were noted for recognition and appropriate treatment of student emergencies involving basic life support (BLS) and airway interventions, diabetic emergencies, and treatment of profuse bleeding. Forty of the 50 (80%) parents surveyed assumed that all teachers were adequately trained in first-aid and CPR.

Public school teachers represent a potentially effective first-response component during disasters and isolated emergencies in the school environment. Overall, most of public school teachers in this study were deficient in both training and knowledge of emergency care and BLS modalities. Lack of effective, formal emergency care training in teacher preparation programs coupled with no continuing education requirement is a possible explanation of these results. Emergency medical services providers should seek opportunities to help with first-responder training and continuing education in their schools.