RCHC Community Project Abstracts

Back to subject search page or search by preceptor site Transfer of patients by ground ambulance vs. fixed wing aircraft from Coquille to Eugene: Evaluation of the Decision Process and Resolution of Policy among Team Members Project Date: 10/12/2009 Patients who present in, or who progress to, a state of critical condition outside the ability of the rural facility need to be transported to a larger facility with greater access to technology and personnel. For patients in Coos County, the most frequent transfer destination is Eugene. The options for transport are ground ambulance, rotor wing aircraft, or fixed wing aircraft. Each has their advantages and disadvantages, and each has a place in patient transfer depending on the circumstance. There is a disagreement among healthcare personnel over when to transport patients by air, and when to use ground ambulance. In short, the first question to be answered is this: Is fixed wing aircraft ever a reasonable option between these two locations? The second question is how can we bring about reconciling the two dissenting factions? As Cool as ICE: A Community Health Initiative Supporting the Use of "In Case of Emergency" Contact Numbers in Cell Phones Project Date: 10/12/2009 Programming an ICE number, or In Case of Emergency contact number, into a cell phone can help emergency workers gain important medical information or contact a family member in the event that a patient is found unconscious or unable to communicate such vital information. Many community members have heard of the worldwide ICE number initiative, yet relatively few have one programmed into their cell phones. Based on previous research investigating methods for increasing the use of ICE numbers among patients already in Emergency Department waiting rooms, this project uses a preventative approach based on the paradigm of inoculation in the primary care setting using the training of “ICE Ambassadors” in the clinic and community. ICE numbers were directly entered into the cell phones of more than 30 community members. Additionally, medical clinic staff and over 80 volunteers with the local fire department were trained how to increase ICE prevalence by explaining WHY the program is important, by knowing HOW to program an ICE number, and by directly HELPing someone else enter one. The student produced and distributed to community members a “business card” with directions for programming an ICE number on one side and the principles of being an ICE Ambassador on the other. Warm Springs Fire and Safety - EMS Funding and Training Challenges Project Date: 9/7/2009 Rural EMS agencies are under similar strains as every other aspect of health care. They struggle to recruit, train, and retain providers. The funding for these agencies, especially in a struggling economy, is at a bare minimum. Many of these agencies in the past have been able to provide continuing education and equipment upgrades with the help of grant funds. The Warm Springs Fire and Safety service is no exception. I tried to identify additional funding or resources that were not being utilized. After a local and regional search I was not able to find any financial sources that had not been evaluated, but I was able to offer some strategies to try to maximize the resources that are available. I also provided 5 hours of training to 2/3 of the staff at this department. Trauma Management at the Cottage Grove ED: Change in Process Project Date: 2/9/2009 Trauma preparedness in small community hospitals remains a Catch-22. On the one hand, these hospitals may not be designated formally as a trauma center – any organized emergency response units recognizing a serious trauma would bypass these hospitals and take the patient to a larger center. On the other hand, the community at large may at any moment arrive with serious trauma, unaware of the specific capabilities of their nearest hospital. Thus, these hospitals must be as prepared for trauma as possible despite often limited resources. Cottage Grove Community Hospital is one such hospital, located in a small town of 9,000 in Cottage Grove, OR. Last year a trauma event that was not handled optimally initiated a major revamping of the hospital’s trauma-preparedness on many levels. This project is aimed at outlining and understanding the process of change thus far, primarily via several discussions with the Emergency Department operations manager, Naomi Grace. Both the process of review of the event as well as the specific modifications made thus far were described in detail. Lastly, Ms. Grace indicated that her next step was to be a literature review of rural trauma. The final contribution of this project was the completion of a literature review and presentation of those findings to her. Planning for Obstetric Emergencies Project Date: 2/9/2009 Obstetric emergencies can be extremely tense situations especially when the health of a newborn infant or mother may be compromised. Planning for these particular emergencies can help provide efficiency and strategy in implementing the best care for the mother and the newborn. It was found at the Madras Medical Group and Mountain View Hospital in Madras, Oregon that that a basic plan for obstetric emergencies had not been established. For my community project, I helped establish an obstetric emergency medication kit that would be stocked and easily accessible in the OB unit for obstetric emergencies. Having a protocol in place and necessary medications in one easily accessible place can reduce the amount of stress and anxiety that often accompanies such obstetric emergencies. Profile of First Responder Program in Harney County Project Date: 2/9/2009 Harney County Emergency Medical Services face unique challenges in providing emergency care to the remote areas of the Oregon’s largest and least densely populated county. The implementation of an all-volunteer First Responder Program around the county permits trained citizens to arrive on the scene sooner than EMS crews and begin to provide care to the patient and information to the crew en route. A profile and critical review of the First Responder Program demonstrates the importance and inherent challenges of maintaining this program that plays an integral role in providing emergency services in rural and frontier regions. Play it be Ear: Designing a Program of Pediatric Anticipatory Guidance for the Prevention of ED and After Hours Clinic Visits for Ear Pain Project Date: 2/9/2009 Ear pain and parental concern for acute otitis media (AOM) drive a high proportion of acute care visits for children. For the past 5 years, otitis media has been consistently among the top three most frequent reasons for pediatric ED visits at Bay Area Hospital in Coos Bay, Oregon. The ED and the urgent care pediatric After Hours Clinic are vital components of the regional health infrastructure, though with limited resources that are often strained by misuse and overuse. Recent studies have demonstrated that such reduction in after-hours and emergency resource utilization for concerns of otitis media can be achieve through directed anticipatory guidance. Consequently, it became the goal of the project to develop standardized anticipatory guidance, to be provided to parents during the most appropriate well-child visit. A survey of charts in the After Hours Clinic was performed, as well as interviews with local pediatricians and emergency room physicians. Moreover, literature review was conducted to determine most current guidelines of establishing pediatric anticipatory education, as well as current approaches to diagnosis and treatment of ear infections. The final product of this project was a comprehensive brochure on the diagnosis and treatment of pediatric ear pain and possible ear infections, which parents and legal guardians of all pediatric patients undergoing 15 months well-child visits with one of the pediatricians in the North Bend Medical Center, Coos Bay, OR. Optimization of the After-Hours Clinic in Coos Bay, OR Project Date: 6/30/2008 High use of the emergency department (ED) among pediatric patients is a major medical issue in Coos County, Oregon. The Bay Area Pediatric & Adolescent After Hours Clinic (AHC) was implemented in 2006 to decrease the ED flow of pediatric patients for non-emergency health conditions. This study was designed to gain an understanding of how the AHC has impacted ED visits in Coos Bounty and to identify potential improvements to the AHC. To learn about the AHC and its effect on the local ED, interviews were conducted with the AHC sponsors and founders. To identify areas of improvement, physicians and patients participating in the AHC were surveyed. The final product of this project was the development of an AHC brochure depicting the essentials of the AHC more comprehensively than materials currently available. Insights gained through interviews and surveys were incorporated into the construction of an information sheet. The ultimate goal was to increase awareness of the AHC and to provide information about this valuable community resource. Emergency Contraception in Baker County: Compliance with Laws Governing Access and Dispensing Project Date: 4/28/2008 In August of 2006, the FDA approved the emergency contraceptive Plan B to e available over-the-counter in pharmacies nationwide. In 2007, during the Oregon Legislative Assembly passed House Bill 2700, which requires health insurance plans in Oregon to cover prescription contraceptives. It also requires emergency rooms to provide information about emergency contraceptives to all female victims of sexual assault, and to administer emergency contraceptives to these patients while they are in the emergency room if they so desire. Interviews with the county's five pharmacists revealed that four of the five pharmacies in Baker County carry Plan B and dispense it over-the-counter to those 18 and older, and with a prescription to those 17 and under. Conversations with Emergency Department staff at St. Elizabeth Health Services revealed compliance with the spirit of the law, as it applies to victims of sexual assault. Access to emergency contraception in Baker County is further improved by the efforts of the health department, where it is available for free. The final area investigated in this project was the state of the high school health curriculum, which competently addresses contraceptives, including Plan B, and teaches students how to access birth control. A letter detailing these findings was distributed to health department workers as well as 7 physicians and 4 nurse practitioners in Baker City. Non-urgent Use of Hospital Emergency Services in Grant County, Oregon: The Impact of Primary Care Physicians Fleeing Rural America Project Date: 2/11/2008 Primary care physicians' covering the Emergency Department is almost exclusively seen in rural health settings. While these physicians rarely encounter problems of overcrowding and prolonged patient wait times often seen in larger cities, several issues arise that are somewhat more unique to rural health. One such issue is the direct relationship between the diminishing number of general physicians practicing in rural areas and the resultant overflow of non-urgent patients into the ED. Regardless, it is these same community doctors providing treatment for these patients creating what may be considered a vicious circle. This magnitude of this issue was explored via a questionnaire directed toward patients visiting the rural Blue Mountain Hospital Emergency Department in John Day, Oregon during a three-week period between February 2008 and March 2008. The results of this study showed that nearly 45% of all patients presenting to the ED during this time had initially attempted to address their health care needs in the primary care setting. These patients also encounter 30% higher costs for health care than their counterparts receiving care via their regular physician. Emergency Preparedness of Non-hospital Medical Offices in Astoria, OR Project Date: 12/31/2007 The problem studied is emergency preparedness of non-hospital medical offices in Astoria, OR. The population in question includes all the residents of Astoria. The methods used include in person interviews of physicians and office managers. The findings are that there were few offices that were prepared for a recent local disaster. This has however, brought to light the importance of a disaster plan for non-hospital facilities. The final product of this project is a plan of action for the education and collaborative disaster planning by local physicians' offices and the emergency preparedness/safety coordinator of Columbia Memorial Hospital. Efficacy of Emergency Medical Systems for transport of patients to Portland hospitals and appropriateness of prehospital treatments at the OHSU family medicine clinic in Scappoose Project Date: 10/15/2007 Columbia County has a population of 46,220, 5 family practitioners, 8 general internists, 14 nurse practitioners, 5 physician assistants and no hospitals. OHSU's family medicine clinic in Scappoose and Legacy's urgent care center in St. Helens, provide the lion share of the health care in the area. However both clinics have limited resources and capabilities in providing emergency care. Patients are often transferred either by Emergency Medical Services (EMS) or private cars, 20 miles away, to hospitals in Portland metro area. The transport on average takes about 30 minutes, time that could be crucial in determining the patient outcome. It is thus important to provide all the appropriate tests and treatments to the patients, especially those with suspected myocardial infarctions, prior to the lengthy transport in order to limit the degree of damage and negative outcomes. Utilization of the Emergency Medical Systems for Transfer of Patients to Portland Hospitals at the OHSU Family Medicine Clinic in Scappoose. Project Date: 9/10/2007 Rural health clinics serve a vital role in providing health care to areas where there are often few options; providers in these areas must often perform a greater variety of procedures with fewer resources than might be desirable. However, there are occasions when a patient must be transported to a hospital where additional resources required for his/her care are available. Scappoose, Oregon is located roughly 20 miles north of the nearest hospitals which are found in Portland. The Emergency Medical Systems and Fire Department of Scappoose are responsible for providing emergency response for a 100 square mile area as well as transferring patients from the OHSU family medicine clinic to Portland hospitals whenever the need arises. The Scappoose EMS consists of three ambulances, three career firemen, and any available volunteers. To better evaluate the utilization of the EMS for patient transfer of the Scappoose Family Medicine clinic, a thorough form for recording that data into a centralized record has been created. Pattern of Emergency Department Use at Mountain View Hospital in Madras, Oregon Project Date: 9/10/2007 The emergency department use in the United States has reached an unprecedented level. The overcrowding and runaway costs that have resulted are an impetus to investigate ways to redirect nonemergent patrons from the emergency department to the primary care clinic. Despite the common opinion that patients who do not have a primary care physician or health insurance account for the majority of misuse, this is not well supported by published evidence. In single urban center research studies and a nationwide survey have found instead that lack of a regular primary care physician or insurance do not correlate with decrease emergency department use. Studies of single urban centers in particular may not be representative of rural healthcare entities. The issue of ED misuse has not been addressed in the specific setting of a rural ED. In this community-oriented primary care project, it was hypothesized that discernible groups among a small community may disproportionately use the emergency department for nonemergent care and thus provide a suitable target for interventions to decrease this misuse. To this end, emergency department visitors with various local primary care providers were documented for a one-week period and categorized as emergent or nonemergent. Although the numbers in the study were low, they suggest that patients from certain primary care clinics do have disproportionately high levels of emergency department use for nonemergencies. Reasons for this may include deficient patient education measures at these clinics and low weekly business hours. The Impact of the recreational tourist on the Hood River ED Project Date: 8/6/2007 Hood River Oregon is situated in the heart of the Columbia River Gorge. It is surrounded by tall mountainous volcanoes, rivers, the mighty and windy Columbia, and miles of orchards and forested trails. Due to this setting, Hood River attracts sports enthusiasts from around the globe. Visitors come from Europe, Southeast Asia, Australia, South America, and nearby United States towns to enjoy this playground. While Hood River is only sixty miles from Portland Oregon, it is still considered a “critical Access area” in terms of medical care. The main hospital is owned and run by the Providence Medical system. The hospital only has twenty four inpatient beds including the ICU, and an eight bed emergency department. This area is facing a great deal of financial and medical difficulty as the closest medical neighbor in the Dalles, faces potential closure. Hood River has a population of five thousand. This number fluctuates seasonally with the summer winds and winter snow. Overall, the full time residents remain near a population of five thousand. This project was intended to investigate a small piece of this access problem. What is the impact of the visiting “recreational tourists” on a small town emergency department? Snow Safety: Preventing the most common types of injury at Mt. Ashland Project Date: 8/6/2007 Mt. Ashland is a small ski resort in Southern Oregon. Despite it's small size Mt. Ashland boasts it's share of difficult runs with approximately 50% of the runs receiving an "advanced" rating. It is primarily a "local" mountain with over 90% of user visits coming from the surrounding area. All of these factors combine to create a scenario where injuries are likely to occur, but where there is a concentrated, local population that is likely to benefit from education on injury prevention strategies. For my rural project, I contacted the ski patrol and administration of Mt. Ashland ski area. We discussed the most common causes of injury at Mt. Ashland, which correlated well with causes of injury nationwide. These causes of injury included knee injuries, head injuries, shoulder injuries and thumb injuries in skiers and ankle injuries, wrist injuries, head injuries and shoulder injuries in snowboarders. I then researched prevention strategies for avoiding these types of injuries and produced an informative poster. I then submitted the poster to the Mt. Ashland administration in order that they might use it to inform the public in hopes of reducing the number and severity of injuries at Mt. Ashland. Cardiac Arrest: Changing Resuscitation Guidelines to Increase Participation, Improve Survival Rates and Extend Community Resources Project Date: 8/6/2007 Each year, several hundred thousand Americans die as a result of cardiac arrest despite several decades' worth of training in cardiopulmonary resuscitation. Widespread confusion about when and how to implement resuscitation protocols, distaste for certain aspects of the procedure, and declining confidence in its potential for success contribute to a lack of bystander participation and resultant strain on local emergency resources. A handout has been prepared to reflect current research on the subject and provide an opportunity for further discussion. Small steps such as this may help to reintroduce the topic of cardiac resuscitation to the lay public, particularly if new guidelines are easier to understand and implement. Traumatic Brain Injury in Harney County Etiologies and Incidence of Emergency Department Visits, Hospitalizations and Deaths Project Date: 7/2/2007 With a population of 7,660 people spread over 26,486km2, Harney County is the most sparsely populated county in the contiguous US and has a low enough population density to qualify it as a “frontier territory”. Given the abundance of uninhabited land, ranching, hunting, off-roading and other outdoor activities are an integral part of the Harney County culture. These pursuits however provide additional potential risk factors for head injuries and thus might predispose the population of Harney County to increased rates of traumatic brain injuries. The purpose of this study is to assess the impact of Harney County’s frontier-county lifestyles on the rates, etiologies, and outcomes of traumatic brain injuries in Harney County. An examination of national, state, and county data on TBI incidence, etiology, and outcome was performed for comparison. National and state data were obtained from online databases while Harney County information was obtained from Harney District Hospital records department. Analysis of primary data found that there is an increase in the incidence and overall proportion of traumatic brain injury from direct livestock-induced injury, secondary injury from MVA-livestock collisions, and off-road related ATV rollovers compared to other etiologies except falls. The overall incidence of TBI’s in Harney County was found to be slightly higher than that of the national or state incidence rate By identifying common causes of head trauma in Harney County, local providers can identify higher risk communities and at-risk individuals and can thus emphasize patient-specific strategies for prevention of future head trauma. Does the presence of a After Hours Pediatric Clinic Reduce the number of Pediatric Emergency Room visits in a Rural Oregon Community Project Date: 4/30/2007 Increasing health care costs continue to be a major problem for the Oregon Health Plan (OHP). OHP continues to find ways to lower costs in order to provide more health care coverage to more people. The objective of this student was to evaluate the efficacy of an After Hours pediatric clinic (AHPC) in decreasing the number of pediatric emergency department visits, particularly in pediatric patients with OHP insurance. In an effort to decrease the number of ED visits OHP agreed to help subsidize the AHPC with a fixed rate per day, with the goal of decreasing the number of ED visits, by OHP patients, by an average of 4 visits per day. Two Coos County pediatric practices, consisting of 9 pediatricians, collaborated to start an After Hour pediatric clinic. The clinic was to be open from 5-8 pm on weekdays, and 8-noon on Saturdays, with the goal of decreasing pediatric emergency department visits. Barriers to Accessing Dental Care and Use of Medical System for Oral Health Problems by Low-income Residents in Jefferson County, Oregon. Project Date: 4/30/2007 Despite the preventable nature of most oral disease, Oregonians have high rates of caries and periodontal disease. Low-income populations are disproportionately affected by dental problems and may be influenced by lack of access to dental care. Barriers to accessing dental care and use of emergency department (ED) services for dental needs were studied using interviews and ICD9 code analysis for a local hospital in rural Oregon. Barriers to accessing dental care include transportation and appointment availability for Oregon Health Plan (OHP) patients and cost and appointment availability for underinsured or uninsured low-income patients. Dental appointments and free preventive services are available for Native American patients suggesting other barriers to good oral health. Uninsured patients and Medicaid patients followed by Native American patients represented the largest percentage of patients seen in the ED for dental problems. Preventive resources and education about oral health in the community are limited. These results indicated that lack of access is only one barrier to poor oral health. Increasing preventive services, educational resources and community awareness about oral health may be more beneficial in improving oral health outcomes. Traumatic injury in off-road vehicle use in rural Oregon Project Date: 4/30/2007 BACKGROUND: Rural MVA mortality is twice that of urban mortality. Pediatric ATV injuries are increasing, and new legislation is being presently debated. The study evaluated the risk of ATV injury in pediatric versus adult populations in the Blue Mountain Hospital service area over 33 months. METHODS: Emergency visits at BMH, selected by E-code E810-825. Outcomes were incidence and odds ratios. RESULTS: ATV’s accounted for 23.9% of the MVA patients. 9.4% of non-ATV injured patients and 22. 4% of ATV injured patients were pediatric. Risk factors for ATV injury include age < 16 (OR 2.85, p = 0.008), male gender (OR 3.18, p = 0.001), and white race (OR 3.408, p = 0.039). Risk of head or neck injury higher in ATV use (OR 2.637, p = 0.004). CONCLUSION: Age restriction as well as requirement of helmets, both currently proposed in the legislature, may decrease the burden of ATV-related injury on the rural pediatric population. Cattle Related Injuries in the Treasure Valley Project Date: 4/30/2007 The beef cattle industry is a $71 billion per year industry providing 28.0 billion pounds of beef to the U.S. public (USDA background statistics 2006). The beef cattle industry is also an important part of the economy of Ontario, Oregon. However, this industry is also subject to a wide variety of hazards and is considered one of the most dangerous industries in the United States and in the State of Oregon. This study attempts to identify the most common causes of agricultural injury by searching national databases, performing a local study and participating in local ranching activities. According to the national database, the most common fatal accidents were caused by tractor and machinery. The most common non-fatal accidents were related to livestock. These accidents were most commonly crush injuries followed by falls. In the local survey, there was a difference between the most common injury reported health professionals and local ranchers. This is likely due to differences in the rancher’s threshold for seeking medical attention based on the type of injury. Access to Care and the Impact on Emergency Department Utilization in Madras, Oregon Project Date: 3/19/2007 Access to health care is an important issue nationwide and is particularly salient in Oregon right now with multiple health care reform measures headed for the legislature. Utilization of emergency services can be used as a proxy to measure access to primary care. Key informant interviews were administered in tape-recorded sessions with health care providers and administrators in a rural Oregon community. The key informants were providers and administrators from Mt. View Hospital (MVH) in Madras, Oregon and from the four clinics that serve MVH. The interview sought to explore primary care providers' perceptions and experience with access to care issues in their communities, including questions about what affects access, trends in access and utilization, perceived needs to improve access and delivery of care, Emergency Department use, and strengths and challenges of primary care. Interviewees indicated that access to care is affected by health insurance, cultural and educational barriers, and common (misperceptions. Trends include a changing population that brings changing health care demands and narrowing financial margin. ED is thought to be overused for non-urgent/non-emergent care, in particular by those who feel no financial consequence. In the opinions of providers as well as administrators, access needs to be improved by legislation that changes the structure of health care programs. Utilization of the ER in Madras: Implications for health care availability and health care costs. Project Date: 9/11/2006 Between 1992 and 1999, the amount of ER utilization increased by 14% from 89.8 million to 102.8 million visits annually. This increase continues. US health care spending has also increased steadily, with rates of increase now in the double digits. Over-utilization of the ER has translated to increased health care spending, as well as inadequate long-term care for the patient. By analyzing the characteristics of patients admitted to Mountain View Hospital ER in Madras, we may gain some insights into the determining factors involved in patients' decisions to go to the ER instead of a primary care clinic. Madras is a rural community in central Oregon with unique health care issues related to its need for greater clinic accessibility, its shortage of primary care providers in the face of a growing population, and its housing of a larger subset of uninsured patients than Oregon as a whole. Mis-utilization of Mountain View Hospital's ER is a problem and solutions are discussed. Does Increased Field Burning Affect the Trends of Emergency Room Visits for Respiratory Symptoms at Santiam Memorial Hospital? Project Date: 8/7/2006 This rural health research project sought to determine if peak grass seed burning within Stayton Fire District boundaries affected the number of Emergency Room visits to the Santiam Memorial Hospital for respiratory symptoms. This study considered primary and secondary respiratory diagnoses on ER admissions reports during the peak burning periods in August of 2005 and 2006. Considered diagnoses included acute and chronic forms of bronchitis, sinusitis, rhinitis, asthma, emphysema, pneumonia, conjunctivitis and upper respiratory infections (8 categories). The number of ER admissions for respiratory symptoms was compared with the acreage of field burning in the Stayton Fire District over 21 to 24 day periods with the 7 or 8 days of heaviest burning acreage wedged between two equal length periods of significantly lighter burning. While a positive trend of increased respiratory symptoms was present in 2006, in 2005 the trend was negative. Due to a limited sample size and several probable confounding factors, there was not much statistical significance to this study but perhaps a framework has been established for further inquiry. A 5-year retrospective analysis of all-terrain vehicle (ATV) injuries in children presenting to the Emergency Room in Reedsport, OR Project Date: 8/7/2006 Reedsport, Oregon is located three miles from the Oregon Dunes National Recreational Area which attracts all-terrain vehicle (ATV) riders from all over the country. The frequency of ATV trauma is increasing nationally and this retrospective review of ATV-related injuries presenting to the local ER over the past 5-year period revealed that ATV trauma is a significant problem in Reedsport, OR. Children under 16 account for 16% of the overall morbidity and appeared to be more vulnerable to head/neck injuries when compared with adults, despite demonstrating good helmet usage upon subsequent analysis. However, children were less likely to be hospitalized or transferred to another hospital than adults, which may indicate that their injuries were not as severe. Tandem riding (i.e., riding as a passenger) was a risk factor for ATV-related injury in children, which is consistent with the literature on pediatric ATV-related injury, and therefore provides a potential target for legislative intervention. Streamlining and Clarification of Alcohol Withdrawal Standing Orders at Harney District Hospital Project Date: 7/3/2006 Harney District Hospital (HDH) administration and medical staff were interested in providing better care for their patients experiencing alcohol withdrawal by revising their current alcohol withdrawal orders and educating their staff. In the recent past they had some increased morbidity from unrecognized alcohol withdrawal that the staff and administration found unacceptable. A comparison of alcohol withdrawal orders from HDH and a larger Portland-area trauma one emergency department revealed some improvements that could be made to help minimize confusion and aid in earlier recognition of alcohol withdrawal syndrome (AWS). Some improvements were addressed in a revision of the current orders that is under submission for the next medical staff meeting at HDH. As a second area of improvement, an in-service was given for HDH nursing staff on alcohol withdrawal syndrome and the proposed revision of the alcohol withdrawal orders. The in-service consisted of a a 30-45 minute PowerPoint presentation about AWS and the proposed revisions of the alcohol withdrawal orders. The nursing staff was informally polled at the in-service about their concerns with the revised orders with an eye toward further clarification of the protocol. This approach was well received by both physicians and support staff at the hospital. Adolescent Injury in Reedsport, Oregon Project Date: 3/20/2006 Unintentional injury remains the leading cause of adolescent and young adult morbidity and mortality in the U.S. The leading causes of non-fatal injury for 13-24 year-olds are: being struck by or against an object, falls, motor vehicle accidents, overexertion and cuts or piercing. Reedsport, Oregon, a town of 7,900 located on the central coast has an aging population in which adolescents comprise 11% of its population. A recent unintentional motor-vehicle-related fatality of a teenager and injury of another in this small town has raised awareness on the lack of data for the incidence of adolescent injury in the community, including what types of injuries are occurring and what are the associated variables. A medical records search for Reedsport adolescents aged 13-24, who were seen and treated in the ER of the Lower Umpqua Hospital during calendar year 2005 for injuries or trauma was completed. A total of 100 charts were reviewed and descriptive statistics on injuries compiled. Reedsport adolescent injury patterns appear comparable to national statistics, although there is a lower incidence of motor-vehicle related accidents among Reedsport adolescents seen at this ER. The value of implementing a systematic adolescent preventive services program and a specific model for doing so are also discussed. Emergency Room Utilization in Harney County Project Date: 2/13/2006 Proper utilization of emergency departments in rural communities is important due to the shortage of local doctors and lack of a full-time emergency medicine (EM) physician. When the same physician is caring for patients in clinic while on-call in the emergency department (ED), it is important that patients be using the emergency room (ER) for urgent, acute issues. I chose to investigate the patterns of emergency medicine use in Harney County, population 7000, over a 2-month interval. I looked at principal diagnosis and whether the patient was admitted to the hospital, put on a 23-hour observation, transferred to another hospital, or discharged directly from the ED. I designed graphs looking at top 10 diagnoses, common system-based diagnoses and outcome in terms of discharge. I discovered that the majority of patients in Harney County are utilizing the emergency room for urgent or acute issues. Principal diagnoses appear to be typical of any emergency department. Lastly, I identified some of the common diagnoses that probably did not warrant an ER visit and what we can do in the future to help decrease the volume and costs in the ED. Chronic Pain Group Classes in Scappoose: Value of the Program, Barriers to Participation, and Advice from Oregon’s Pain Management Leaders Project Date: 1/2/2006 Chronic pain management continues to be a challenging issue for patients and physicians. Multidisciplinary chronic pain management groups have become an important part of pain management for many patients in Oregon. A group of this nature was recently attempted in a Scappoose, Oregon family medicine clinic. The main obstacle to success was poor attendance. This study attempted to identify barriers to attendance and investigate solutions used by experts who have faced and overcome this obstacle within their own programs. The design was interviews with patients of the Scappoose family practice clinic as well as interviews with pain management leaders. Outcomes data was collected, where possible, to assess the potential value of continuing a multidisciplinary chronic pain management group at the clinic. RESUSCITATION STATUS IN A RURAL HOSPICE Predictors of status & ease of identifying patient preferences in emergent situations Project Date: 9/12/2005 Hospice is a growing resource in American health care that is being increasingly utilized by greater proportions of the population. In order to receive full hospice benefits, a terminal diagnosis with less than six months of expected life is required. Yet, a DNR status is not mandatory for patients who accept hospice benefits. This study attempted to identify patient characteristics that may make a hospice client more or less likely to choose a specific resuscitation status. Methodology included a chart review of 237 patients of Heart n’ Home Hospice and Palliative Care, in Fruitland, Idaho. This hospice first opened in April, 2004. The files surveyed represent all clients of this business thus far. Specific patient characteristics including resuscitation status, age, sex, hospice diagnosis and religious preference were analyzed. Additionally, impromptu hospice employee interviews provided further data concerning project limitations as well as helped to identify an area of need for which this project could serve a purpose. Though unintended during original inception, this project prompted standardization of resuscitation status within the hospice files. Therefore, the final outcome of this project is a standardized system for which emergency inquiries into a particular patient’s resuscitation status could be quickly answered. Skateboarding Safety: A project in Warms Springs, Oregon Project Date: 8/8/2005 Skateboarding has become a fast growing trend in the United States. It is projected that by the end of 2005 there will be 15 million participants in this sport7. Unfortunately, accompanying this increasing popularity is an increasing numbers of injuries. In 2002, a study done by the Consumer Product and Safety Commission demonstrated that skateboarding had the highest injury rate compared to other wheeled sports including bicycling, in-line skating and scooters7. According to American Academy of Orthopedic Surgeons, each year in the US skateboarding injuries cause about 50,000 visits to emergency departments. In addition, more than 1500 children need to be hospitalized for head injuries or disabilities that frequently result in loss of vision, hearing or speech, as well as changes in thinking and behavior. Furthermore, in most fatal cases the rider was not wearing a helmet3. The community of Warm Springs, located on the Warm Springs reservation in central Oregon, has a population of nearly 4000. Approximately one year ago, the community built a skate park for their youth; it is unknown exactly how many injuries have occurred at this park since its construction, but according to health care provider reports it is estimated to be significant. This study was designed to determine the underlying rationale of the children of the Warm Springs community for not wearing protective equipment, including helmets and pads, while skateboarding. A survey was developed to assess the motives of the children under the ages of 18 utilizing the skate park. In addition, an informative brochure was developed with educational activities as well as information for parents on the importance of wearing helmets while doing all wheeled sports. Twenty-one children were surveyed. The answers from the children paralleled responses from children across the nation. The most frequent response regarding not wearing a helmet was “I don’t get hurt and so I don’t need to”. Other popular answers included “I don’t know”, “It’s uncomfortable” and “I don’t like the way it looks”. Four children said they would wear them if it were required while others said they still would not. Eight children owned helmets. In addition, it was observed that many other wheeled vehicles were being used at the skate park including bicycles and scooters, again without helmets or other safety equipment. The information collected in this study will be used for further educational opportunities for the children as well as possible legislation. A Quality Improvement Evaluation of Initial and Final ER Radiology Readings at Lower Umpqua Hospital Project Date: 7/4/2005 Reedsport, a town of 4,400 residents, is situated on Highway 101 in the midst of the Oregon Dunes National Recreation Area on the central Oregon coast. The timber and fishing industries traditionally had been the major industries in the area, but in recent years natural resource extraction has declined. Reedsport has more recently become more of a retirement community, as well as a destination for out-of-town visitors who come for the wide range of outdoor activities available. Dune Fest, held in the nearby community of Winchester Bay each summer, draws thousands of people to the area for ATV races and associated events. Because there are so many visitors to the Reedsport area, many of the people presenting in the ER of Lower Umpqua Hospital are not from Reedsport or nearby towns, but are instead people who have come to ride ATVs on the dunes. This project was undertaken because many of the individuals inolved in the process of taking and reading ER radiographs did not have a good understanding of how the sytem worked, especially how discrepancies are handled. Skateboarding Safety in the Community of Reedsport, Oregon Project Date: 3/21/2005 In 1996 it was estimated that approximately 5.8 million kids between the ages of five to eighteen years old participated in skateboarding. Of those 5.8 million, an estimated 750,000 skateboarded on a weekly basis (1). It is likely that this estimate will increase as the popularity of skateboarding surges. Paralleling the revival of skateboarding, there has been an increase in skateboard-related injuries. Most recently, the number of injured individuals younger than 20 years has increased from an estimated 24,000 in 1994 to approximately 51,000 in 1999 (1). Numerous studies have concluded that skateboarding-related injuries are more severe and have more serious consequences than those injured while roller skating or in-line skating (3). Reedsport has recently opened a skateboard park for its youth. The goal of my community project was threefold: 1. Assess how the skateboarding youth of Reedsport compare with national statistics regarding injury frequency and patterns. 2. Determine what methods to prevent injury were utilized among kids. 3. Promote helmet safety. Survey of Lower Umpqua Hospital’s emergency department records demonstrated that over 19 months a total of 345 encounters were recorded for trauma, ATV, and skateboarding accidents. Of the 345, 26 (8%) were related to skateboarding. The age range for skateboarding injuries was 8 – 29 years with an average of 16.6 years. 93% (23/26) were male. Skateboarding injuries were categorized by area injured including head, thorax, and extremities. 65% (17/26) of skateboard injuries were to extremities. Of extremity injuries 71% (12/17) were fractures. Alternatively stated, 46% of the 26 skateboarding injuries were fractures. Head injuries comprised 23% (6/26) of skateboard related injuries with one of these injuries also qualifying as a trauma secondary to a closed head injury. Injuries to the thorax comprised 12% (3.26) of the skateboard injuries. Multiple casual observations (> 10 occasions) of kids using the skate park revealed that most kids are not using a helmet when skateboarding, particularly older teenagers. In addition, on no occasion was a supervising adult present. To promote helmet safety and awareness I designed a locally based helmet safety pamphlet featuring many of the local skateboarders. The pamphlet was distributed to local skate shops (Pandemonium, Waxer’s), the elementary and junior/senior high schools, the local emergency department and the Dunes Family Health Care clinic. A summary of the pamphlet was also sent home to all the parents of children attending the junior/senior high school. I also collaborated with the outdoor editor of the local newspaper “The World” and wrote an article focusing on helmet safety and awareness. Lastly, I solicited sponsorship from five companies (The Tony Hawk foundation, Bell, Viking helmets, Wal-Mart, The Oprah Winfrey show) for 20 skateboard helmets. Waxer’s donated 3 helmets with elbow and knee pads. The rest of the sponsorship requests are pending at this time. If in the future more helmets are donated then I will return to Reedsport and work with the local fire department to distribute the helmets to kids in need on during the town’s annual “Skate Jam.” Prevention of Traumatic Pediatric Falls in Grant County Oregon Project Date: 3/21/2005 Trauma is the number one cause of mortality and morbidity in children ages 0- 14 years old. This study compares national and Grant County trends in fatal and nonfatal trauma focusing on unintentional fall injury in a rural community in eastern OR. Although MVA represent the number one cause of mortality among pediatric populations, accidental falls and fall related injury provide the number one source of morbidity and hospitalization among children aged 0-14. We sought to examine the trends of pediatric fall related injury in a rural community in order to focus efforts at prevention of morbidity amongst this vulnerable population. Systematic review of all emergency room visits among patients aged 0-14 between 1/1/1999-12/31/2004 at Blue Mountain Hospital in John Day Oregon were evaluated. Injury trends were determined by examining data included presenting complaint, primary diagnosis (ICD-9), and injury mechanism (E-code). Results: Mechanism of injury leading to ER visits in peds 0-14YO: FALLS 310 (31%), BLUNT TRAUMA 123 (12%), SHARP OBJ 101 (10%), MVA 78 (7.8%), REC VEH (3%), BIKES 62 (6.2%) HORSE REL INJ (1.7%) SPORTS 55 (5.5%) Mechanism of falls: GROUND LEVEL/NOS 102 (35%), PLAYGROUND EQUIP 31 (10%), FURNITURE/BED 30 (9.7%), ON OTHER OBJ/NOS 28 (9.1%) SPORTS 12 (3.9%) STAIRS 12 (3.5%) Types of injuries secondary to falls:OPEN WOUND OF HEAD, NECK, AND TRUNK 76 (22.7%), CONTUSION WITH INTACT SKIN SURFACE 71 (21.2%) FX OF UPPER LIMB 61 (18.2%), SPRAINS/STRAINS OF JOINTS 58 (17.3%) Falls represent a significant source of traumatic injury in the rural pediatric population of John Day, OR and surrounding communities. Prevention measures are a major public health concern and prevention efforts in Grant County should be focused at prevention of accidental falls at home (furniture/bed falls) and school (playground equip). A brochure on child safety and prevention was developed with the concerns of this rural community to be distributed at the emergency room to parents of children aged 0-14 years old. Urgent Care Center in Lebanon – another example of serving the needs of the community Project Date: 2/7/2005 Developing a healthcare systems centered around the needs of a community has been an evolving and ever developing process spanning the past two decades in the small community of Lebanon, Oregon. Earliest efforts consolidated a group of primary care physicians – Family Practice physicians and Internists – employed under the umbrella of Samaritan Health Services. These efforts were directed toward providing primary health care focused on community need. By placing primary care office visits under the larger Samaritan Health Systems organizational umbrella, primary care physicians could better spread the responsibility of caring for all in the community -- those with insurance, those without insurance, as well as recipients of Medicare, Medicaid, and Oregon Health Plan. In 2000 when outside independent Urgent Care organizations were seriously looking at Lebanon as a new location of a “doc in a box” center, Samaritan Health Services rallied again in their “community needs” approach. From these efforts were born the remodeling efforts of the Samaritan Lebanon Emergency Room, designed to provide adjoining Urgent Care / Emergency Room services at the local Lebanon hospital. Since its opening in 2001, the Samaritan Lebanon Urgent Care has been well received by the community as well as area PCP’s, and has become a successful and profitable addition to the Samaritan Network of HealthCare Services. Providing adjunct services to those provided by a patient’s PCP, acute health care issues can be handled in the same day, without an appointment, at a cost equal to or within 5% of a standard PCP office visit. Minor acute illness and injuries can be funneled to the urgent care center for treatment. There, patient care does not incur the high costs of Emergency Room handling, and ER volume strain is reduced. The Samaritan Lebanon Urgent Care center is open 7 days a week, handles between 50 to 75 patient cases daily, and provides acute healthcare to patients with private insurance, Oregon Health Plan, Medicare, Medicaid, as well as self paying patients. Emergency Medical Services in Malheur County Project Date: 1/3/2005 During my rural health rotation in Ontario, Oregon, I completed a community project about the local EMS system. I gathered information by speaking with members of the EMS service including the Fire Chief of the Ontario Fire Dept., Paramedics working for Treasure Valley Paramedics, and the Medical Director of the EMS service. I also observed first hand how the system operates while riding along with the Treasure Valley Paramedics. I focused my study on how the EMS service is structured and what challenges it faces providing for the medical needs of citizens in a rural area. The main challenges that I identified are the need to cover a large, sparsely populated area, scarce resources including money, equipment, and trained personnel, and the fact that the system has a low capacity that can easily become overwhelmed. Assessment and Treatment of Acute Psychiatric Disturbances in Madras, Oregon Project Date: 1/3/2005 A review of medical records in the Madras Mountain View Hospital over the past year reveals that physicians in Madras, Oregon are not managing psychiatric emergencies up to the standards that they are capable of meeting. For instance, physicians in the Madras Medical Group are placing acutely psychotic patients in restraints or seclusion 61% of the time. This is significantly more than the 20% of time that experts find these measures appropriate. This difference is not likely a reflection of a threefold increased number of psychiatric patients in Madras compared to the rest of the country. Rather, it more likely reflects the fact that the psychiatrically ill population of Madras is not being appropriately cared for in emergent settings. In fact, experts would consider 60% of “holds” in Madras inappropriate. Fifty percent of patients placed in the Madras holding room did not even have a physician-documented psychiatric evaluation in their chart. The primary reasons for these problems are the limitations of a rural setting, increased level of complexity involved in emergent behavioral care, and rural physician discomfort with their acting role as psychiatrist. Madras does not have even a single community psychiatrist. These factors indicate that the Madras Medical Group would benefit from a review of appropriate delivery of acute psychiatric care. Specifically, an approach that better balances the rights of patients with considerations of safety and good standard of care is presented here and contrasted with the current level of care in Madras. Recommendations for improved assessment, charting, and intervention are offered. Furthermore, an outline of appropriate pharmacological treatments is provided. How Oregon Health Plan Cutbacks Have Affected Rural Oregon: Trends in Emergency Department Use at Blue Mountain Hospital, John Day, Oregon Project Date: 1/3/2005 In early 2003, Oregon’s Medicaid program underwent a number of revisions in order to comply with new budgetary limitations that were a result of the state’s fiscal crisis. Among the changes were reduced benefits and increased cost sharing via premiums and co-payments. Rural communities in Oregon face a unique set of healthcare challenges, to which these Oregon Health Plan cutbacks were added. The purpose of this study was to compare emergency department use at Blue Mountain Hospital in John Day, Oregon, in the months preceding and following the cutbacks. Total ED visits and payer type data were gathered using the hospital’s computerized billing system. The results were analyzed at 95% confidence intervals for both percent changes in absolute number of visits per month and proportion of ED visits due to each group; T-values and relative risk were calculated where appropriate. OHP managed care visits decreased 24%, and the proportion of all ED visits for which they were responsible fell from 13% to 9% (RR 0.904), whereas OHP fee-for-service visits increased 95% per month, their proportion rising from 2% to 4% (RR 1.79). Uninsured visits rose a statistically insignificant 6% and their proportion of total ED visits was practically unchanged. Following the cutbacks, the percentage of Grant County citizens eligible for OHP who were enrolled dropped from a monthly average of 86% to 72%. In addition to the sudden drop in OHP enrollment and resultant decreased use of the ED by OHP managed care beneficiaries, new barriers to healthcare may have caused the significant rise in ED visits by OHP fee-for-service patients. Although the number and proportion of visits by the uninsured was unchanged, deteriorating health and continued lack of state support will force this growing group to turn to emergency departments for care. Financial Burden on Lower Umpqua Hospital (LUH) Due to Traumatic ATV Accidents of Uninsured Patients’ During 2004 Project Date: 1/3/2005 Reedsport, Oregon is located within the Oregon Dunes National Recreation (ODNR) area, a vast landscape of sand dunes that is used, among other activities, for riding all-terrain vehicles (ATV). Riding is open all year long, but there is a four-day event at the end of July known as DunesFest during which riders come from all over the nation to race their ATV’s and party. Alcohol is not strictly regulated on the dunes and, this, combined with periods of heavy ATV traffic, results in a significant number of trauma accidents throughout the year. Given that ATV riding is an expensive sport, nearly all riders could afford insurance. However, many of those that are injured are either inadequately insured or, more likely, do not have health insurance. This puts a great financial burden on LUH, as one of its very important functions within the community is acting as a “safety net” hospital, treating many uninsured patients’ for unforeseen illness and acute injury. The added impact of expensive ATV traumas that go unpaid compromises the ability of the hospital to act as a safety net. This research showed that uninsured ATV traumas were costly to the hospital during 2004 and that during the month of July the amount unpaid was a significant percentage of the total billed. Additionally, it was shown that July, August and September were particularly hard hit by uninsured ATV trauma and that most of the patients were either from out of town or from a different state. Finally, the results were used to formulate a plan to contact a state legislator to discuss the feasability of mandating accident insurance for all ATV riders riding within the ODNR area. Forming an Emergency Operations Plan for Josephine County Project Date: 8/9/2004 The Josephine County Public Health Department, in conjunction with local physicians, emergency services personnel, infectious disease experts, and other interested parties, are currently working on an Emergency Response Plan in the event of natural disaster or acts of bioterrorism. This is in conjuction with Health Resources and Services Administration funding for Josephine and jackson Counties to create a Hospital and Healthcare System Bioterrorism Preparedness Program. This plan seeks to designate how resources in Josephine County will be used in the case of natural disaster such as fire, earthquake, or emerging infectious disease, or intentionally caused disasters such as Smallpox, chemical releases, or intentionally food-bourne illness. The geographical layout of Josephine County brings specific challenges to developing a plan for use of alternative care sites, Stategic National Stockpils resources, medical personnel, and transporation during an emergency that must be planned-out in advance to best coordinate the services necessary. Joesphine County has the unfortunate advantage of having a recent natural disaster, the Biscuit Fire of 2002, which has helped motivate Josephine County to work together on this plan, and has provided insight to its necessity. This project describes Josephine County and the Emergency Response Plan that has been developed by the Josephine County Public Health Department. Demographic changes in the Lower Umpqua Hospital Emergency Room from July of 1994 to July of 2004. Project Date: 7/5/2004 America's emergency rooms have been subjected to a significant amount of change in the last decade. This study compared the demographics of Lower Umpqua Hospital's emergency room over a two-week period in 2004 to that same period in 1994 to see how it compared to the national averages. The approach that I took was to identify the patients seen over each period using the logbooks, find their charts, record the different information that I was interested in, and then analyze the data. Major trends that were found included an eighty-two percent increase in the number of patients seen, a five year average age increase in patients seen, and three times as many ATV related visits from 1994 to 2004. Farming and Ranching Injuries in Ontario Oregon: Survey of injury occurrence and development of a patient handout on farm safety Project Date: 7/5/2004 In Ontario Oregon, where agriculture is a cornerstone of the economy, farming and ranching injuries contribute to the morbidity and mortality of the community. The main objective of this study is to understand the epidemiology of machinery, livestock and exposure related injuries that affect those patients and their families seen at Dr. David Brauer’s family practice clinic. Approximately forty percent of Dr. Brauer’s patients are part of the agriculture industry. A survey of farming and ranching patients was conducted over a four-week period that evaluated if the patient, a family member, or employee had been injured in a farm or ranch related accident in the last two years. The second part of the study reviewed a random set of hospital charts coded for occupational injuries. The same statistics were recorded for both the patient survey and the chart review, and the data was compiled for the final assessment. Only twenty eight percent of 60 patients surveyed remained free of injury over the last 2 years. The highest rate of injury in the clinic survey occurred with machinery, then livestock, and lastly exposures. In the random chart review of thirty charts, livestock related injuries were the highest, followed by machinery and exposure related. After combining the two data sets, most injuries occurred to the upper extremity, and the 25-50 year old age group was at highest risk for injury. To complete the project, a patient handout was left at the clinic that details the findings specific to Ontario Oregon in the hopes to raise safety awareness. Mechanisms to avoid injuries by age groups are discussed in the handout. In conclusion, there is a need for a more detailed evaluation of ranching and farming injuries over a longer period of time with increased subject numbers in Ontario, Oregon and the outlying areas. It will also be important in the future to understand how effective tools are in increasing safety awareness. Off Highway Vehicle Injuries at Lower Umpqua Hospital in 2002 and 2003. Project Date: 5/10/2004 Introduction: In May 2003, the US Forest Service implemented a policy banning the possession of alcohol outside of designated areas in the Oregon Dunes National Recreation Area. The goal of that policy was to reduce the risks of using Off Highway Vehicles (OHV) to both the people using them and the natural environment. Organizers of a OHV centered event called Dunefest also attempted to increase regulation of riders in an attempt to increase safety. Methods: A retrospective chart review was conducted of all patient charts presenting to the Lower Umpqua Hospital emergency room between July 1 and August 31 of 2002 and 2003. 165 charts were abstracted for the following variables: date, time, patient age, Dunefest weekend, insurance status, EMS usage, alcohol use prior to the incident, protective equipment used at time of incident, type of injury, and disposition. Chi-square and Fisher’s exact test were used to analyze the data. Results: The average age of injured riders was 27.9 with 34 patients being 16 years old or younger. No significant change in the number of OHV related injuries was found other than a decrease in the number of patients without helmets. Alcohol use was associated with higher rates of admission or transfer to higher levels of care, lack of documented insurance, presentation to the ER between 2100 and 0700, and lack of helmet usage. Thirty-one (19%) patients had no documented insurance representing a significant potential financial burden for the hospital. Conclusions: While the new US Forest Service policy did not appear to reduce the number or severity of injuries presenting to LUH ER, the number of unhelmeted patients declined. Riding OHV’s while under the influence of alcohol was associated with greater risk of injury and higher morbidity. Efforts to decrease the operation of OHV’s under the influence of alcohol should continue. Physicians may utilize the ER encounter to screen for alcohol use among injured patients and apply brief interventions to educate patients and their friends and families about risks of combining alcohol with OHV recreation. Future studies will be needed to better determine the effects of the policy. Emergency Contraception: Knowledge Among and Attitudes at Philomath Family Medicine Project Date: 3/29/2004 Unplanned pregnancy is a major medical, social and public health issue. In the United States, unintended pregnancies account for approximately one half of the 6 million annual pregnancies. These unintended pregnancies result in an estimated 1.4 million abortions and 1.2 million unplanned births each year. Despite better and more effective contraceptive tools, these unintended pregnancy rates persist. Research has demonstrated that emergency contraceptive pills (ECPs) are safe and effective in preventing intended pregnancies. However, for emergency contraception (EC) to be effective women need to know that it exists, how to use it, and be willing to use it. This project was conducted to assess both the awareness of and attitudes toward emergency contraception among female patients and health care providers at Philomath Family Medicine. Data was gathered through the use of two separate surveys: one for patients and a second for providers. Among the 36 women who completed surveys, the majority, 97%, had heard of emergency contraceptive pills, but 17-56% lacked at least one key piece of knowledge about emergency contraceptive pills that may preclude effective use. Additionally, among the 6 health care provider surveyed, all described themselves as at least somewhat familiar with emergency contraceptive pills and all had prescribed them in the past, 5 out of 6 had prescribed them in the past year. RSI for the Lebanon Fire District Project Date: 9/29/2003 The purpose of this study is to determine whether the Lebanon Fire District (LFD) has the need for a Rapid Sequence Intubation (RSI) program. The American College of Emergency Physicians recommended that RSI be practiced by all emergency physicians and is also currently practice by Paramedics in 29 states that allow such procedures. We developed an objective set of criteria for RSI candidates and then applied this in a retrospective records review to define the number of candidates in the patient population. We found that of 3 of the 14 intubations preformed this year meet the criteria for RSI. All of these patients were managed by other means of airways control. Due to the low number of candidates, lack of poor outcomes, and limited resources available to maintain a RSI program we feel it is not justified in the case of the LFD. Determining Efficacy of the Seatbelt Coalition: Finding other areas of outreach Project Date: 11/10/2003 Deaths due to unintentional injuries ranks first among the people aged 1-44 years old living on the Warm Springs Reservation. Compared to U.S. accidental death reates (which ranks as the fifth leading cause of death among the same age group). Before the passage of a tribal seatbelt law, the safety officer at the warm springs health & wellness center began to collect survey data on the use of seat belts in Warm Springs, OR. Dating back as far as 1992, the data has shown a slow and consistent rise in the use rate of 88% (as of 2002) This project was designed to invesigate what the Seatbelt Coalition's goals and activities, provide an assessment of data collected on seatbelt use, and develop a set of educational materials for the Warm Springs Health & Wellness Center and its patient population. Results revealed a average seat belt use of around 56% in drivers and 42% in passengers in 2003. A set of ten slides were created that attempted to reach out to the younger at-risk population to help them gain insight into the reasons for using seat belts. Further efforts by the seatbelt coalition are needed to continue the fight to get more community memebers to use seat belts. This will ultimatley reduce the number of fatalities due to MVA that can be saved by simply using a seat gelt. Continuing Education of Emergency Physicians at a Level IV Trauma Center - A Solution to Boost Medical Morale Project Date: 2/10/2003 Many rural communities are struggling financially. The medical community experiences these same fiscal challenges. Such is the case in Baker City, Oregon where the community hospital is $18 million in debt and local healthcare providers struggle to maintain positive revenue position. Morale is down throughout the medical community. This situation has brought about many changes. One of these changes is primary care physicians leaving their practices to become ER physicians. These emergency medicine providers are in a unique position. By updating and strengthening their emergency skills, they can improve patient clinical outcomes and boost the morale of the medical and patient communities with concomitant financial success of the local medical institutions. The Emergency Procedures Training Program for Rural Oregon can provide customized instruction to these ER providers, enabling them to assist in this improvement of their community. Time to Acute Myocardial Infarction Diagnosis and Reperfusion Therapy in Baker City, Oregon versus National Average Project Date: 12/30/2002 Objective - Acute myocardial infarction (AMI) is the largest cause of morbidity and mortality within the United States. Reperfusion therapy, which consists of thrombolysis and/or percutaneous transluminal coronary angioplasty (PTCA), is the cornerstone of contemporary AMI therapy. The benefits of both modalities are greatest when given within two hours of symptom onset. One might expect the time from emergency department (ED) presentation to thrombolysis would be shorter at St. Elizabeth Hospital, a rural hospital in Baker City, Oregon, when compared to a national, urban average. Conversely, it may be assumed that time from ED presentation to PTCA will be longer in Baker City than in large, urban institutions. This project compares time to 1st ECG, thrombolysis, and PTCA in patients with AMI presenting to St. Elizabeth Hospital from 1/01 to 9/02 versus a national, urban average. Methods - The average urban time from presentation to 1st ECG, thrombolysis, and PTCA was obtained from the National Registry of Myocardial Infarction 2 study. Average time to first ECG, thrombolysis, and minimum time to PTCA for nineteen patients presenting to St. Elizabeth Hospital with AMI was determined by chart review. Results - Time from presentation to 1st ECG and thrombolysis was found to be four and six minutes earlier in Baker City than the national average, respectively. Time to PTCA was considerably longer, 386 minutes, for patients presenting at St. Elizabeth Hospital. Discussion - While shorter at St. Elizabeth, the difference in time to thrombolysis is not significant enough to impact patient outcome relative to the national average. However, the time to PTCA was appreciably different, with patients in Baker City having to wait over three hours longer than patients in an urban environment. This time difference is composed of an observation period following thrombolysis and transfer time to St. Alphonsus Hospital. This project focused on treatment delay and its impact on time to reperfusion therapy in rural versus urban communities. Future projects might determine if patients in Baker City wait longer to seek medical attention than their urban counterparts, thus delaying the administration of thrombolytics. Unlicensed Off-road Vehicle Injuries in Tillamook County Project Date: 11/4/2002 It is said by health care professionals that unlicensed off-road vehicle associated injuries are numerous in Tillamook County. Despite testimonials, no study has looked at the frequency and degree of injuries associated with these vehicles. This is a retrospective chart review study of all patients presenting to the Tillamook Country General Hospital Emergency Department in the first 11 months of 2002. Demographics were looked at including; age, sex, driver or passenger, need for transfer to a level 1 trauma center, and injury location and severity. There were 131 patients, with a mean age of 24.92±12.21 (2-57), and 76% male. Injuries are divided into anatomic location and severity. The classification scheme is described. There were 85 (64.9%) patients with "minor" injuries, and 46 (31.1%) "major" injuries. The later included 15 (11.4%) trauma system entries that required transfer to a level 1 trauma center. Age, adulthood, driver vs. passenger and sex did not significantly predict degree of injury. In conclusion, unlicensed off-road vehicles in Tillamook County cause a sufficient number of injuries to warrant a more comprehensive study that looks at crash variables, longer-term outcomes, the effectiveness of public service efforts and the use of alcohol. Emergency Need Occupational Injuries in a Rural Town Setting: John Day, Oregon Project Date: 7/1/2002 Work place injuries continue to be a major concern in many blue-collar industries across the United States. In rural Northeastern Oregon these blue-collar industries are the predominant basis of the economy and thus on-the-job injuries are of major importance. This study was designed to evaluate which industries have the most on-the-job injuries that require emergency room treatment in and around the town of John Day, OR. The design was observation of Blue Mountain Hospital Emergency Department visits during a six-week clinical rotation with a local physician, as well as an extensive medical records compilation for the past year of all emergency room visits classified as on-the-job injuries. In this study, it was found that many injuries occurred as a result of inexperience in high turnover positions and seasonal, long work hour positions that led to intense physical activity without proper equipment and training. Of those injuries that were preventable in nature, lack of equipment such as proper gloves and boots as well as lack of training in operation of heavy equipment led to most injuries. Therefore, the most important conclusion of this project was that although these industries carry much inherent danger, better training and equipment could significantly reduce the number of work related injuries in John Day. Emergency Eminent: Dunefest 2002 Project Date: 7/1/2002 OBJECTIVE: To assess the emergency preparedness of the Umpqua Lower Hospital's Emergency Room, EMS system, and Operating Room for Dunefest 2002. To offer suggestions for next year's Dunefest based on the problem areas identified through this assessment. METHODS: Dunefest planning meetings, sponsored by the Reedsport Chamber of Commerce, were attended. Records of past Dunefests were reviewed, including ER and EMS logs, and these were discussed with personnel who were present those years. An assessment was made concerning the state of preparedness for Dunefest 2002. After the event, preparedness was reassessed based on experiences in on ambulance rides, in the ER and OR, and through discussion with hospital and EMS administrators. RESULTS: Chart review and previous Dunefest experience from 1999, 2000, and 2001 dictate the importance of increasing law enforcement and decreasing the number of people camped at the event site. This year, EMS was well prepared and easily handled their responsibilities. Increased staffing in the OR allowed for the multiple orthopedic cases that were expected; however, some supplies were low or unavailable. The ER physicians were challenged in keeping up with the number of emergencies resulting from the event. The hospital is most likely losing money through the event, due to the increased influx of uninsured patients. CONCLUSIONS: This year's preparation was adequate. An internal audit is recommended to determine whether Dunefest is resulting in a net loss in the hospital's finances. The Dunefest committee for 2003 should consider a fee for event insurance to offset the costs of treating the uninsured accident victims. The OR and ER should be stocked at least three days prior to the Dunefest events. A backup plan should be devised for overburdened ER physicians during the event. EMS in Harney County: Benefits of Transition from a City-run, Volunteer Fire Department Based Program to a Hospital-owned Program with Paid Personnel Project Date: 2/11/2002 This report is a review of the changes made in recent years to the Emergency Medical Services (EMS) program in Harney county. In the past the City of Burns has been the responsible party for provision of EMS; the program has been run under the auspices of the Fire Department. For the most part EMS personnel have been voluntary and the levels of training among personnel have been quite varied. Rather than being run as a business, the service was run as a volunteer-based program. There were no full-time paid personnel whose responsibility it was to keep the service functioning at a level that provided a quality service to the public as well as keep the service solvent economically. Over the long run the service was a drain on the resources of the community: the service cost a great deal of money to provide and the City was still unable to maintain needed equipment and keep appropriately trained personnel. Two years ago Harney District Hospital took over the EMS program, hired a full-time paramedic to run the service, and with the help of the experience of the hospital administration and the new director began to bill appropriately, look at ways to qualify for government funds for purchase of equipment and education of personnel, and overall made changes directed at running the service as a business. Through the changes that have been made the quality of service has been greatly improved and the EMS program has become solvent. The following discussion is intended to examine the changes that have taken place and consider whether or not this program may function as a model for similar communities to improve their EMS systems. Paramedic Decision-making Regarding Method of Transport and Destination Project Date: 2/11/2002 The goal of this study was to understand what factors contribute to paramedics' decisions regarding method of transport and destination of critically ill and injured patients. This is a descriptive study based on the experience of prehospital care providers in a rural area. Factors identified primarily focused on operational considerations for trauma patients including: limitations of aeromedical transport, transport time, multiple patient scenes and factors that prolong scene time. Also identified were neurologic injuries, as neurosurgical care is not available in this community. Medical Triage Guidelines for an Assisted Living Facility in John Day Oregon Project Date: 2/11/2002 Inappropriate use of the ambulance and emergency room by the staff and residents of Valley View assisted living residence was identified as source of frustration among the physicians of John Day. The cause of this problem is the very limited medical training of the med aid staff at Valley View. An algorithm consisting of a series of simple yes/no questions was proposed as a triage system that would match the medical training of the staff at Valley View to the expectations of the local physicians. The triage algorithm was presented to the staff at Valley View and is being implemented on a trial basis. Once the Valley View staff have become comfortable with the tool and it has been in use for several months the local physicians will be polled to evaluate the triage system's effectiveness. Assessment Of The Signs And Symptoms Of Acute Myocardial Infarction Of The Elderly In The Emergency Setting In Reedsport, Oregon. Project Date: 1/2/2002 The purpose of this study was to examine elderly patients who presented to the emergency department (ED) in Reedsport, Oregon for symptoms of acute myocardial infarction (AMI). The objective was to determine what diagnoses were ultimately found for these persons, and then to determine if the presenting signs and symptoms of the elderly with a discharge diagnosis of myocardial infarction (MI) were representative of the national average. The ultimate goal was to determine whether the elderly with AMI are being underdiagnosed in Reedsport, and, if so, can improvements be made to diagnose them? A case review was done of approximately one year's prior time of all persons greater than 70 years of age presenting to the emergency room (ER) with symptoms of AMI. These cases were reviewed for chief complaint, associated symptoms, electrocardiogram (ECG), cardiac markers (Troponin-I, CK-MB, and myoglobin), and other various findings. It was found that 9% of subjects selected were ultimately diagnosed with an AMI. 35% had other cardiac problems (13% related to angina and 22% related to non-ischemic etiologies), and 56% had diagnoses unrelated to cardiac origin. The ECGs, cardiac marker findings, and other studies are described. It is thought that due to limitations in specificity and sensitivity of the ECG and cardiac markers, but moreover, the prevalence of atypical presentations of AMI in the elderly, that it is possible that a number of MIs in the elderly are not being diagnosed in Reedsport. Recommendations for improvement are given. Evaluation of Acute Stroke Treatment in Reedsport, OR: A look at thrombolytic therapy in this rural setting. Project Date: 5/6/2002 Unlike some of the rural settings in Oregon, Lower Umpqua Hospital in Reedsport currently does not have a protocol for thrombolytic use in acute stroke. The goal of this project was to evaluate standard acute stroke treatment in Reedsport and the surrounding rural communities, then to assess what it would entail to incorporate thrombolytic therapy into the hospital’s stroke treatment. The evaluation for the project involved many components, including: 1) assessment of local stroke epidemiology, 2) assessing Reedsport physician support of acute stroke therapy, 3) assessing patient recognition and response to signs and symptoms of stroke, and their current utilization of EMS services, 4) analyzing the hospital and EMS needs for providing acute stroke treatment, and 5) questioning physicians from areas that provide thrombolytics for acute stroke. The report will address various aspects of providing acute stroke treatment in a rural setting vs. an urban setting. The findings in this report are meant to be informational and do not suggest whether acute stroke thrombolysis should or should not be integrated in the Reedsport ER protocol. The report does, however, provide a basic set of guidelines for helping establish acute stroke treatment in Reedsport should they decide to pursue this. Firefighter Injuries And The Impact On The Emergency Department And Physicians In Harney County Project Date: 7/2/2001 OBJECTIVE: Harney District Hospital is the only emergency room for the 10,288 square mile Harney County. A high desert climate, many wildfires occur between May 15th - October 15th. The 2000 census showed the population of Harney County as 7,609; during the fire season this population can almost double. The impact of this influx can be substantial; the physicians are unaware of the type and rate of injuries that will be seen in the emergency room. The purpose of this project is to study the rate and type of firefighter injuries in Harney County that lead to visits. Reasons for the injuries will be compared with the national data. SETTINGS: Harney District Hospital in Burns, Oregon - Harney County. METHODS: Part I: Interviews with fire crews in Harney County. An average rate of injury was calculated from this as was the most common types of injuries, as were the role of stress and exhaustion on the injury occurring. Part II: A search of United States Forest Service (USFS) and Bureau of Land Management (BLM) injury files for the years 1999 and 2000 was done to show how many of these injuries were sent to the emergency room. Part III: A record search and susequent calculations were done to determine the number of emergency room visits for a fire season. RESULTS: Part I: An average injury rate of 0.7125 injuries per season per firefighter was shown. The season is defined at May 15th to October 15th, a 153 days. For the 150 firefighters stationed in Harney county, this is an estimated 107 injuries per season. Part II: Records from the BLM and USFS showed that 4% of these injuries were major enough to warrant a trip to the emergency room. Of the 107 injuries per season for the Harney county firecrews, five would result in emergency room visits per season. Part III: There were a total of 2,443 visits to the Harney District Hospital emergency room for the 365 days of the year 2000. This averages out to 6.7 visits to the emergency room per day, and for a fire season, that would be 1024 visits. CONCLUSIONS: The overall injury rate for a firefighter in Harney County is 0.7125 injuries per season. The five visits to the emergency room from the 150 firefighters stationed in Harney County account for only 0.5% of all visits. The influx of personal for the summer wildfires can increase the emergency room use by between 4% - 25%. Seizure Recognition And First Aid Training Among Likely Primary Respondents in Ontario, Oregon Project Date: 7/2/2001 Seizures are a common and possibly life threatening condition effecting 10% of Americans throughout their lifetime. This study is a cross-sectional assessment of the exposure to seizure recognition and first aid training among likely primary responders in the rural community of Ontario, Oregon. Likely responders were defined as public safety officials, child and senior care providers, and educational professionals. The results of this study indicate that while 70% likely primary responders as a group are receiving the exposures of interest, training within the specific sub-population of childcare providers has only a 60% prevalence. Discussed in this report are some of the issues influencing the training of individuals in the rural community and recommendations to the Epilepsy Foundation of Oregon on how to increase the prevalence of seizure recognition and first aid training in rural communities. Back to subject search page or search by preceptor site