RCHC Community Project Abstracts

Back to subject search page or search by preceptor site Two Year Analysis of Total Joint Replacements at the Lower Umpqua Hospital Project Date: 3/16/2009 Hospital procedure volume has been shown to be inversely proportional to postoperative complications. The objective of this study was to determine if total knee and hip arthroplasties can be effectively and safely performed in a low procedure volume hospital such as the Lower Umpqua Hospital in Reedsport, Oregon. The medical records of patients undergoing elective, primary total knee and hip arthroplasties between January 2007 and December 2008 were reviewed for outcomes occurring three months after the procedure. Results were compared to a large Medicare cohort treated with similar procedures. At this hospital, the rates of complications were minimal to none. There was an acceptable rate of manipulation under anesthesia and no dislocations. One superficial infection was noted, but no deep infections. No deaths, DVT’s, PE’s, MI’s or pneumonias were experienced in this cohort. In conclusion, total knee and hip arthroplasties can be effectively and safely performed at the Lower Umpqua Hospital, a low procedure volume hospital. Access to Orthopedic Services in Cottage Grove, Oregon Project Date: 8/4/2008 Access to health care services meets many barriers in rural communities and the experiences of community members in South Lane and North Douglas Counties are no exception. While Cottage Grove Community Hospital is generally successful in meeting its community’s primary care needs, the availability of specialty services continues to be lacking. Through observation, interviews of patients and the medical community, and data compilation, the need for orthopedic services in Cottage Grove, Oregon, was assessed. Based on the data and observations, it can be concluded that Cottage Grove Community Hospital patients face significant obstacles to receiving orthopedic care. Furthermore, it can be suggested that there is sufficient patient demand for orthopedic services for CGCH to consider bringing orthopedic services to the facility. It is hoped that this assessment will raise the awareness of specific barriers to health care and provide a direction in which to work to minimize the obstacles Cottage Grove Community Hospital staff and patients face in providing and receiving specialty care, specifically orthopedics. Can Astoria Support a Physiatrist? Project Date: 6/30/2008 Rural communities are disproportionately affected by disabling conditions and chronic diseases. Labor-intensive occupations, older demographics and shortages of medical services contribute to faster progression of disease in rural settings. To address these issues, Columbia Memorial Hospital became interested in the viability of a physical medicine and rehabilitation specialist in Astoria. One of the most significant factors to the success of physiatrist is whether this specialist can obtain referrals from primary care clinicians. The purpose of this study was to assess the attitudes, potential competition, past referral patterns, and predicted referral patterns of clinicians in Astoria and Seaside with respect to physiatry. The majority of surveyed clinicians self-report a high degree of familiarity with physiatry. They are comfortable referring patients to this field and they believe physiatry would provide unique services to the area. While some are concerned about competition with a physiatrist, the overall attitude from local clinicians is supportive of this addition to Columbia Memorial Hospital. While an adequate referral base may exist locally, the catchment area for this specialty can extend beyond Astoria and Seaside to ensure a sustainable number of patient encounters. Educating primary care clinicians about physiatry and cultivating relationships with colleagues in the service area should provide adequate referrals to support this addition to Columbia Memorial Hospital. A Study of Specialty Referral Patterns from Scappoose Family Practice Project Date: 12/31/2007 Patients are referred from Scappoose Family Medicine Clinic to specialty practices which are usually located in Portland, 20 miles away. Accessibility to specialists and coordinating care with specialists for patients is cumbersome and time consuming. This study was undertaken to help determine feasibility for a specialist to visit Scappoose clinic at a reasonable frequency. Referral information was collected from the business office of the clinic. The study determined that orthopedics surgery was the most referred specialty with 6 patient referrals per week and physical therapy (PT) was the most referred service also with 6 patients per week. While PT is well supported in Scappoose, a weekly orthopedic clinic would better serve the needs of the community. However, a pre-requisite for a viable orthopedic clinic, with quick turnaround, is an onsite x-ray facility. No data exists that indicates the number of x-ray images that are ordered by the providers at the Scappoose clinic. To support the volume of patients, about 350 – 400 patients per week, it is certainly feasible to have an x-ray machine. Fall Prevention Services For Geriatric Patients In St. Helens, OR Project Date: 10/15/2007 Geriatric morbidity and mortality increases after fall injuries.1 Many of these falls may be avoided with fall-prevention strategies that involve improving geriatric strength and mobility. The goal of this study was to identify local fall-prevention resources and services for geriatric patients--specifically, programs that could provide mobility-assistance-device (i.e. canes, walkers) training, home fall-prevention safety consultations and home mobility improvements/installations. Geriatrics patients from the St. Helens, OR community and their medical and social services providers were interviewed. Although rehabilitation services in St. Helens for geriatric patients who have already experienced a fall injury are easy to identify and access, services to prevent healthy, active seniors avoid falls are not. Use of Vicscosupplementation in Patients Suffering from Osteoarthritis of the Knee: Improving Outcomes for the Patients of Klamath Family Practice Center Project Date: 10/15/2007 Osteoarthritis is a widespread problem, especially among older adults. Due to the pain and immobility associated with the condition its effect on quality of life is often detrimental. The relatively large number of patients seen for osteoarthritis at the Klamath Family Practice Clinic made the relevance of osteoarthritis treatment to the Klamath Falls community quite clear. The rural quality of the community adds a further level of importance, since employment and household responsibilities tend to be physical and dependent upon mobility. Hyaluronic Acid injections are a relatively new form of treatment of osteoarthritis of the knee. They represent a new tool for primary care physicians in helping their patients to overcome the disabling effects of osteoarthritis of the knee. I interviewed a number of patients who had received the Hyaluronic Acid injections and a pair of doctors who have given the injections to their patients to assess the efficacy and subjective value of this therapy. I also reviewed current literature on the therapy. Research showed that the injections are moderately effective in controlling pain and improving mobility, with better duration of effect (up to ~12 months) than current non-surgical therapies. Subjective data showed a large perceived benefit for most patients and doctors utilizing the treatment, with exceptions tending toward patients with more advanced disease. 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. General Surgery & Lower Umpqua Hospital: A Case Study and Perspective of Surgery in Rural America Project Date: 8/6/2007 The presence of a general surgeon is essential for health care in rural communities. Across America many rural communities and hospitals are underserved in terms of general surgery coverage. Lower Umpqua Hospital (LUH) in Reedsport, Oregon has experienced this shortage of rural surgeons first hand. Six years ago, LUH lost its first full-time surgeon. Since that time, LUH has had two additional general surgeons come and go, with the last leaving in March 2007. At times when the hospital has found itself without a surgeon it has turned to locums tenens for surgical coverage. Locums tenens surgeons change as frequently as once a month, significantly interrupting continuity of care and communication between the patient, surgeon and primary care provider. LUH is dependent on its surgical productivity for income and for keeping surgical patients within the rural health care system. This project investigated how surgical productivity varies when LUH has a full-time general surgeon versus locums tenens coverage and found that when LUH loses a surgeon, and must turn to locums tenens for surgical coverage, surgical productivity decreases considerably. This loss in surgical productivity has significant and far reaching effects on LUH, the community of Reedsport and the primary care providers of Dunes Family Health Care. Interfacility transfers from Harney District Hospital, Burns, OR Project Date: 4/30/2007 Harney District Hospital (HDH) is the lone health care center for the 7,600 people living in Harney County, the largest county in all of Oregon. They are able to handle most every medical and surgical problem; however, as a small hospital with limited resources, certain patients come through that require transfer to a tertiary care facility for additional care. The hospital’s ambulance service conducts these interfacility transports; however, they are never quite sure what type of patient to expect when they back their ambulance in. This uncertainty makes it difficult to train and educate ambulance crews, arrange crew configurations, and equip and supply the ambulances. Similar ambiguity exists for the hospital as well. This study aims to elucidate what patient problems require transfer to other facilities, from which setting they are transferred, and by which mode of transportation. Data on every patient which required interfacility transport between December 2005 and April 2007 were collected from hospital databases, and analyzed categorically. During the study period, HDH transferred 3.5% of their patients. The majority of these 171 patients were transferred by ambulance; however, a full 1/3 of patients were transported by air. 50% of all patient transfers were for patients with cardiac, orthopedic, or surgical problems: a large fraction of acute issues. Some problems, like psychiatric, infectious, and oncologic were rarely transferred out. Proportionally, more patients from the inpatient ward required transport than from the ED; however, any given transfer was equally likely to have originated from either setting. These data will hopefully help county EMS to focus education on the high yield and rare maladies, appreciate how to efficiently equip and supply ambulances, and balance the skill level of crewmembers with the anticipated acuity of patients. The hospital may also find valuable information in this project, elucidating where additional specialist care, equipment, and education may decrease the necessity of some transfers, allowing more patients to receive definitive care within their community. 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. "Exercise by Prescription" Project Date: 3/19/2007 A routine of exercise and physical activity has been shown to decrease morbidity in patients suffering from things such as heart disease, cerebrovascular disease, hypertension and osteoporosis. Physical Inactivity however has been correlated with many external factors beyond the patients’ control. This study attempts to identify key barriers to physical activity in a rural population, specifically among the elderly. The design was the questioning of patients over 50 who came to Klamath Family Practice, and the Merle West Medical Center in Klamath Falls Oregon. Each patient who was being seen as a follow up for hypertension, Diabetes, or was having a complete physical exam was questioned on the primary reason that they did not perform a routine form of physical activity and or exercise. 2 different focus groups of 10 and 12 senior citizens at Klamath Senior Center & Center for Aging were also questioned about the same issue. This study found that the major barriers included weather in Klamath, safety and motivation along with other barriers. Whereas there was a great deal of emphasis on the importance of physical activity, the barriers to those activities were not being addressed by physicians and/or residents. In fact it was rare that a consultation was held at all to discuss physical activity for many patients who would obviously benefit. Therefore my intervention sought to decrease the burden of those same barriers in an effort to motivate the patients to seek out the recommended amount of physical activity set forth by “Healthy People 2010.” This included but was not limited to, making trail maps for walking and jogging, convincing local fitness centers and rentals shops to give discounts to patients mentioning “exercise by prescription” from their doctor. Such a sheet of information and incentives give the physicians in office, something to have in hand in order to have a worthwhile discussion about exercise with patients and to hopefully further impact preventive care in Klamath Falls. Shoulder injuries and rehabilitation Project Date: 3/19/2007 Shoulder injuries are one of the most common musculoskeletal injuries in Lebanon, Oregon. The only injury more common is low back pain. While working there, it became apparent that there was need for educational material to share with the people of Lebanon. Although in the office we could show pictures and describe how to care for their shoulder injury, we had no hard copy of information to reinforce the patient’s newly acquired knowledge. Additionally, there is a large amount of the population that was receiving all of their rehabilitation care through the physician’s office. These patients did not have access to therapy services, or they were unable to go secondary to lack of transportation, or work, or funds. For the patient who supports themselves by ranching, farming, or working in a factory, a shoulder injury, like a rotator cuff, can be a devastating and debilitating injury. Besides affecting their occupation, this also affects patient’s self care, leisure activities, and even rest. Even if they did have access to Physical Therapy, there was often a great deal of patient education that needed to occur while in the physician’s office, as well as a need for a written material for the patient to refer to when at home. Early Identification of Post-operative Needs of Hip Fracture Patients in Grants Pass, Oregon Project Date: 7/3/2006 Hip fractures are common and debilitating injuries that predominantly affect older people. They results in significant morbidity for those who suffer from them and place a considerable burden on the health care system. Three Rivers Community Hospital in Grants Pass, Oregon has initiated a comprehensive program directed at senior citizens in its service area that includes fall prevention, osteoporosis care and hip fracture treatment. An important part of treatment is meeting the post-operative needs of patients through timely and appropriate discharge planning. This student examined records of 91 patients treated at Three Rivers Hospital for hip fractures in 2005 to determine what factors at presentation predict length of hospital stay and whether patients are transferred to their homes or to skilled nursing facilities. Available charts were reviewed of the 93 hip fracture reductions performed at Three Rivers Hospital in 2005. Analyses demonstrated no relationship between the number of comorbidities listed for a patient and her length of stay in the hospital. 85% of patients required post-operative transfer to skilled nursing facilities. The mean age of those patients was 8 years older than the mean age of patients who were discharged to their homes. Also, patients bound for nursing facilities had an average of 2.2 greater comorbidities on admission than patiens who were sent home. Patients living at home with a spouse before injury were the most likely to be able to return home after surgery. Further investigation is needed to assess potential relationships between the types of fractures, types of procedures, and discharge plans. The ability to prepare for post-operative placement early in the course of treatment would facilitate the recovery process and provide for the optimally efficient utilization of hospital resources in Grants Pass. Choosing the Path Less Traveled: Walking for Health in Reedsport, Oregon Project Date: 7/3/2006 This paper introduces the concept of the “walkable” community and discusses opportunities for incorporating exercise into the daily routines of residents in the Reedsport, Winchester Bay, and Gardiner area. Past community health efforts and student research projects have reiterated the importance of health promotion in this population. Interviews with local residents and a literature search revealed the need for a more extensive list and map of pedestrian routes in the area to highlight a variety of walking and jogging options close to home. A survey of the Dunes Family Health Care clinicians demonstrated that exercise is important to medical providers, and a patient survey identified the need for better outreach to make health handouts available at multiple locations in the area. The final product is an easily reproducible brochure of walking and jogging trails in the Reedsport, Winchester Bay, and Gardiner area. Osteoporosis: Fractures in an Aging Population Project Date: 2/13/2006 Osteoporosis is a skeletal disease characterized by loss of bone mass and strength, leading to the increased likelihood of fragility fractures. Osteoporosis primarily affects the elderly and fractures due to osteoporosis are a principle cause of morbidity and mortality. The goal of this project is to increase awareness of patients and providers on prevention, screening, and treatment of osteoporosis. This was accomplished by examining the current practices of screening for osteoporosis by area providers and identifying the incidence of fragility fractures at Reedsport. A literature review was done to educate providers about the latest in bisphosphonate therapy, and finally a brochure was made to empower patients with knowledge about osteoporosis. From September 2004 to January 2006, there were a total of 53 total fractures in patients 60 years and older treated at Lower Umpqua Hospital. Forty six of the fractures were from low-intensity traumas and only 15% of these patients were previously diagnosed with osteoporosis or osteopenia. It appears osteoporosis is currently under-diagnosed in Reedsport. This is mainly due to provider’s views of the high cost of treatment for their patient’s and ineffective treatment options. Evaluation of Diabetes Mellitus Management in John Day, Oregon: Are current standards of care being implemented? Project Date: 2/13/2006 Diabetes Mellitus is a major medical problem in the United States, affecting 6% of the population. Due to the morbidity and mortality associated with diabetes, standards of care have been designed to help reduce complications of the illness. As part of maintaining its status as an Oregon Federally Certified Rural Health Center, the Strawberry Wilderness Community Clinic (SWCC) is required to perform yearly chart reviews. The purpose of this project was to develop a chart review form for diabetes screening and treatment based on established diabetes guidelines. This form was then used in a chart review of thirty patients, ten from three physicians, to assess if SWCC is currently implementing these guidelines in its practice. Results of the review demonstrated that physicians are meeting guidelines for HbA1c measurement, use of ACE inhibitors, reviewing self monitored blood glucose readings, and checking creatinine annually. Areas of improvement were found to be screening for dyslipidemia and microalbuminuria. The biggest deficits in care were found to be in ensuring that patients received yearly dilated eye exams, visual foot inspection at each visit, comprehensive foot exams annually, and using aspirin therapy in patients > 40 years of age. These results can be used by the SWCC to help design methods to improve deficits in diabetes management and therefore reduce morbidity associated with the disease in their community. Mental Health Care Resources in Linn County Project Date: 1/2/2006 Mental healthcare delivery everywhere is being provided to greater extents by primary care physicians than ever before, especially in rural settings where community mental health resources are lacking. This report assesses the prevalence and disease burden of mental illness in the U.S. overall, and in our rural communities like Linn County. Second, it discusses barriers to mental health care in rural settings. Next, it poses possible solutions to rural disparities in mental health care. Finally I discuss my project. The goal of this project was to examine the need for mental health services in Linn County, identify mental health resources in Linn County, and formulate a consolidated list of local mental health resources including their areas of expertise for use by local health care providers and community members. Management of Chronic Back Pain: Evaluation of the Efficacy of Spinal Surgery Project Date: 8/8/2005 Less than 10% of individuals who experience back pain will develop a chronic back pain syndrome. Of these patients, a fraction will fail all conservative therapies and seek relief through one or more spinal surgeries. There is much controversy regarding the effectiveness of surgery compared to an intense rehabilitation program. During a meeting of the Independent Physician's Association (IPA) of Josephine County, this issue was discussed in relationship to disbursement of state and federal funds to provide coverage for a procedure that has not been shown to have steadfast value in the management of patients with chronic back pain. This project was devised with the ultimate goal of examining the pre- and post-operative functionality and use of prescribed medications of patients undergoing back surgery. A small sample of patients who have undergone one or more back surgeries were selected from a family practice clinic in Grants Pass, Oregon. Their charts were reviewed and documented information on functionality, number of office visits relating to pain, and medication usage were extrapolated. The results of this project were inconclusive as insufficient information was present in the patients charts. Future research could evaluate efficacy of surgical treatment by utilizing IPA databases, contacting and surveying patients, and running analyses on changes in medication utilization. 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. Documenting a disparity between the musculoskeletal knowledge and skill requirements of primary care physicians in Tillamook County. Project Date: 3/25/2002 Musculoskeletal problems are a major source of pain and disability in our society. The purpose of this study was to determine if there is a disparity between musculoskeletal knowledge and the skill requirements of primary care physicians within Tillamook County. The number of musculoskeletal complaints evaluated and treated in a primary care physician's office was recorded over a one-month period between 1 April and 30 April 2002. Additionally, self-administered questionnaires comparing physician confidence with common musculoskeletal disorders and common medical issues were distributed to all primary care physicians in Tillamook County. The prevalence of musculoskeletal disorders was 17.9% (n=49) among 274 office visits. Survey results suggested that physicians felt more confident managing common medical issues than common musculoskeletal disorders (avg. confidence score=9.0 and 4.2). Specifically, physicians felt most confident with the principles of cardiac rehabilitation, performing comprehensive cardiovascular examinations, and indicating/interpreting flexible sigmoidoscopy (avg. confidence score=9.0, 9.6 and 9.6 respectively). They felt least confident with the principles of bracing and casting, performing comprehensive musculoskeletal examinations, and indicating joint injections (avg. confidence scores=3.6, 7.0, and 3.0). The results suggest that a disparity between skill requirements and musculoskeletal knowledge exists among primary care physicians in Tillamook County. Competence in managing musculoskeletal disorders is a necessity for any primary care physician. To appropriately address this disparity, a new curriculum addressing common musculoskeletal problems should be developed which could be implemented at any, or all, levels of medical training. Back to subject search page or search by preceptor site