Mobilizing transport for obstetric emergencies in northwestern Nigeria. The Sokoto PMM Team

PRELIMINARY STUDIES

Focus group discussions and a village case study in Kebbi State revealed delay in the transport of women with obstetric complications. Among contributing factors identified were shortages of vehicles and fuel, and unwillingness of drivers to transport women at affordable fares.

INTERVENTIONS

The cooperation of the local transport workers union was enlisted to address the situation. In 1993, drivers were sensitized and trained and a revolving emergency fuel fund was established. Prior to these activities, emergency obstetric services at nearby facilities had been upgraded.

RESULTS

Over two years, 29 women with obstetric complications were transported. Of these, only one died. Mean cost of transport to patients was US $5.89. Mean time from the onset of complications to treatment was 9 h. Substantial numbers of non-obstetric patients in need of emergency care were also transported. Although defaulting eventually resulted in depletion of the fuel fund, the reimbursement system had become sufficiently well-established that most drivers no longer requested funds in advance.

COSTS

Cost of the transport intervention was US $268, with 72% coming from project funds.

CONCLUSIONS

Improving transport to emergency care does not necessarily require ambulances. Commercial transport owners and communities can be mobilized to provide affordable emergency transport for women with complications.

Community loan funds and transport services for obstetric emergencies in northern Nigeria

PRELIMINARY STUDIES

Focus group discussions and a community survey indicated that inadequate funds and transport caused delays in deciding to seek emergency obstetric care and in reaching facilities.

INTERVENTIONS

Following improvements in the quality of obstetric services, a community loan program was established in early 1995. Community members determined its features: compulsory contributions; community administration; loans for obstetric complications only; no interest; a 6-month grace period; and 24-month repayment. A transport system was also established, in which private vehicle drivers agreed to respond to calls for emergency transport and charge a set fee.

RESULTS

The equivalent of US $20,500 was collected from 81 annual and 2273 one-time contributors. Eighteen loans were approved in 9 months. Repayment data are not yet available. For the transport system, 23 drivers pledged permanent participation and 58 pledged to take part in 6-month rotations. They transported 18 women.

COSTS

The cost of these interventions was $3409 for the loan fund and $2272 for the transport system. Sixty percent of the cost was paid by the community and the rest by the PMM project.

CONCLUSIONS

Community-managed loan and transport systems for women with obstetric emergencies can be established and may contribute to reducing delay in obtaining emergency obstetric care.

Emergency loan funds to improve access to obstetric care in Ekpoma, Nigeria. The Benin PMM Team

PRELIMINARY STUDIES

Focus group discussions in the community identified difficulties in paying for transport as a major barrier to seeking and reaching emergency care for obstetric complications.

INTERVENTIONS

After emergency obstetric services in local health facilities had been upgraded, the clans in Ekpoma were mobilized in 1995 to set up emergency loan funds for women with complications. Funds were managed entirely by the clans, with ongoing monitoring and supervision by project staff. Two percent simple interest was charged.

RESULTS

Of the 13 clans contacted, 12 successfully launched loan funds. Total donations amounted to US$793, of which four-fifths were contributed by the community. In the 1st year of the operation, 456 women/families requested loans (ranging from US$7 to US$15), and 380 (83%) were granted. Three-hundred and fifty-four (93%) loans were repaid in full. In addition to being used for transport, loans were used to help pay for drugs, blood and hospital fees.

COSTS

The cost of establishing the loan fund was US$1360, including initial donations to the loan funds. The PMM project paid 55% of the total.

CONCLUSIONS

With relatively little outside financial input, communities can set up and administer loan funds for emergency obstetric transport and care. However, sustaining the funds over the long term requires continuing effort and involvement with the communities.

Costs of gunshot and cut/stab wounds in the United States, with some Canadian comparisons

This article estimates the costs of U.S. gunshot and cut/stab wound by intent. It also compares U.S. to Canadian gunshot experience. Incidence data are from published sources, the National Hospital Ambulatory Medical Care Survey (NHAMCS), and cause-coded emergency department discharge and hospital discharge data systems. Medical care payments and lost earnings per case come from National Crime Survey data, a literature review, and weighting of costs by diagnosis from Databook on Nonfatal Injury-Incidence. Costs, and Consequences by Miller et al. (The Urban Institute Press, Washington, DC. 1995) with the diagnosis distribution of penetrating injuries from the discharge data systems. Quality of life losses are estimated primarily from jury awards to penetrating injury victims. In 1992, gunshots killed 37,776 Americans; cut/stab wounds killed 4095. Another 134,000 gunshot survivors and 3,100,000 cut/stab wound survivors received medical treatment. Annually, gunshot wounds cost an estimated U.S. $126 billion. Cut/stab wounds cost another U.S. $51 billion. The gunshot and cut/stab totals include U.S. $40 billion and U.S. $13 billion respectively in medical, public services, and work-loss costs. Across medically treated cases, costs average U.S. $154,000 per gunshot survivor and U.S. $12,000 per cut/stab survivor. Gunshot wounds are more than three times as common in the U.S. than in Canada, which has strict handgun control. With the same quality of life loss per victim, gunshot costs per capita are an estimated U.S. $495 in the U.S. vs U.S. $180 in Canada. Per gun, however, the costs are higher in Canada, Gunshot wound rates rise linearly with gun ownership.

Hazardous materials exposure information service: development, analysis, and medical implications

The Hazardous Materials Exposure Information Service (HMEIS) was established at the Washington Poison Center (WPC) to rapidly provide information to medical professionals who treat victims of hazardous-materials exposure. Incident description and exposure information is collected from on-site hazardous-materials teams and immediately analyzed by WPC medical toxicologists. Diagnostic and treatment recommendations are provided to prehospital personnel and receiving physicians. Over the first 22 months of operation, 50 calls were received that met HMEIS criteria. Of the 466 individuals exposed, 256 (55%) were transported to a medical facility for treatment. When the WPC was contacted before the decision to transport a patient to a medical facility, 28 of 185 exposure victims (15%) were transported, compared with a transport rate of 81% of exposure victims (66% change; 95% confidence interval [CI], 60% to 72%) in all other concurrent incidents and a historical transport rate of 63% (25% change; 95% CI, 14% to 36%) before the establishment of the HMEIS. These findings, although preliminary and subject to potential confounding, suggest that the HMEIS reduces health care costs through more efficient use of medical resources.

[The financial costs of health care: a follow-up survey of women having a high-risk delivery]

Our aim was to analyze the financial costs of health care for women in labor transferred to primary referral maternity units in childbirth at risk. Another aim was to consider the willingness of women and their husbands to financially save and support the increasing costs of health care. For 15 consecutive days, medical students interviewed all women transferred for a risky delivery in 12 of the 17 primary referral maternity units in Burkina Faso. The median cost for transferring the women and their necessary health care was approximately 30,500 CFA. The median cost for the kit of surgical supplies was 15,000 CFA; the costs of medicine and transportation fare for the woman and her husband were 14,000 CFA and 9,800 CFA, respectively. The median cost for the health care of the newborn was 2,400 CFA. When the decision for the transfer was made, the necessary money to pay for the expenses was available for only 40 out of 79 women. Women and their husbands were willing to save for health care either through existing community institutions such as groups of villagers and popular savings developments (69 women and men); or through annuity schemes to be created (33 women and men); or through banks (4 women and men). Four women and 6 men refused to contribute because of previous experiences of poor management of collective funds. The average savings were low and insufficient to cover the expected expenses for the transfer and care of the women. The savings were reserved for payment of the transportation fare for the women and their husbands to the referral units (21 women and 20 men), prescriptions (9 women and 5 men), the medical consultation (1 woman), and to provide for both (37 women and 39 men). The costs of health care are expensive. The poverty of the couple facing an urgent problem of life or death made them discover new options for investing in their available community associations such as groups of villagers and popular savings developments and other options such as annuity schemes. A policy directed towards the involvement of these populations could facilitate the transfer and treatment of women during their pregnancy.

A multisite survey of factors contributing to medically unnecessary ambulance transports

OBJECTIVES

To determine the social and demographic factors associated with medically unnecessary ambulance utilization, and to determine the willingness of patients to use alternate modes of transportation to the ED.

METHODS

A multisite prospective survey was conducted of all patients arriving by ambulance to 1 suburban and 4 urban EDs in New York State during a 1-week period.

RESULTS

For 626 patients surveyed, 71 (11.3%) transports were judged medically unnecessary by the receiving emergency physicians using preestablished guidelines. The patient's type of medical insurance and age were significant predictors of unnecessary ambulance transport (stepwise forward logistic regression analysis). Of the 71 patients whose ambulance transports were deemed medically unnecessary, 42 (59%) were Medicaid recipients and 53 (74%) were < 40 years of age. The most common reason for using ambulance transport was lack of an alternate mode of transportation (38.5%), although 82% would have been willing to use an alternate mode of transportation if it had been available. Of those who had medically unnecessary ambulance use, 30% indicated that they would not pay for the ambulance service if billed and 50% believed the cost of their ambulance transports was < $100. More than 85% of the patients whose ambulance transports were deemed medically unnecessary were unemployed; and nearly 85% reported a net annual income of < $20,000. While 33% had a primary care provider, only 22% had attempted to contact their doctors before requesting an ambulance.

CONCLUSIONS

Patient age < 40 years and Medicaid coverage were associated with medically unnecessary ambulance use. Those patients for whom ambulance use was considered medically unnecessary commonly had no alternate means of transportation. Providing alternate means of unscheduled transportation may reduce the incidence of unnecessary ambulance use.

The costs of managing lower limb-threatening ischaemia

One hundred and fifty consecutive patients presenting with limb-threatening ischaemia were studied prospectively to determine treatment and rehabilitation costs in the first year. Limb salvage was attempted in 104 (69%) patients but failed in 13%. Mortality at 1 year was 27%. The cost of treatment, inpatient stay, occupational therapy, physiotherapy, convalescence, disablement services, home adaptations, home care, district nursing, transportation and outpatient visits were determined for each patient. The patients were classified according to their presentation and initial treatment into five groups (number of patients) whose median management costs (interquartile range) for 12 months were: Gp 1 (23 - Revascularisation for acute ischaemia = 3970 pounds (2984-5511) Gp 2 (29) - Angioplasty for critical ischaemia = 6611 pounds (3630-10,200) Gp 3 (52) - Reconstruction for critical ischaemia = 6766 pounds (4337-9677) Gp 4 (34) - Primary amputation = 10,162 pounds (7894-13,026) Gp 5 (12) - Primary bilateral amputations = 13,848 pounds (11,440-18,056) At 1 year, there was no significant difference in the cost of managing a patient with a critically ischaemic limb by angioplasty or surgical reconstruction. The cost of revascularisation for acute ischaemia was comparatively low because these patients required minimal rehabilitation. The median cost of managing a patient following amputation was almost twice that of successful limb salvage justifying an aggressive revascularisation policy. However, justification of such a policy on economic grounds requires salvage failure episode to be minimised as they increase costs considerably.

Mission, staffing, and budget data of flight programs in the United States

INTRODUCTION

Manage care and other health care reform initiatives have forced all hospitals to evaluate their work processes. In this era of cost containment, many flight programs are examining the structure of their programs to determined whether they are functioning in an efficient, cost-effective fashion.

METHODS

A survey was sent to the chief flight nurse of 240 flight programs in the United States.

RESULTS

Eighty-five programs (35.4%) responded. Data were collected on demographics, management structure, mission information, staffing issues, and budgets. Results in each program varied widely.

CONCLUSION

Benchmark data are available against which programs can compare themselves. Such comparisons may allow the discovery of opportunities to enhance program efficiency and cost-effectiveness.

Health services market testing--the experience of the community services review team in British Forces Germany

During 1993-1995 the health services in British Forces Germany were subjected to a market testing process by which the primary, community and acute health services for the British Servicemen and women, their families and attached civilian staff, a population of 70,000, were put out to competitive tender with the then current provider, the Defence Medical Services, as one tenderer for the contract. This paper outlines the methodology developed by the Health Alliance Community Services Review team in formulating a successful bid. It is considered that the process outlined could be of value to those involved in future market tests, commissioning projects or performance improvement programmes.

A comparison of pediatric and adult trauma patients transported by helicopter and ground EMS: managed-care considerations

INTRODUCTION

There is a paucity of data comparing injured pediatric patients transported by helicopter emergency medical services (HEMS) with patients transported by ground ambulance. The purpose of this study was to compare HEMS pediatric trauma patients to: 1) pediatric patients transported by ground to an urban level-1 trauma center (TC), and; 2) a similar cohort of adult patients. The managed-care consequences of these comparisons are highlighted.

METHODS

All trauma patients flown directly from the scene by HEMS from January 1, 1990, to April 30, 1993, were compared to a cohort of trauma patients arriving by ground advanced life support (ALS). All patients were transported to the same level-1 TC. The data collected included the mechanism of injury and the prehospital procedures performed, the injury severity score (ISS), and outcome.

RESULTS

There was no difference in the ISS between the HEMS (n = 216) and ground ALS (n = 355) pediatric patients (16.8 vs 17.1; p = 0.55). Adult HEMS patients (n = 202) had significantly higher ISS than did injured adults (n = 1652) transported by ground (18.0 vs 13.6; p < 0.0001). Overall, trauma patients transported by air directly from the scene have a higher ISS than patients transported by ground (17.5 vs 13.6; p < 0.001).

CONCLUSIONS

Pediatric patients transported by HEMS were as severely injured as those transported by ground, in contrast to adult patients. We conjecture that since trauma triage schemes classically focus on adults, ground personnel are more selective about which patients are flown to a TC, and less selective for pediatric patients. Trauma centers and HEMS programs should develop pediatric trauma triage protocols that do not overemphasize physiologic parameters.

Air medical transport for the trauma patient requiring cardiopulmonary resuscitation: a 10-year experience

INTRODUCTION

Air medical response and transport for the injured patient in cardiopulmonary arrest remain controversial. This study is a large, single-program experience.

METHODS

A retrospective chart review and descriptive study of all injured patients requiring cardiopulmonary resuscitation (CPR) immediately before or during air medical transport. The crew functioned under advanced cardiac life support/advanced trauma life support protocols.

SETTING

The patients, when transported, went to a variety of facilities, with the majority of patients transported to a level-I trauma center. The service area was primarily rural.

RESULTS

During 1985 to 1994, inclusive, there were 12,518 completed missions. A total of 320 injured patients required CPR (284 with blunt injury and 36 with penetrating injury), six of the 320 patients (1.9%) survived. Survivors and nonsurvivors did not differ significantly in age, mechanism of injury, time from initiation of CPR to arrival in the emergency department (ED), year of injury or initial cardiac rhythm. All survivors did, however, present to the ED in normal sinus rhythm with a palpable blood pressure.

CONCLUSION

Air medical transport for the injured patient without signs of life following prehospital intervention appears futile.

Confusion surrounding the treatment of traumatic cardiac arrest

BACKGROUND

To delineate the most reasonable approach to patients with traumatic cardiac arrest we studied the experience at our level 1 trauma center.

STUDY DESIGN

Patients with life-threatening trauma admitted during a 41-month period were screened to identify 245 patients who suffered cardiac arrest. Mechanisms of injury, location of arrest, length of arrest, transport methods, treatment rendered, neurologic state, outcomes, and cost of treatment were determined.

RESULTS

Six (2.4 percent) patients survived. Mechanism of injury, location of arrest, and age did not correlate with survival. Arrest time longer than ten minutes and loss of neurologic function were associated with mortality. Cost of care was not excessive.

CONCLUSIONS

Patients with traumatic cardiac arrest with intact neurologic function should receive treatment. Resuscitation should not be attempted in patients who also have severe brain injury or prolonged time of cardiac arrest.

A more cost-effective use of medical air evacuation personnel

Air transport of severely traumatized patients has evolved from novel pilot programs into integral services provided by tertiary care health centers. Medical air evacuation (MedEvac) effectiveness is mainly due to the rapid transport of critically injured (90% blunt trauma) patients to the hospital by highly trained medical personnel. A recent self-study of a University-based MedEvac crew showed that 67 per cent of their on-duty time was "available." Only 33 per cent of duty time was flying or related patient care. In this era of cost containment, the optimal use of materials and services must be reassessed. The most cost-effective use of the crew may require expanding the role of the MedEvac to include Emergency Department responsibilities as part of the job description. This represents change and stressful group dynamics. However, by coordinating the Emergency Department and MedEvac schedules, the hospital is able to make more efficient use of resources. No flight was delayed by this work proposal.