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Diversion
Kinds of Diversion Terms modified by Diversion Selected AbstractsThe Effects of Ambulance Diversion: A Comprehensive ReviewACADEMIC EMERGENCY MEDICINE, Issue 11 2006Julius Cuong Pham MD Objectives To review the current literature on the effects of ambulance diversion (AD). Methods The authors performed a systematic review of AD and its effects. PubMed, EMBASE, the Cochrane database, societal meeting abstracts, and references from relevant articles were searched. All articles were screened for relevance to AD. Results The authors examined 600 citations and reviewed the 107 articles relevant to AD. AD is a common occurrence that is increasing in frequency. AD is associated with periods of emergency department (ED) crowding (Mondays, mid-afternoon to early evening, influenza season, and when hospitals are at capacity). Interventions that redesign the AD process or that provide additional hospital or ED resources reduce diversion frequency. AD is associated with increased patient transport times and time to thrombolytics but not with mortality. AD is associated with loss of estimated hospital revenues. Short of anecdotal or case reports, no studies measured the effect of AD on ED crowding, morbidity, patient and provider satisfaction, or EMS resource utilization. Conclusions Despite its common use, there is a relative paucity of studies on the effects of AD. Further research into these effects should be performed so that we may understand the role of AD in the health system. [source] The Global Diversion of Pharmaceutical DrugsADDICTION, Issue 9 2010Opiate treatment, the diversion of pharmaceutical opiates: a clinician's perspective ABSTRACT Aim To provide a clinician's perspective on the problem of diversion of prescribed pharmaceuticals. Methods The paper provides a personal account of working in a treatment context where diversion from opioid substitution treatment (OST) became a political issue potentially compromising the continued delivery of OST. It summarizes evidence on the impact of diversion, and measures to contain it, from the United Kingdom 1986,2006, Australia 1996,2008 and the United States and France from the mid-1990s. Results Opioid diversion to the black market occurs in proportion to the amount of opioids prescribed to be taken without supervision, and in inverse proportion to the availability of heroin. Diversion for OST programmes using supervision of dosing is less than diversion of opioids prescribed for pain, which is now a growing public health problem. Adverse consequences of diversion include opioid overdose fatalities, an increased incidence of addiction (particularly in jurisdictions where heroin is scarce) and compromising the public acceptance of long-term opioid prescribing. All long-term opioid prescribing requires monitoring of risk and appropriate dispensing arrangements,including dilution of methadone take-aways, supervision of administration for high-risk patients and random urine testing. Clinical guidelines influence practice, although prescribing often deviates from guidelines. Conclusion Clinical guidelines and clinical audit to enhance compliance with guidelines are helpful in maintaining the quality and integrity of the treatment system, and can contribute to keeping diversion within acceptable levels. [source] The global diversion of pharmaceutical drugsADDICTION, Issue 3 2009India: the third largest illicit opium producer? ABSTRACT Aims This paper explores India's role in the world illicit opiate market, particularly its role as a producer. India, a major illicit opiate consumer, is also the sole licensed exporter of raw opium: this unique status may be enabling substantial diversion to the illicit market. Methods Participant observation and interviews were carried out at eight different sites. Information was also drawn from all standard secondary sources and the analysis of about 180 drug-related criminal proceedings reviewed by Indian High Courts and the Supreme Court from 1985 to 2001. Findings Diversion from licit opium production takes place on such a large scale that India may be the third largest illicit opium producer after Afghanistan and Burma. With the possible exceptions of 2005 and 2006, 200,300 tons of India's opium may be diverted yearly. After estimating India's opiate consumption on the basis of UN-reported prevalence estimates, we find that diversion from licit production might have satisfied a quarter to more than a third of India's illicit opiate demand to 2004. Conclusions India is not only among the world's largest consumer of illicit opiates but also one of the largest illicit opium producers. In contrast to all other illicit producers, India owes the latter distinction not to blatantly illicit cultivation but to diversion from licit cultivation. India's experience suggests the difficulty of preventing substantial leakage, even in a relatively well-governed nation. [source] Finding a Solution for Ambulance DiversionACADEMIC EMERGENCY MEDICINE, Issue 7 2002Robert Steele MD No abstract is available for this article. [source] A Much-Needed Window on Opioid DiversionPAIN MEDICINE, Issue 2 2007David E. Joranson MSSW No abstract is available for this article. [source] Integrating nine prescription opioid analgesics and/or four signal detection systems to summarize statewide prescription drug abuse in the United States in 2007,PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 9 2009Michael F. Schneider MS Abstract Purpose Integrate statewide rankings of abuse across different drugs and/or signal detection systems to summarize prescription drug abuse in each state in 2007. Methods Four signal detection systems (Opioid Treatment Programs, Key Informants, Drug Diversion, and Poison Centers) that covered heterogeneous populations collected data on the abuse of nine opioids: hydrocodone, immediate-release oxycodone, tramadol, extended-release [ER] oxycodone, fentanyl, morphine, methadone, hydromorphone, and buprenorphine). We introduce here linearized maps which integrate nine drugs within each system; four systems for each drug; or all drugs and systems. Results When rankings were integrated across drugs, Rhode Island, New Hampshire, Maine, West Virginia, and Michigan were in the highest tertile of abuse in three systems. When rankings were integrated across signal detection systems, there was a geographic clustering of states with the highest rates for ER oxycodone (in Tennessee, Mississippi, Kentucky, Ohio, Indiana, Michigan, and in Massachusetts, New Hampshire, Maine, and Vermont) and methadone (Massachusetts, Rhode Island, New Hampshire, Maine, Vermont, Connecticut, and New Jersey). When rankings were integrated across both drugs and signal detection systems, states with 3-digit ZIP codes below 269 (i.e., from Massachusetts to West Virginia): Massachusetts, New Hampshire, Maine, Vermont, Washington DC, Virginia, and West Virginia were in the highest tertile and only Delaware was in the lowest tertile. Conclusions We have presented methods to integrate data on prescription opioid abuse collected by signal detection systems covering different populations. Linearized maps are effective graphical summaries that depict differences in the level of prescription opioid abuse at the state level. Copyright © 2009 John Wiley & Sons, Ltd. [source] How to Put the Community in Community-Based Justice: Some Views of Participants in Criminal Court DiversionTHE HOWARD JOURNAL OF CRIMINAL JUSTICE, Issue 2 2004Tammy Landau Individuals charged with criminal offences who meet strict criteria are diverted from the criminal process in exchange for performing a community sanction. Under this model, direct community involvement is critical to ,success'. This study is an evaluation of these projects, combining file data with the results of interviews with the main participants. Results suggest that the projects are highly successful, and that involved communities are highly supportive of the current form and structure of post-charge diversion. [source] Ambulance Diversion as a Proxy for Emergency Department Crowding: The Effect on Pediatric Mortality in a Metropolitan AreaACADEMIC EMERGENCY MEDICINE, Issue 2 2009Rohit P. Shenoi MD Abstract Objectives:, The objective was to determine the prevalence of emergency department (ED) ambulance diversion among Houston pediatric hospitals and its association with mortality of pediatric patients. Methods:, Hospital diversion and patient data between August 2002 and December 2004 were used to examine the impact of diversion on mortality of children under age 18 years. Patients were assumed to be exposed to ED crowding if diversion and admission or ED arrival times overlapped. Univariate and logistic regression were performed to determine if diversion was associated with mortality while controlling for age, illness severity, injury, and transfer status. Results:, Mean hospital diversion hours as a percentage of operating hours were 10.58 (standard deviation [SD] ± 9). Overall, of 63,780 admissions, there were 4,095 (6.4%) children admitted during diversion. Fewer severely ill patients were admitted during diversion than nondiversion times (odds ratio [OR] = 0.72; 95% confidence interval [CI] = 0.66 to 0.78). The presence of diversion was protective for mortality (OR = 0.51; 95% CI = 0.34 to 0.77) in bivariate analysis. Mortality was associated with presence of major or extreme illness (OR = 60.7; 95% CI = 45.2 to 81.5), injury (OR=1.7; 95% CI = 1.4 to 2.1), and transfer status (OR = 6.3; 95% CI = 5.4 to 7.3). Using conditional logistic regression, major or extreme illness (OR = 50.7; 95% CI = 37.7 to 68.3), injury (OR 3.7; 95% CI = 2.9 to 4.7), and transfer (OR = 2.7; 95% CI = 2.2, 3.2) were associated with mortality, but diversion did not show any association with mortality. After combining ED and inpatient deaths, no association between diversion and mortality was observed. Conclusions:, Hospital diversion due to ED crowding is common in pediatrics. The authors found no evidence of an association between diversion and ED and inpatient pediatric mortality. [source] The Financial Impact of Ambulance Diversion on Inpatient Hospital Revenues and ProfitsACADEMIC EMERGENCY MEDICINE, Issue 1 2009Daniel A. Handel MD Abstract Objectives:, The objective was to study the association between ambulance diversion and weekly inpatient hospital revenues and profits. Methods:, This was a retrospective review of administrative data from one academic medical center from July 1, 2003, to December 31, 2006. Given the high amount of daily variability, inpatient hospital revenues and profits were collapsed by week and evaluated in four categories: no diversion, mild diversion (from >0 and <10 hours), moderate diversion (>10 and <20 hours), and high diversion (>20 hours). Revenues and profits for two categories of patients admitted to the hospital were calculated: 1) patients admitted from the emergency department (ED; i.e., those arriving by ambulance and by other means) and 2) electively admitted patients. Results:, A total of 166,460 ED patients were included in the analysis. Inpatient hospital revenues were included from 85,111 patients, 28,665 of which were admissions from the ED (33.7%). For patients admitted from the ED, the average weekly revenues during periods of high diversion were $265K higher than periods of no diversion. For patients admitted on an elective basis, revenues were significantly higher when comparing periods of mild divert to high diversion (an additional $415K weekly). The overall increase in profitability was significant for periods of severe divert compared to no divert ($119K per week). Conclusions:, Periods of greater diversion are associated with higher inpatient revenues and profits for ED, electively admitted patients, and the overall inpatient hospital population. Therefore, no financial disincentive exists from an inpatient perspective for the boarding of admitted patients in the ED and increasing periods of diversion. Efforts to decrease ambulance diversion must therefore be based on other rationales, like patient safety, quality of care, and improving access to care, or new models of reimbursement that reward hospitals for reducing ambulance diversion. [source] Decreasing Lab Turnaround Time Improves Emergency Department Throughput and Decreases Emergency Medical Services Diversion: A Simulation ModelACADEMIC EMERGENCY MEDICINE, Issue 11 2008Alan B. Storrow MD Abstract Background:, The effect of decreasing lab turnaround times on emergency department (ED) efficiency can be estimated through system-level simulation models and help identify important outcome measures to study prospectively. Furthermore, such models may suggest the advantage of bedside or point-of-care testing and how they might affect efficiency measures. Objectives:, The authors used a sophisticated simulation model in place at an adult urban ED with an annual census of 55,000 patient visits. The effect of decreasing turnaround times on emergency medical services (EMS) diversion, ED patient throughput, and total ED length of stay (LOS) was determined. Methods:, Data were generated by using system dynamics analytic modeling and simulation approach on 90 separate days from December 2, 2007, through February 29, 2008. The model was a continuous simulation of ED flow, driven by real-time actual patient data, and had intrinsic error checking to assume reasonable goodness-of-fit. A return of complete laboratory results incrementally at 120, 100, 80, 60, 40, 20, and 10 minutes was compared. Diversion calculation assumed EMS closure when more than 10 patients were in the waiting room and 100% ED bed occupancy had been reached for longer than 30 minutes, as per local practice. LOS was generated from data insertion into the patient flow stream and calculation of time to specific predefined gates. The average accuracy of four separate measurement channels (waiting room volume, ED census, inpatient admit stream, and ED discharge stream), all across 24 hours, was measured by comparing the area under the simulated curve against the area under the measured curve. Each channel's accuracy was summed and averaged for an overall accuracy rating. Results:, As lab turnaround time decreased from 120 to 10 minutes, the total number of diversion days (maximum 57 at 120 minutes, minimum 29 at 10 minutes), average diversion hours per day (10.8 hours vs. 6.0 hours), percentage of days with diversion (63% vs. 32%), and average ED LOS (2.77 hours vs. 2.17 hours) incrementally decreased, while average daily throughput (104 patients vs. 120 patients) increased. All runs were at least 85% accurate. Conclusions:, This simulation model suggests compelling improvement in ED efficiency with decreasing lab turnaround time. Outcomes such as time on EMS diversion, ED LOS, and ED throughput represent important but understudied areas that should be evaluated prospectively. EDs should consider processes that will improve turnaround time, such as point-of-care testing, to obtain these goals. [source] The Financial Impact of Ambulance Diversions and Patient ElopementsACADEMIC EMERGENCY MEDICINE, Issue 1 2007Thomas Falvo DO Abstract Objectives Admission process delays and other throughput inefficiencies are a leading cause of emergency department (ED) overcrowding, ambulance diversion, and patient elopements. Hospital capacity constraints reduce the number of treatment beds available to provide revenue-generating patient services. The objective of this study was to develop a practical method for quantifying the revenues that are potentially lost as a result of patient elopements and ambulance diversion. Methods Historical data from 62,588 patient visits to the ED of a 450-bed nonprofit community teaching hospital in central Pennsylvania between July 2004 and June 2005 were used to estimate the value of potential patient visits foregone as a result of ambulance diversion and patients leaving the ED without treatment. Results The study hospital may have lost $3,881,506 in net revenue as a result of ambulance diversions and patient elopements from the ED during a 12-month period. Conclusions Significant revenue may be foregone as a result of throughput delays that prevent the ED from utilizing its existing bed capacity for additional patient visits. [source] Diversions and diversity: Does the personalisation agenda offer real opportunities for taking children's home literacies seriously?ENGLISH IN EDUCATION, Issue 2 2009Marilyn Mottram Abstract This paper argues that the current commitment to personalised learning opens up real opportunities for changing the language and practice of literacy teaching as it currently operates in England. We argue that there is a need to seize the opportunities currently on offer, to educate teachers differently and to develop classroom practice and pedagogies that acknowledge the complexities of children's lives and literacies. We draw on evidence from a year-long ethnographic research study, conducted between 2006,2007, of fourteen children and their families. The children attended the same inner city primary school in an area of urban regeneration characterised by high levels of economic deprivation, high crime and many social problems. The resulting evidence suggests that personalising learning becomes a reality when teachers are given space and time to develop their understanding of the uses and meaning of literacy in the communities they serve. [source] IMPACT OF COAL SURFACE MINING AND RECLAMATION ON SUSPENDED SEDIMENT IN THREE OHIO WATERSHEDS,JOURNAL OF THE AMERICAN WATER RESOURCES ASSOCIATION, Issue 4 2000James V. Bonta ABSTRACT: Prior to PL95,87 little research had been conducted to determine the impacts of mining and reclamation practices on sediment concentrations and yields on a watershed scale. Furthermore, it was unknown whether sediment yield and other variables would return to undisturbed levels after reclamation. Therefore, three small watersheds, with differing lithologies and soils, were monitored for runoff and suspended sediment concentrations during three phases of watershed disturbances: undisturbed watershed condition, mining and reclamation disturbances, and post-reclaimed condition. Profound increases in suspended-sediment concentrations, load rates, and yields due to mining and reclamation activities, and subsequent drastic decreases after reclamation were documented. Even with increases in runoff potential, reductions in suspended-sediment concentrations and load rates to below or near undisturbed-watershed levels is possible by using the mulch-crimping technique and by removing diversions. Maximum concentrations and load rates occurred during times of active disturbances that exposed loose soil and spoil to high-intensity rains. Sediment concentrations remained elevated compared with the undisturbed watershed when diversions were not well maintained and overtopped, and when they were not removed for final reclamation. Diversions are useful for vegetation establishment, but should be maintained until they are removed for final reclamation after good vegetative cover is established. [source] The Financial Impact of Ambulance Diversions and Patient ElopementsACADEMIC EMERGENCY MEDICINE, Issue 1 2007Thomas Falvo DO Abstract Objectives Admission process delays and other throughput inefficiencies are a leading cause of emergency department (ED) overcrowding, ambulance diversion, and patient elopements. Hospital capacity constraints reduce the number of treatment beds available to provide revenue-generating patient services. The objective of this study was to develop a practical method for quantifying the revenues that are potentially lost as a result of patient elopements and ambulance diversion. Methods Historical data from 62,588 patient visits to the ED of a 450-bed nonprofit community teaching hospital in central Pennsylvania between July 2004 and June 2005 were used to estimate the value of potential patient visits foregone as a result of ambulance diversion and patients leaving the ED without treatment. Results The study hospital may have lost $3,881,506 in net revenue as a result of ambulance diversions and patient elopements from the ED during a 12-month period. Conclusions Significant revenue may be foregone as a result of throughput delays that prevent the ED from utilizing its existing bed capacity for additional patient visits. [source] Clinical aspects on neonatal cholestasis based on observations at a Swedish tertiary referral centreACTA PAEDIATRICA, Issue 2 2001B Fischler The aim of the study was to investigate the clinical aspects of neonatal cholestasis. The medical records of 85 cholestatic infants were retrospectively reviewed. A majority of the patients were referred from other parts of the country. The most common diagnoses were extrahepatic biliary atresia (n= 30 patients), ,1 -antitrypsin deficiency (n=11) and progressive familial intrahepatic cholestasis (n= 11). On presentation, the biliary atresia group had higher mean serum values of bilirubin, G-GT and cholesterol than the patients with intrahepatic cholestasis, with no significant differences noticed for any other biochemical parameter. A lack of excretion on hepatobiliary scintigraphy was noticed in all investigated patients with biliary atresia, but also in 9 of 34 patients with intrahepatic neonatal cholestasis. There was no statistical correlation between the age at portoenterostomy and the outcome in patients with biliary atresia. However, both the detection of a partial flow on perioperative cholangiogram and the establishment of a non-icteric phase within 6 mo after the portoenterostomy correlated to a good outcome. Eight of 11 patients with progressive familial intrahepatic cholestasis were treated with a biliary diversion procedure, five of eight experienced a sustained cholestatic remission. Conclusions: Progressive familial intrahepatic cholestasis may be a more common cause of neonatal cholestasis in Sweden than reported elsewhere and that the experience with biliary diversion is positive. While early referral in patients with extrahepatic biliary atresia remains important, a portoenterostomy should be attempted also in patients referred after 3 mo of age. [source] Why Games Will Be the Preeminent Art Form of the 21stCenturyCOMPUTER GRAPHICS FORUM, Issue 3 2001Chris Hecker Computer games share many artistic and technical characteristics with films of the early 1900s. Games' artistic evolution is hampered by the lack of artistic respect from society at large, and the lack of technical standards that would allow artistic innovation. The same problems affected cinema during its birth. During the early 20th century, film managed to find its way from popular diversion to highly respected art form. Will games follow the same course, or will they be stuck forever in the ghetto of pop culture? What technological and artistic changes need to occur in the medium for games to evolve beyond merely shooting aliens and into an art form worthy of association with painting, music, writing, and film? This talk will pose some of those questions, if not attempt to answer them. [source] DISRUPTING ILLEGAL FIREARMS MARKETS IN BOSTON: THE EFFECTS OF OPERATION CEASEFIRE ON THE SUPPLY OF NEW HANDGUNS TO CRIMINALS,CRIMINOLOGY AND PUBLIC POLICY, Issue 4 2005ANTHONY A. BRAGA Research Summary: The question of whether the illegal firearms market serving criminals and juveniles can be disrupted has been vigorously debated in policy circles and in the literature on firearms and violence. To the extent that prohibited persons, in particular, are supplied with guns through systematic gun trafficking, focused regulatory and investigative resources may be useful in disrupting the illegal supply of firearms to criminals. In Boston, a gun market disruption strategy was implemented that focused on shutting down illegal diversions of new handguns from retail sources. Multivariate regression analyses were used to estimate the effects of the intervention on new handguns recovered in crime. Our results suggest that focused enforcement efforts, guided by strategic analyses of ATF firearms trace data, can have significant impacts on the illegal supply of new handguns to criminals. Policy Implications: The problem-oriented policing approach provides an appropriate framework to uncover the complex mechanisms at play in illicit firearms markets and to develop tailor-made interventions to disrupt the illegal gun trade. Strategic enforcement programs focused on the illegal diversion of new firearms from primary markets can reduce the availability of new guns to criminals. However, the extent to which criminals substitute older guns for new guns and move from primary markets to secondary markets in response to an enforcement strategy focused on retail outlets remains unclear. Our evaluation also does not provide policy makers with any firm evidence on whether supply-side enforcement strategies have any measurable impacts on gun violence. Jurisdictions suffering from gun violence problems should implement demand-side violence prevention programs to complement their supply-side efforts. [source] The Effects of Ambulance Diversion: A Comprehensive ReviewACADEMIC EMERGENCY MEDICINE, Issue 11 2006Julius Cuong Pham MD Objectives To review the current literature on the effects of ambulance diversion (AD). Methods The authors performed a systematic review of AD and its effects. PubMed, EMBASE, the Cochrane database, societal meeting abstracts, and references from relevant articles were searched. All articles were screened for relevance to AD. Results The authors examined 600 citations and reviewed the 107 articles relevant to AD. AD is a common occurrence that is increasing in frequency. AD is associated with periods of emergency department (ED) crowding (Mondays, mid-afternoon to early evening, influenza season, and when hospitals are at capacity). Interventions that redesign the AD process or that provide additional hospital or ED resources reduce diversion frequency. AD is associated with increased patient transport times and time to thrombolytics but not with mortality. AD is associated with loss of estimated hospital revenues. Short of anecdotal or case reports, no studies measured the effect of AD on ED crowding, morbidity, patient and provider satisfaction, or EMS resource utilization. Conclusions Despite its common use, there is a relative paucity of studies on the effects of AD. Further research into these effects should be performed so that we may understand the role of AD in the health system. [source] Clinical and Economic Factors Associated with Ambulance Use to the Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 8 2006Jennifer Prah Ruger PhD Background: Concern about ambulance diversion and emergency department (ED) overcrowding has increased scrutiny of ambulance use. Knowledge is limited, however, about clinical and economic factors associated with ambulance use compared to other arrival methods. Objectives: To compare clinical and economic factors associated with different arrival methods at a large, urban, academic hospital ED. Methods: This was a retrospective, cross-sectional study of all patients seen during 2001 (N= 80,209) at an urban academic hospital ED. Data were obtained from hospital clinical and financial records. Outcomes included acuity and severity level, primary complaint, medical diagnosis, disposition, payment, length of stay, costs, and mode of arrival (bus, car, air-medical transport, walk-in, or ambulance). Multivariate logistic regression identified independent factors associated with ambulance use. Results: In multivariate analysis, factors associated with ambulance use included: triage acuity A (resuscitation) (adjusted odds ratio [OR], 51.3; 95% confidence interval [CI] = 33.1 to 79.6) or B (emergent) (OR, 9.2; 95% CI = 6.1 to 13.7), Diagnosis Related Group severity level 4 (most severe) (OR, 1.4; 95% CI = 1.2 to 1.8), died (OR, 3.8; 95% CI = 1.5 to 9.0), hospital intensive care unit/operating room admission (OR, 1.9; 95% CI = 1.6 to 2.1), motor vehicle crash (OR, 7.1; 95% CI = 6.4 to 7.9), gunshot/stab wound (OR, 2.1; 95% CI = 1.5 to 2.8), fell 0,10 ft (OR, 2.0; 95% CI = 1.8 to 2.3). Medicaid Traditional (OR, 2.0; 95% CI = 1.4 to 2.4), Medicare Traditional (OR, 1.8; 95% CI = 1.7 to 2.1), arrived weekday midnight,8 AM (OR, 2.0; 95% CI = 1.8 to 2.1), and age ,65 years (OR, 1.3; 95% CI = 1.2 to 1.5). Conclusions: Ambulance use was related to severity of injury or illness, age, arrival time, and payer status. Patients arriving by ambulance were more likely to be acutely sick and severely injured and had longer ED length of stay and higher average costs, but they were less likely to have private managed care or to leave the ED against medical advice, compared to patients arriving by independent means. [source] Reliability of Computerized Emergency TriageACADEMIC EMERGENCY MEDICINE, Issue 3 2006Sandy L. Dong MD Objectives: Emergency department (ED) triage prioritizes patients based on urgency of care. This study compared agreement between two blinded, independent users of a Web-based triage tool (eTRIAGE) and examined the effects of ED crowding on triage reliability. Methods: Consecutive patients presenting to a large, urban, tertiary care ED were assessed by the duty triage nurse and an independent study nurse, both using eTRIAGE. Triage score distribution and agreement are reported. The study nurse collected data on ED activity, and agreement during different levels of ED crowding is reported. Two methods of interrater agreement were used: the linear-weighted , and quadratic-weighted ,. Results: A total of 575 patients were assessed over nine weeks, and complete data were available for 569 patients (99.0%). Agreement between the two nurses was moderate if using linear , (weighted ,= 0.52; 95% confidence interval = 0.46 to 0.57) and good if using quadratic , (weighted ,= 0.66; 95% confidence interval = 0.60 to 0.71). ED overcrowding data were available for 353 patients (62.0%). Agreement did not significantly differ with respect to periods of ambulance diversion, number of admitted inpatients occupying stretchers, number of patients in the waiting room, number of patients registered in two hours, or nurse perception of busyness. Conclusions: This study demonstrated different agreement depending on the method used to calculate interrater reliability. Using the standard methods, it found good agreement between two independent users of a computerized triage tool. The level of agreement was not affected by various measures of ED crowding. [source] Linked electronic medication systems in community pharmacies for preventing pseudoephedrine diversion: A review of international practice and analysis of results in AustraliaDRUG AND ALCOHOL REVIEW, Issue 6 2009CONSTANTINE G. BERBATIS Abstract Introduction and Aims. Pseudoephedrine is a precursor often diverted into the illegal manufacture of amphetamine type substances (ATS). The aim of this study was to evaluate the effectiveness of a linked electronic medication recording system (LEMS) established in Australian pharmacies in 2005 for preventing the diversion of pseudoephedrine. Design and Methods. The number of illegal ATS laboratories detected in each jurisdiction of Australia from 1996,1997 to 2004,2005 were analysed by linear regression nationally and by each jurisdiction. The statistical significance of seizures in 2005,2006 was based on the comparison of the observed value to the 95% prediction confidence intervals calculated from the historical data for each jurisdiction and nationally. Results. Pharmacies in Queensland commenced an LEMS in late 2005 to minimise retail pseudoephedrine diversion. The number of ATS laboratories seized in 2005,2006 in Queensland was significantly lower (P < 0.05) than predicted by historical data. For all other jurisdictions and nationally the totals of laboratories seized in 2005,2006 were not significantly different from predicted values. Discussion and Conclusions. The significant decline in ATS illegal laboratories seized in Queensland in 2005,2006 suggests the effective use of LEMS in pharmacies to minimise pseudoephedrine diversion. In order to evaluate a national LEMS, more frequent data on numbers of linked pharmacies, ATS laboratories seized and indicators of pseudoephedrine sales and misuse are required. Testing the use of LEMS by pharmacies for preventing the diversion of other medicines seems appropriate.[Berbatis CG, Sunderland VB, Dhaliwal SS. Linked electronic medication systems in community pharmacies for preventing pseudoephedrine diversion: A review of international practice and analysis of results in Australia. Drug Alcohol Rev 2009] [source] Evidence-based policy or policy-based evidence?DRUG AND ALCOHOL REVIEW, Issue 4 2007The role of evidence in the development, implementation of the Illicit Drug Diversion Initiative Abstract Issues. Evidence-based policy is promoted as the ideal in drug policy, yet public policy theorists suggest that policy-based evidence may be a more fitting analogy, where evidence is used selectively to support a predetermined policy direction. Approach. The following paper assesses the resonance of this notion to the development of the Illicit Drug Diversion Initiative (IDDI), an apparently pragmatic reform adopted in Australia in 1999 through the Federal Coalition ,Tough on Drugs' strategy. It utilises interviews with key informants from the Australian drug policy arena conducted in 2005 to assess the role of evidence in the design and implementation of the IDDI. Key Findings. The current paper shows that while policy-makers were generally supportive of the IDDI and viewed drug diversion as a more pragmatic response to drug users, they contend that implementation has suffered through a selective and variable emphasis upon evidence. Most notably, the IDDI is not premised upon best-practice objectives of reducing harm from drug use, but instead on ,Tough on Drugs' objectives of reducing drug use and crime. Implications. This paper contends that policy-based evidence may facilitate the adoption of pragmatic reforms, but reduce the capacity for effective reform. It therefore has both functional and dysfunctional elements. Conclusion. The paper concludes that greater attention is needed to understanding how to mesh political and pragmatic objectives, and hence to maximise the benefits from policy-based evidence. [Hughes CE. Evidence-based policy or policy-based evidence? The role of evidence in the development and implementation of the Illicit Drug Diversion Initiative. Drug Alcohol Rev 2007;26:363,368] [source] Trends in morphine prescriptions, illicit morphine use and associated harms among regular injecting drug users in AustraliaDRUG AND ALCOHOL REVIEW, Issue 5 2006LOUISA DEGENHARDT Abstract This paper examines population trends in morphine prescriptions in Australia, and contrasts them with findings from annual surveys with regular injecting drug users (IDU). Data on morphine prescriptions from 1995 to 2003 were obtained from the Drug Monitoring System (DRUMS) run by the Australian Government Department of Health and Ageing. Data collected from regular IDU as part of the Australian Illicit Drug Reporting System (IDRS) were analysed (2001,2004). The rate of morphine prescription per person aged 15,54 years increased by 89% across Australia between 1995 and 2003 (from 46.3 to 85.9 mg per person). Almost half (46%) of IDU surveyed in 2004 reported illicit morphine use, with the highest rates in jurisdictions where heroin was less available. Recent morphine injectors were significantly more likely to be male, unemployed, out of treatment and homeless in comparison to IDU who had not injected morphine. They were also more likely to have injected other pharmaceutical drugs and to report injection related problems. Among those who had injected morphine recently, the most commonly reported injecting harms were morphine dependence (38%), difficulty finding veins into which to inject (36%) and scarring or bruising (27%). Morphine use and injection is a common practice among regular IDU in Australia. In some cases, morphine may be a substitute for illicit heroin; in others, it may be being used to treat heroin dependence where other pharmacotherapies, such as methadone and buprenorphine, are perceived as being unavailable or undesirable by IDU. Morphine injection appears to be associated with polydrug use, and with it, a range of problems related to drug injection. Further research is required to monitor and reduce morphine diversion and related harms by such polydrug injectors. [source] ASIA PACIFIC COLUMN: New challenges and opportunities in managing substance abuse in MalaysiaDRUG AND ALCOHOL REVIEW, Issue 5 2006MAHMUD MAZLAN MD Abstract Until recently, Malaysia has lagged behind in the treatment of drug addiction and related disorders, despite experiencing severe drug problems. By the end of 2004, 234 000 heroin users or heroin-dependent individuals had been registered in the official government registry, but other estimates exceed 500 000 for heroin abusers in the country. Amphetamine-type stimulant abuse is also increasing and of considerable public and government concern. Among the population of drug users, HIV and other infectious diseases rates are very high. In the Western Pacific regions, Malaysia has the second highest HIV prevalence (after Vietnam) among adult populations (0.62%) and the highest proportion of HIV cases resulting from injection drug use (76.3%). Drug use and related disorders exert a heavy burden on the country's health care and legal systems. Historically, drug abusers were rehabilitated involuntarily in correctional, rather than health-care, facilities. This primarily criminal treatment approach had limited effectiveness which led to widespread public dissatisfaction and the recent introduction of medical treatments for addiction. Naltrexone was introduced in 1999; buprenorphine was introduced in 2001 and methadone in 2003. Agonist maintenance programmes were embraced rapidly by the medical community in Malaysia. Currently, over 30 000 opiate-dependent patients are treated with agonist maintenance treatments by more than 500 medical practitioners in Malaysia. Despite these recent advances, treatments for amphetamine-type stimulant abuse or dependence are underdeveloped, and diversion of agonist medications is an emerging concern. [source] Telemetry Monitoring during Transport of Low-risk Chest Pain Patients from the Emergency Department: Is It Necessary?ACADEMIC EMERGENCY MEDICINE, Issue 10 2005Adam J. Singer MD Abstract Background: Low-risk emergency department (ED) patients with chest pain (CP) are often transported by nurses to monitored beds on telemetry monitoring, diverting valuable resources from the ED and delaying transport. Objectives: To test the hypothesis that transporting low-risk CP patients off telemetry monitoring is safe. Methods: This was a secondary analysis of a prospective, observational cohort of ED patients with low-risk chest pain (no active chest pain, normal or nondiagnostic electrocardiogram, normal initial troponin I) admitted to a non,intensive care unit monitored bed who were transported off telemetry monitor by nonclinical personnel. A protocol allowing transportation of low-risk CP patients off telemetry monitoring to a monitored bed was developed, and an ongoing daily log of patients transported off telemetry was maintained for the occurrence of any adverse events en route to the floor. Adverse events requiring treatment included dysrhythmias, hypotension, syncope, and cardiac arrest. The study population included patients who presented during September,October 2004, whose data were abstracted from the medical records using standardized methodology. A subset of 10% of the medical records were reviewed by a second investigator for interrater reliability. Death, syncope, resuscitation, and dysrhythmias during transport or immediately on arrival to the floor were the outcomes measured. Descriptive statistics and confidence intervals (CIs) were used in data analysis. Results: During the study period, 425 patients had CP of potentially ischemic origin, of whom 322 (75.8%) were low risk and met the inclusion criteria and were transported off monitors. Their mean (±standard deviation) age was 58.3 (±16.0) years; 48.1% were female. During transport from the ED, there was no patient with any adverse events requiring treatment and there was no death (95% CI = 0% to 0.93%). Conclusions: Transportation of low-risk ED chest pain patients off telemetry monitoring by nonclinical personnel to the floor appears safe. This may reduce diversion of ED nurses from the ED, helping to alleviate nursing shortages. [source] Effects of vegetation on channel morphodynamics: results and insights from laboratory experimentsEARTH SURFACE PROCESSES AND LANDFORMS, Issue 9 2010Michal Tal Abstract A series of laboratory experiments demonstrates that riparian vegetation can cause a braided channel to self-organize to, and maintain, a dynamic, single-thread channel. The initial condition for the experiments was steady-state braiding in non-cohesive sand under uniform discharge. From here, an experiment consisted of repeated cycles alternating a short duration high flow with a long duration low flow, and uniform dispersal of alfalfa seeds over the bed at the end of each high flow. Plants established on freshly deposited bars and areas of braidplain that were unoccupied during low flow. The presence of the plants had the effect of progressively focusing the high flow so that a single dominant channel developed. The single-thread channel self-adjusted to carry the high flow. Vegetation also slowed the rate of bank erosion. Matching of deposition along the point bar with erosion along the outer bend enabled the channel to develop sinuosity and migrate laterally while suppressing channel splitting and the creation of new channel width. The experimental channels spontaneously reproduced many of the mechanisms by which natural meandering channels migrate and maintain a single dominant channel, in particular bend growth and channel cutoff. In contrast with the braided system, where channel switching is a nearly continuous process, vegetation maintained a coherent channel until wholesale diversion of flow via cutoff and/or avulsion occurred, by which point the previous channel tended to be highly unfavorable for flow. Thus vegetation discouraged the coexistence of multiple channels. Varying discharge was key to allowing expression of feedbacks between the plants and the flow and promoting the transition from braiding to a single-thread channel that was then dynamically maintained. Copyright © 2010 John Wiley & Sons, Ltd. [source] The Global Diversion of Pharmaceutical DrugsADDICTION, Issue 9 2010Opiate treatment, the diversion of pharmaceutical opiates: a clinician's perspective ABSTRACT Aim To provide a clinician's perspective on the problem of diversion of prescribed pharmaceuticals. Methods The paper provides a personal account of working in a treatment context where diversion from opioid substitution treatment (OST) became a political issue potentially compromising the continued delivery of OST. It summarizes evidence on the impact of diversion, and measures to contain it, from the United Kingdom 1986,2006, Australia 1996,2008 and the United States and France from the mid-1990s. Results Opioid diversion to the black market occurs in proportion to the amount of opioids prescribed to be taken without supervision, and in inverse proportion to the availability of heroin. Diversion for OST programmes using supervision of dosing is less than diversion of opioids prescribed for pain, which is now a growing public health problem. Adverse consequences of diversion include opioid overdose fatalities, an increased incidence of addiction (particularly in jurisdictions where heroin is scarce) and compromising the public acceptance of long-term opioid prescribing. All long-term opioid prescribing requires monitoring of risk and appropriate dispensing arrangements,including dilution of methadone take-aways, supervision of administration for high-risk patients and random urine testing. Clinical guidelines influence practice, although prescribing often deviates from guidelines. Conclusion Clinical guidelines and clinical audit to enhance compliance with guidelines are helpful in maintaining the quality and integrity of the treatment system, and can contribute to keeping diversion within acceptable levels. [source] The abuse potential of the synthetic cannabinoid nabiloneADDICTION, Issue 3 2010Mark A. Ware ABSTRACT Aim Nabilone is a synthetic cannabinoid prescription drug approved in Canada since 1981 to treat chemotherapy-induced nausea and vomiting. In recent years, off-label use of nabilone for chronic pain management has increased, and physicians have begun to express concerns about nabilone becoming a drug of abuse. This study evaluates the evidence for abuse of nabilone, which is currently ill-defined. Study design Scientific literature, popular press and internet databases were searched extensively for evidence of nabilone abuse. Focused interviews with medical professionals and law enforcement agencies across Canada were also conducted. Findings The scientific literature and popular press reviews found very little reference to nabilone abuse. Nabilone is perceived to produce more undesirable side effects, to have a longer onset of action and to be more expensive than smoked cannabis. The internet review revealed rare and isolated instances of recreational use of nabilone. The database review yielded little evidence of nabilone abuse, although nabilone seizures and thefts have occurred in Canada in the past few years, especially in Ontario. Most law enforcement officers reported no instances of nabilone abuse or diversion, and the drug has no known street value. Medical professionals reported that nabilone is not perceived to be a matter of concern with respect to its abuse potential. Conclusions Reports of nabilone abuse are extremely rare. However, follow-up of patients using nabilone for therapeutic purposes is prudent and should include assessment of tolerance and dependence. Prospective studies are also needed to definitively address the issue of nabilone abuse. [source] Commercial aviation in-flight emergencies and the physicianEMERGENCY MEDICINE AUSTRALASIA, Issue 1 2007Robert Cocks Abstract Commercial aviation in-flight emergencies are relatively common, so it is likely that a doctor travelling frequently by air will receive a call for help at some stage in their career. These events are stressful, even for experienced physicians. The present paper reviews what is known about the incidence and types of in-flight emergencies that are likely to be encountered, the international regulations governing medical kits and drugs, and the liability, fitness and indemnity issues facing ,Good Samaritan' medical volunteers. The medical and aviation literature was searched, and information was collated from airlines and other sources regarding medical equipment available on board commercial aircraft. Figures for the incidence of significant in-flight emergencies are approximately 1 per 10,40 000 passengers, with one death occurring per 3,5 million passengers. Medically related diversion of an aircraft following an in-flight emergency may occur in up to 7,13% of cases, but passenger prescreening, online medical advice and on-board medical assistance from volunteers reduce this rate. Medical volunteers may find assisting with an in-flight emergency stressful, but should acknowledge that they play a vital role in successful outcomes. The medico-legal liability risk is extremely small, and various laws and industry indemnity practices offer additional protection to the volunteer. In addition, cabin crew receive training in a number of emergency skills, including automated defibrillation, and are one of several sources of help available to the medical volunteer, who is not expected to work alone. [source] The global diversion of pharmaceutical drugsADDICTION, Issue 3 2009India: the third largest illicit opium producer? ABSTRACT Aims This paper explores India's role in the world illicit opiate market, particularly its role as a producer. India, a major illicit opiate consumer, is also the sole licensed exporter of raw opium: this unique status may be enabling substantial diversion to the illicit market. Methods Participant observation and interviews were carried out at eight different sites. Information was also drawn from all standard secondary sources and the analysis of about 180 drug-related criminal proceedings reviewed by Indian High Courts and the Supreme Court from 1985 to 2001. Findings Diversion from licit opium production takes place on such a large scale that India may be the third largest illicit opium producer after Afghanistan and Burma. With the possible exceptions of 2005 and 2006, 200,300 tons of India's opium may be diverted yearly. After estimating India's opiate consumption on the basis of UN-reported prevalence estimates, we find that diversion from licit production might have satisfied a quarter to more than a third of India's illicit opiate demand to 2004. Conclusions India is not only among the world's largest consumer of illicit opiates but also one of the largest illicit opium producers. In contrast to all other illicit producers, India owes the latter distinction not to blatantly illicit cultivation but to diversion from licit cultivation. India's experience suggests the difficulty of preventing substantial leakage, even in a relatively well-governed nation. [source] | ||||||||||||||||||||||||||||||||||||||||||||||||||||