Showing posts with label critical care. Show all posts
Showing posts with label critical care. Show all posts

Tuesday, February 17, 2015

Racial-Ethnic Disparities in Managing Children with Type 1 Diabetes: Do They Exist?

     Everyone would agree that the care they provide to one child versus another shouldn't differ on the basis of race or ethnicity—but unfortunately, disparities in the management of diabetes do exist on that basis—as per some important findings contained in a study being released this week by Willi et al. (doi:10.1542/peds.2014-1774). 
The authors looked at disparities as documented in a national type 1 diabetes clinical registry for more than 10,000 children and teens between 1 year and 18 years of age with the disease.  Even after adjusting for socioeconomic status, differences existed in insulin treatment methods and treatment outcomes. 
So why does this happen—and just what are the disparities noted?  Are results due to different management strategies or perhaps it is because the genetics of the disease differs by race and ethnicity resulting in different achievable levels of hemoglobin A1C and other diabetic outcome measures. 
The authors offer some insight into the findings they have analyzed, but we have also asked diabetologist Dr. Stuart Chalew (doi: 10.1542/peds.2014-4136) to share his perspective on this study via a commentary released simultaneously.  Both the study and commentary are thought provoking, and we hope will generate some conversation from our readers as well via a response in the comments below, an e-letter or comment on our Facebook or Twitter pages.  Do you agree with the findings relative to your own practice?  We look forward to your comments as to whether the disparities noted are ones we can improve upon.

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Thursday, November 13, 2014

NICU Evacuation During Hurricane Sandy

By: Editorial Board Member Joann Schulte, DO, MPH

Ambulances at the ready during Hurricane Sandy.
Photo by mlcastle via Flickr
One of the most stressful nights of my life was in a disaster shelter in Florida about 48 hours after Hurricane Charley came ashore near Port Charlotte on the west coast. As a public health physician, my job was to set up the surveillance for storm-related injuries and deaths and deal with whatever else needed medical attention.

I was relieved that the storm had taken a last-minute left hand turn into Charlotte County and spared St. Petersburg where I owned a home. But many other Florida residents had no such luck.  In the two days after Charley’s landfall on August 13, 2004, Florida opened 228 shelters housing 47,458 people. Another 59 special needs shelters housed 3,119 residents, mostly elderly, who required basic medical monitoring and administration of medications.

I found myself in the Sarasota Convention Center, dealing with new arrivals who seemed sleepy and announced that they’d been using a generator inside a garage. Diagnosing possible carbon monoxide didn't require a medical genius. After they were dispatched to a hyperbaric chamber, I wanted a rest.

But rest wasn't in the cards when I learned that a bus with 13 Alzheimer’s patients would be arriving because the nursing home’s generator had failed. “I’m sorry, but some of them are pretty combative,” was the message from the nursing director, who had performed a miracle in finding a bus to transport them to the convention center. Obviously the special needs shelters that dealt with diabetics or patients with COPD weren't ready or capable for the care of Alzheimer’s patients. I started half a dozen people on the phone making calls to find places that could take the 13 impaired men and women.

That’s why I found it easy to identify with the dilemma on the other end of life—evacuating a neonatal intensive care unit (NICU) that Dr. Michael Espiritu and his co-authors describe in the current issue of Pediatrics (doi: 10.1542/peds.2014-0936).

Portions of New York City, including the medical campus of New York University (NYU), can be flooded by the water surge driven by hurricane winds. The authors describe their experiences during 2012’s Hurricane Sandy, which arrived 15 months after Hurricane Irene.  With Irene, the neonatologists at NYU Langone Medical Center had successfully evacuated a population of 19 infants, including three who were mechanically ventilated and had done so in advance of the storm.  Sandy was another story.

The NYU hospital had an incident command structure and plans to deal with patient care. High-risk pregnant women were transferred out to minimize the odds of delivery room resuscitation or new NICU admissions; stable infants were discharged. On October 29, 2012, governmental decision makers had decreed that NYU and other hospitals would shelter in place, and the hospital had checked all the red power outlets that connect to emergency generators. The ventilators and other essential equipment had been plugged in and staffing was arranged. The NYU NICU had a census of 21 infants, including one on conventional ventilation and one on the high frequency oscillator (HFOV). Four other infants were on NCPAP. Then the power went out at 8:30 p.m.

Dr. Espiritu describes the measure taken for patient safety, and the ultimate transfer of infants to six other NYC hospitals. The infants left one by one. The NYU NICU is on the ninth floor and teams composed of nurses and respiratory therapist and a physician taking the infants down the unlighted stairs. One nurse carried an infant, sometimes holding the endotracheal tube in place. Others lugged IV pumps, oxygen tank and additional equipment. The physician ventilated each infant.

The authors report the evacuation took 10 minutes per infants, a passage lit by flashlights held by students at each landing. The infants departed between 945 p.m. and 1 a.m. The infants were all successfully transported to the receiving hospitals in ambulances contracted by FEMA.

The NYU NICU was closed for two and a half months after the Hurricane Sandy evacuation. Dr. Espiritu reports that the major problem was finding beds.  Who could accept a transfer patient was not a uniform decision – some hospitals permitted a fellow to do it. In others, it might be the chief of service. The authors suggested that future evacuations of NICUs or other hospital units might be more easily managed if the disaster response included a central bed management authority.

That was a lesson I learned from Charley with the elderly patients at the other extreme of life. It took us eight hours to find the nursing homes that could take the Alzheimer’s patients. The NYU authors describe a situation that many hospitals may have to face and suggest some concrete steps hospitals should take. Maybe your hospital isn't on the coast, but the weather isn't always sunny, and you never know what the wind might bring your way. What kind of planning and drilling have you done?