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Korfhagen, Joseph JA Non-invasive Prototype Device for Detecting Intracerebral Hemorrhage
PhD, University of Cincinnati, 2014, Medicine: Neuroscience/Medical Science Scholars Interdisciplinary
Intracerebral hemorrhage (ICH) causes 67,000 deaths per year with the total volume of blood being the best predictor of outcome. Therefore, it is important to detect the ICH as early as possible to minimize damage to the brain. Often, the patient will have symptoms, which will allow the physician to determine if there is a hemorrhage by obtaining a computed tomography (CT) scan of the brain. Yet, the progression of the hematoma is unknown without getting another CT. After bleeding has occurred, the ICH causes perihematomal edema (PE), a secondary injury that causes further deficits in the patient. Even though most patients suffering from an ICH show symptoms, comatose or sedated patients do not, so it is difficult to know what their neurological status is at any given time. Therefore, there is a clinical need for a real-time, non-invasive device that can monitor the neurological status of a patient at any given time. A device using radiofrequency (RF) electromagnetic radiation has been developed that can detect hemorrhage and PE in an in vivo porcine model. This device is limited because it can only detect relative changes from an initial measurement. In this dissertation, the progress of this device is discussed, from a stationary dual-antennae setup that can detect changes due to the presence of ICH to the development of a mobile antennae system, which allows for RF antennae to be moved and monitor for changes throughout the brain. A brain-mimicking gelatin model, which simulates the electrical properties of the human brain, was developed for in vitro experimentation. Cavities of different volumes and geometrical configurations of blood were placed in the gel to simulate an ICH, and blood volumes as small as 1 mL could be detected. From these results, a qualitative model for detecting ICH was developed and discussed in relation to the experimental data. Different frequencies were studied, and it has been found that 950 MHz is an optimal frequency for detecting changes due to ICH and PE in an in vivo porcine ICH model. By moving the antennae around the head in a grid pattern, the different grid locations could be compared to each other, and there is potential to use these comparisons to determine if ICH and PE are present without requiring baseline measurements. Overall, there has been significant development in determining the optimal antennae characteristics necessary for developing an array of antennae that can monitor a patient for changes due to an ICH.

Committee:

Steve Danzer, Ph.D. (Committee Chair); Joseph Clark, Ph.D. (Committee Member); James Eliassen, Ph.D. (Committee Member); George Shaw, Ph.D. (Committee Member); Kenneth Wagner, Ph.D. (Committee Member)

Subjects:

Neurology

Keywords:

Intracerebral hemorrhage;Device;Radiofrequency;Neuroscience;Emergency Medicine;Edema

Bentley, Melissa AnnAn Assessment of Depression, Anxiety, and Stress among Nationally Certified EMS Professionals
Master of Science, The Ohio State University, 2011, Public Health

Among EMS professionals, occupational exposures in mental illness literature are not well-represented. Currently, no literature exists examining the prevalence of mental illness in a large national cohort of EMS professionals. As such, the purpose of this study is to address the lack of scientific knowledge and evidence in the field of mental illness among EMS professionals.

The objectives of this master’s thesis are three fold. The first objective is to estimate the prevalence and severity of depression, anxiety, and stress among a cohort of nationally certified EMS professionals. Because other healthcare professions may have similar occupational exposures related to mental illness, the second objective of this study is a comparison of nationally certified EMS professionals’ depression, anxiety, and stress prevalence to other healthcare professions. The third objective of this master’s thesis is the determination of differences between cases and controls (defined by the 21- question Depression, Anxiety, and Stress Scale (DASS-21)) from the same cohort with respect to clinical depression, anxiety, stress, and demographic and work-life characteristics.

n accordance with previous methodologies, a questionnaire was included as part of the 2009 biennial recertification paperwork mailed to all nationally certified EMS professionals prior to their 2009 expiration date. This questionnaire contained demographic and work-life characteristic items as well as the DASS-21. Three outcome variables of interest were derived from the DASS-21: clinical depression, clinical anxiety, and clinical stress. Any scores above “normal” for each of the outcomes were determined to be a case and controls were defined as those whose scores fell below the case cutpoint. A complete case-control analysis was performed for each of the three outcome variables. Independent variables were chosen based on previous methodologies and plausibility. A total of 15 independent variables were assessed.

The prevalence of depression among the cohort was found to be 6.8%, the prevalence of anxiety was found to be 6.0%, and the prevalence of stress was 5.9%.

In the final logistic regression models, certification level, service type, general health, exercise, smoking status, and age were found to be statistically significant in each of the depression, anxiety, and stress models. Further, years of experience, race, and education level was found to be unique only to the depression and stress models. Marital status was found to be statistically significant in only the depression and anxiety models. Lastly, gender was unique to the depression logistic model.

This study was able to identify statistically significant demographic and work-life characteristic variables that predicted depression, anxiety, and stress. Future research should attempt to follow EMS professionals prospectively to determine specific characteristics associated with occupational traumatic exposure and the development of clinical depression, anxiety, and stress. Likewise, specific research efforts should be undertaken to establish early recognition criteria in EMS professionals to ensure adequate and quick treatment of mental disorders.

Committee:

J.Mac Crawford, PhD (Advisor); Jay Wilkins III, DPH (Committee Member)

Subjects:

Public Health

Keywords:

EMS; prehospital emergency medicine; depression; anxiety; stress; paramedic; EMT

Feufel, Markus AlexanderBounded Rationality in the Emergency Department
Doctor of Philosophy (PhD), Wright State University, 2009, Human Factors and Industrial/Organizational Psychology PhD
This research aimed at understanding bounded rationality – that is, how simple heuristics result in satisfactory outcomes – in a naturalistic setting where agents have to meet environmental demands with limited resources. To do so, two methodological approaches were taken, an observational and an experimental study of U.S. emergency physicians who have to provide a satisfactory level of care while simultaneously coping with uncertainty, time and resources constraints. There are three major findings. First, based on observations of 12 resident and 6 attending physicians at two Midwestern emergency departments (ED), ED physicians use at least two general heuristics. One heuristic exploits symptom-disease relationships with the goal to rule out ‘worst cases’ that would require immediate medical attention. The other heuristic aims at identifying diseases that are commonly associated with a set of symptoms. Thus, whereas the former heuristic emphasizes medical safety by aiming at identifying even unlikely ‘worst cases,’ the latter stresses efficiency by aiming at separating typical worst from common benign cases to allocate resources appropriately. Second, the selection of general heuristics is situated in an environmental context. This context is reflected in epidemiological constraints that delimit the range of patients’ potential medical problems as well as sociocultural constraints that delimit the range of potential, desirable, or required care solutions. ED physicians’ exploit these constraints to actively (re)formulate the problem to-be-solved and select strategies that satisfy requirements for safe and efficient care. Third, based on observations and data from 39 clinicians-in-training who participated in the experimental study, emergency care delivery is the solution of medical problems in a socially dynamic setting. ED physicians aim at understanding their patients’ needs and circumstances to obtain salient information about potential (medical) problems and, ultimately, adapt the selection of general heuristics to a particular situation/patient. Thus, a caring attitude and safe and effective emergency care are not contradictory but dynamically intertwined. The descriptive-exploratory methodology chosen does not allow conclusive statements. However, findings point to promising avenues for future research such as the impact of sociocultural constraints on the selection of safe and efficient care strategies or the clinical relevance of the social connection between patient and physician.

Committee:

John Flach, PhD (Advisor); Glenn Hamilton, MD, MSM (Committee Member); Valerie Shalin, PhD (Committee Member); Scott Watamaniuk, PhD (Committee Member); Tamera Schneider, PhD (Committee Member)

Subjects:

Psychology

Keywords:

bounded rationality; ecological rationality; naturalistic decision making; ethnography; sociocultural systems; emergency medicine; medical decision making; human factors; cognitive systems

Curreri, Allen JINFORMATION TECHNOLOGY IN THE EMERGENCY ROOM: THE ROLE OF MINDFULNESS
Doctor of Philosophy, Case Western Reserve University, 2017, Management
Split-second decisions in emergency departments often have life-or-death consequences for patients. Yet researchers are just beginning to understand the complexities of clinical decision making in emergency medical settings, where traditional, rule-based models are proving often inadequate. Meanwhile, hospitals are under increased pressure to cut costs while continuing to improve quality and safety of care and comply with new regulations. One way hospitals have responded to this pressure is by rapidly adopting healthcare information technology (HIT) systems, especially rule-based clinical decision support systems (CDSSs). By understanding what factors influence how physicians use HIT to reliably arrive at the correct diagnosis and treatment decisions, management can implement programs that improve the practice of emergency medicine. This sequence of three studies explores the role of mindfulness in emergency physicians’ HIT-supported decision making. The first study qualitatively explores decision making among emergency physicians and finds that experienced physicians do not rely on rule-based decision strategies, instead they employ intuitive reasoning supported by mindful awareness of clinical contexts. The second study quantitatively tests a model of the relationship between HIT and emergency physician performance as mediated by mindfulness. Results reveal that mindfulness dampens a negative relationship between HIT use and performance, regardless of HIT characteristics. Finally, the third study sharpens the focus on mindfulness through a two-phase, embedded mixed-method design exploring the role of mindfulness in generating patterns of CDSS use. Findings reveal a significant positive correlation between mindfulness and performance. Results also show that more mindful physicians are open to change and may use CDSSs for confirmation only, rather than for initial diagnosis and treatment information. Overall, results reveal several important research directions and recommendations for healthcare management. It is clear that mindfulness has beneficial effects on physician performance, particularly in environments characterized by high HIT use. Managers should invest in training and interventions designed to improve mindfulness in ER physicians. They should also implement HIT use policies that allow physicians to use decision support tools in a supportive role. These findings should be of interest to HIT designers, who are advised to focus on designing tools that support, rather than hinder, user mindfulness.

Committee:

Kalle Lyytinen, Dr. (Committee Chair); Richard Boland, Dr. (Committee Member); Ritu Agarwal, Dr. (Committee Member); David Aron, Dr. (Committee Member)

Subjects:

Health; Health Care; Health Care Management; Information Science; Information Systems; Information Technology; Management; Medicine; Organizational Behavior

Keywords:

healthcare information technology; clinical decision support; emergency medicine; clinical decision making; mindfulness; situational awareness

Sterrett, Emily CAre Quality Improvement Outcomes Sustainable within a Dynamic Clinical Environment?
MS, University of Cincinnati, 2016, Medicine: Clinical and Translational Research
Methods A retrospective study of patients with long-bone extremity fractures using electronic medical record data from 2007 to 2014. The primary outcome was the proportion of patients receiving timely IV opioids. Control charts and time series models were used to determine if changes in the clinical microenvironment were associated with changes in the outcome measure. Long-term unintended consequences included patients receiving potentially unnecessary IVs and the process being applied to patients without long-bone extremity fractures. Results Improved timeliness of IV opioids was sustained. The type of physician who staffed the process and faculty physician staffing hours were associated with a 9.6% decrease, and 11.8% increase in timely IV opioids. Implementation of the IV opioid process was not associated with an increase in potentially unnecessary IV placement. Of patients receiving the IV opioid process, 22% did not have a long-bone extremity fracture, of whom 91% were diagnosed with another painful injury. Conclusion Improving IV opioid timeliness was robust despite changes in the clinical microenvironment. Changes in physician staffing and responsibilities in a PED may be especially important to consider when planning future improvement initiatives. Our findings support the importance of higher reliability interventions, such as identification and utilization of existing patterns of behavior, as being particularly high-yield for improvement teams striving to achieve sustained outcomes.

Committee:

Erin Nicole Haynes (Committee Chair); Terri L. Byczkowski| (Committee Member); Eileen Murtagh Kurowski (Committee Member)

Subjects:

Immunology; Surgery

Keywords:

quality improvement;sustainability;unintended consequences;emergency medicine;pediatrics;pain

Stephens, Robert JosephManaging the Margin: A Cognitive Systems Engineering Analysis of Emergency Department Patient Boarding
Doctor of Philosophy, The Ohio State University, 2010, Industrial and Systems Engineering
The emergency medicine system absorbs much of the burden of the chronic problems facing healthcare in the United States today: an increasingly unhealthy populace, variability in access to primary care, and severe resource shortages. This makes emergency medicine, and in particular the emergency department (ED), an excellent natural laboratory in which to study adaptation and cognitive work. The primary objectives of this research are to 1) identify how differing availability of resources influences timeliness of admission for lower-resourced and higher-resourced patient cohorts, and 2) identify strategies for managing margin of maneuver in a complex, socio-technical setting. This research was conducted from a cognitive systems engineering perspective, which has adaptation to complexity as a central conceptual lens. The research was conducted in an ED at one academic hospital; this environment is a complex, socio-technical setting, being characterized by high uncertainty, high consequences for failure, distributed work across specialized roles, and high variation in workload. In particular, this dissertation examines one problem, patient boarding, focusing on the causes and correlates of boarding for two contrasting patient cohorts. A cognitive systems engineering perspective focuses analysis on how boarding exacerbates, and is exacerbated by, challenges to workload capacity, coordination, and ultimately resilience in the ED. Both observations of actual ED work and aggregate chart review are used as inputs to the analysis. The findings have implications for short- and long-term interventions to address boarding and other quality of care-related issues in the ED. Selected findings include that the barriers and facilitators to patient admission are different for patient cohorts that have comparatively more and less resources, and that a variety of solutions, including the creation of a special buffer, are used by the ED to ease the impact of lower-resourced patient cohorts on overall system performance. The findings suggest three categories that systems could potentially employ to manage their margin of maneuver: defensive, cooperative, and autonomous. Future research directions are discussed, including extending current cognitive systems engineering models of resilient performance.

Committee:

Emily Patterson, PhD (Advisor); David Woods, PhD (Committee Member); Philip Smith, PhD (Committee Member)

Subjects:

Industrial Engineering

Keywords:

cognitive systems engineering; cognitive engineering; healthcare; emergency medicine; emergency department; boarding; crowding; length of stay; resilience; human factors; margin of maneuver; mental health; intensive care unit

El Rimawi, NidalDevelopment of an Audio Visual Tool for Medical Training at Kennedy Space Center
Master of Science (MS), Wright State University, 2006, Aerospace Medicine
El Rimawi, Nidal. M.D. M.S., Department of Aerospace Medicine, Wright State University, 2006. Development of an Audio-Visual Tool for Medical Training at Kennedy Space Center As part of an effort to improve efficiency of space-flight medical support at Kennedy Space Center, a training video was created to replace a series of lectures given before a launch or landing of the Space Shuttle. The video was designed to familiarize volunteer physicians from around the country with the specific emergency response protocols for a Space Shuttle launch or landing emergency at Kennedy Space Center. The methods used were consistent with standard film making techniques as outlined in several film making texts. The Production was divided into three phases; A pre-production phase wherein the research, screenwriting and production planning took place, a Production phase consisting of the actual filming of the various scenes in the script and finally, a post-production phase during which the video was edited, music was added and the finished video screened and copied. The result was that the video was completed in seven months with the participation of over a hundred people. The final video won several awards for educational and government film and met all expectations of the author and the medical department. It was ultimately given to the Aerospace Medicine Residency program at Wright State University and to the medical staff at Kennedy Space Center.

Committee:

Robin Dodge (Advisor)

Keywords:

Aerospace Medicine; Space Medicine; Medical Education; Audio-Visual Tool; Kennedy Space Center; Space Medical Support; Emergency Medicine; Spaceflight Support; Spaceflight Emergencies; Film Production

King, Hillary S.An Ethically Informed Consideration of the Use of a Waiver of Informed Consent in Emergency Medicine Research
Master of Arts (MA), Ohio University, 2013, Philosophy (Arts and Sciences)
The concept of informed consent arose in the mid-20th century as a mechanism for protecting patients and research subjects from abuses. But recent technological advances in the field of emergency medicine research have created new challenges for informed consent procedures. As a result, in 1996 the FDA passed a “Final Rule,” which provides for a waiver of informed consent in a narrow class of studies. In this paper I will first conduct a historical survey of the development of informed consent regulations. Then, I will lay out several of the main arguments for the use of the waiver in emergency medicine research. I will conclude that these arguments are unsatisfactory, and that conducting research on human subjects without their consent is ethically dubious, at best. Lastly, I will consider alternative ways in which this socially valuable research might still be carried out, albeit without the use of the waiver of informed consent.

Committee:

Mark LeBar, Ph.D. (Advisor); Arthur Zucker, Ph.D. (Committee Member); James Petrik, Ph.D. (Committee Member)

Subjects:

Ethics; Medical Ethics; Philosophy

Keywords:

Waiver of Informed Consent; Emergency Medicine Research