From the Feds: Research, Programs, and Products

Transcription

1 FROM THE FEDS From the Feds: Research, Programs, and Products Laurie Flaherty, RN, MS, Washington, DC Department of Health and Human Services Health Consequences Among First Responders After Events Associated With Illicit Methamphetamine Laboratories No Evidence That Back Belts Reduce Injury Seen in Study of Back Belt Users Evidence for the Prevention of Thromboembolism After Injury Laurie Flaherty, Mid-Maryland Chapter, is Emergency Nurse at Suburban Hospital, Bethesda, Md, and a Contract Employee of the National Highway Traffic Safety Administration in Washington, DC. For reprints, write: Laurie Flaherty, RN, MS, 3519 Rittenhouse St, NW, Washington, DC 20015; lflaherty@nhtsa.dot.gov. J Emerg Nurs 2001;27: Copyright 2001 by the Emergency Nurses Association /2001 $ /9/ doi: /men PUBLIC HEALTH SERVICE Centers for Disease Control and Prevention (CDC) Health consequences among first responders after events associated with illicit methamphetamine laboratories: Methamphetamine, a central nervous system stimulant, is manufactured in illicit laboratories with use of over-thecounter ingredients. Many of these substances are hazardous and, when released from illicit laboratories, can place first responders at risk for serious injuries and death. The CDC recently released a report that summarizes methamphetamine laboratory events resulting in injury to first responders and suggests injury prevention strategies to protect these public safety professionals. The report findings were based on data obtained from the Hazardous Substances Emergency Events Surveillance (HSEES) system from 1996 to This database is maintained in 16 states by the Agency for Toxic Substances and Disease Registry. Of the 23,327 events reported to the HSEES system during the 3-year period, 1673 resulted in injuries, 112 events were associated with methamphetamine, and 59 methamphetamine-related events resulted in injuries. Of the 112 events associated with methamphetamines, 155 persons were injured, 79 of whom were first responders: 55 police officers, 9 EMTs, 8 firefighters, and 7 hospital employees. The 79 injured first responders sustained 111 injuries; 60 experienced respiratory irritation (eg, cough, difficulty breathing, and throat irritation) and 12 had eye irritation. Sixty-one first responders were treated at a June :3 JOURNAL OF EMERGENCY NURSING 267

2 FIGURE 1 Most common comorbidities in hospital patients. COPD, Chronic obstructive pulmonary disease; HTN, hypertension. From: Agency for Healthcare Research and Quality. Hospitalization in the United States, 1997 (HCUP fact book No. 1). Rockville (MD): The Agency; AHRQ Publication No hospital and did not require admission. None of the injured first responders was wearing personal protective equipment at the time of injury. Of the 36 events that caused injury in which the type of substance was known, 12 involved exposure to anhydrous ammonia and 11 involved hydrochloric acid. These toxic substances were released by air emission, fires, or explosions. Of all HSEES events, methamphetamine-associated events accounted for a small number. However, these events were more likely to result in injuries than were events caused by other agents. Substances used in methamphetamine laboratories are often corrosive, explosive, flammable, and toxic. These illicit laboratories are often found in motel rooms, private residences, campgrounds, and motor vehicles. An estimated 20% to 30% of these laboratories are discovered because of fires, explosions, and other uncontrolled reactions. Hazardous substances released during or after an event usually enter the body by inhalation or skin absorption. Acute exposures can result in cough, headache, chest pain, burns, pulmonary edema, respiratory failure, coma, and death. Of the types of first responders affected, police officers had the greatest number of injuries because they were present during or immediately after a release event. EMTs sustained most injuries through on-site exposure or direct contact with clothing or skin of contaminated persons. Firefighters were least often injured and most likely to be wearing personal protective equipment. Hospital personnel injuries are thought to have been caused by exposure to injured persons who were not decontaminated before being brought into the hospital. Standard uniforms worn by police, EMTs, and hospital personnel provided little or no chemical or respiratory protection. Interventions that can reduce risk for injuries among first responders include the following: increasing awareness of the risks involved with illicit drug laboratories, 268 JOURNAL OF EMERGENCY NURSING 27:3 June 2001

3 encouraging training in situations involving hazardous materials, identifying the nature of the event before entering the contaminated area, wearing appropriate personal protective equipment, and following proper decontamination procedures after exposure to hazardous substances. Emergency nurses are often charged with caring for first responders who are injured in the line of duty. Because this report included injuries sustained by hospital personnel while they were caring for first responders, it would seem wise for emergency nurses to be aware of their institution s policies and procedures pertaining to hazardous materials and where personal protective equipment is kept to avoid falling victim to the injuries caused by exposure. Information about the hazards likely to be encountered and protective measures that can be taken at methamphetamine-associated events can be found at the following Web site: http// Substances used in methamphetamine laboratories are often corrosive, explosive, flammable, and toxic. These illicit laboratories are often found in motel rooms, private residences, campgrounds, and motor vehicles. National Institute for Occupational Safety & Health (NIOSH) No evidence that back belts reduce injury seen in study of back belt users: Back injuries have consistently been a leading cause of disability in the United States for people younger than 45 years and have been one of the most expensive health care problems for persons between 30 and 50 years of age, accounting for 23% ($8.8 billion) of total workers compensation payments in 1995 alone. The Bureau of Labor Statistics indicates that in 1998, 279,507 back injuries occurred that resulted in lost work days. In response to the increasing human and economic costs of back injury, employers have attempted preventive measures, including the use of industrial back belts. In the largest prospective cohort study of back belt use conducted to date, NIOSH found no evidence that back belts reduced back injury or back pain for the retail workers in the study who used them while lifting or moving merchandise. The study, conducted during a 2-year period, found no statistically significant difference between the incidence rate of workers compensation claims for job-related back injuries among employees who reported that they usually used back belts every day and the incidence rate of such claims among employees who reported never using back belts or using them no more than once or twice a month. Similarly, no statistically significant difference was found when the incidence of self-reported back pain among workers who used back belts every day was compared with the incidence among workers who reported never using back belts. From April 1996 to April 1998, NIOSH interviewed 9377 employees at 160 newly opened stores owned by a national retail chain. Through interviews, detailed data were gathered on workers back belt wearing habits, work history, lifestyle habits, job activities, demographic characteristics, and job satisfaction. The study also examined workers compensation claims for back injuries among employees at the stores during the 2-year period. Even for employees in the most strenuous types of jobs, comparisons of back injury claims and self-reported back pain failed to show any differences in rates or incidence associated with back belt use. NIOSH found no evidence that back belts reduced back injury or back pain for the retail workers in the study who used them while lifting or moving merchandise. In recent years, back belts, also called back supports or abdominal belts, have been widely used in numerous industries to prevent worker injury during lifting. Approximately 4 million belts were purchased for workplace use in 1995, the most recent year for which data were available. Hospital personnel, including those in the emergency department, have used back belts as a way to reduce back pain and injury. This study would seem to negate any benefit of back belt use as a replacement of or augmentation to the simple use of proper body mechanics. Because emergency care requires so much lifting, those who continue to work in the June :3 JOURNAL OF EMERGENCY NURSING 269

4 emergency setting may do well to depend on lifting teams, lifting devices, and other proven strategies. AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ) Evidence for the prevention of thromboembolism after injury: In a study conducted for AHRQ by the Southern California Evidence-based Practice Center, results showed insufficient evidence to establish whether therapies used to prevent blood clots in trauma patients are better than one another or better than no therapy. Venous thromboembolism (VT) is a major health problem, causing 50,000 deaths annually and resulting in 300,000 to 600,000 hospitalizations in the United States every year. Injured patients are at high risk for VT because of changes in coagulation and thrombolysis mechanisms that are induced by trauma. Spinal fractures and spinal cord injury are risk factors for deep venous thrombosis (DVT). Methods for preventing VT include sequential compression devices, low-dose heparin, low molecular weight heparin, vena cava filters, or a combination of these methods. All of these methods are associated with contraindications and morbidity, and thus selecting the appropriate method for each trauma patient is important. The difficulty of selecting the best prophylaxis is in part a result of the inconclusiveness of relevant trauma literature. As a result, wide variability exists among physician practices, preventing consistency in quality of care. In this AHRQ study, existing data in the medical literature were evaluated and meta-analyzed to produce scientific answers in controversial areas relating to this topic and to identify research gaps in areas in which scientific evidence is minimal or absent. A panel of 17 experts, representing the academic, private, and managed care sectors, was formed to assist in the design and execution of this project. Several key questions were developed: What is the best method of prevention of VT after injury? Which groups of trauma patients are at high risk of having VT develop? What is the best method of screening for VT in trauma patients? What is the role of vena cava filters in preventing pulmonary embolism (PE) after injury? Fatal PE is reported in one third of trauma patients in whom a PE develops. The panel summarized the existing evidence for all trauma patients (excluding elderly patients with injuries following low-energy trauma, eg, hip fractures) included in the available medical literature as well as evidence for individual trauma patient groups (ie, orthopedic trauma, minor trauma) when data were available. Data were restricted to trauma patients only. Forms were designed to extract relevant data on study design and quality, methods used, risk factors, and outcomes. The main findings include the following: Spinal fractures and spinal cord injury are risk factors for deep venous thrombosis (DVT). Other frequently reported risk factors, such as head injury and pelvic and long bone fractures, were not shown to increase DVT risk. Trauma patients in whom DVT develops are older and have more severe injuries than patients in whom it does not develop; however, specific age or injury severity score threshold could not be extracted from the available data. Fatal PE is reported in one third of trauma patients in whom a PE develops. Length of stay for patients in whom DVT develops is significantly longer (by 15 days) than for patients without DVT. The reported incidence of DVT and PE varies widely among different studies depending on study design, type of trauma patients included, and methods of screening and prophylaxis. The pooled rates of DVT and PE are 11.8% and 1.5%, respectively. Low-dose heparin was not statistically superior to no prophylaxis in preventing VT after injury. Mechanical prophylaxis was not statistically superior to no prophylaxis in preventing VT after injury. 270 JOURNAL OF EMERGENCY NURSING 27:3 June 2001

5 Comparison of low molecular weight heparin and lowdose heparin shows no statistically significant difference between the 2 methods of preventing PE. Comparison of low-dose heparin and mechanical prophylaxis shows no statistically significant difference between the 2 methods in preventing DVT. Only a few random controlled trials address methods of VT prophylaxis in trauma patients. Most of the studies reviewed used different methods of prevention. Combining the limited data from studies using the same methods produces small sample sizes from which to draw conclusions. Future research should be directed at 2 areas: identifying the appropriate groups of trauma patients in need of VT prophylaxis and evaluating different methods of prophylaxis with regard to their safety and efficacy in trauma patients. Emergency nurses who care for trauma patients on a daily basis may want to monitor future research or participate in future research to establish more solid evidence for the use of any and all methods of VT prophylaxis and to establish new standards of care for trauma patients. A limited number of prepublication copies of this report are available free of charge from the AHRQ Publications Clearinghouse by calling (800) and asking for Evidence Report/Technology Assessment No. 22, Prevention of Venous Thromboembolism After Injury (AHRQ Publication No. 00-E027). June :3 JOURNAL OF EMERGENCY NURSING 271