Vivek Parwani

Beth Israel Medical Center, New York City, New York, United States

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Publications (14)17.19 Total impact

  • Prehospital Emergency Care 08/2009; 8(1):94-95. · 1.86 Impact Factor
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    ABSTRACT: Communication failures contribute to errors in the transfer of patients from the emergency department (ED) to inpatient medicine units. Oral (synchronous) communication has numerous benefits but is costly and time consuming. Taped (asynchronous) communication may be more reliable and efficient but lacks interaction. We evaluate a new asynchronous physician-physician sign-out compared with the traditional synchronous sign-out. A voicemail-based, semistructured sign-out for routine ED admissions to internal medicine was implemented in October 2007 at an urban, academic medical center. Outcomes were obtained by pre- and postintervention surveys of ED and internal medicine house staff, physician assistants, and hospitalist attending physicians and by examination of access logs and administrative data. Outcome measures included utilization; physician perceptions of ease, accuracy, content, interaction, and errors; and rate of transfers to the ICU from the floor within 24 hours of ED admission. Results were analyzed both quantitatively and qualitatively with standard qualitative analytic techniques. During September to October 2008 (1 year postintervention), voicemails were recorded about 90.3% of medicine admissions; 69.7% of these were accessed at least once by admitting physicians. The median length of each sign-out was 2.6 minutes (interquartile range 1.9 to 3.5). We received 117 of 197 responses (59%) to the preintervention survey and 113 of 206 responses (55%) to the postintervention survey. A total of 73 of 101 (72%) respondents reported dictated sign-out was easier than oral sign-out and 43 of 101 (43%) reported it was more accurate. However, 70 of 101 (69%) reported that interaction among participants was worse. There was no change in the rate of ICU transfer within 24 hours of admission from the ED in April to June 2007 (65/6,147; 1.1%) versus April to June 2008 (70/6,263; 1.1%); difference of 0%, 95% confidence interval -0.4% to 0.3%. The proportion of internists reporting at least 1 perceived adverse event relating to transfer from the ED decreased a nonsignificant 10% after the intervention (95% confidence interval -27% to 6%), from 44% preintervention (32/72) to 34% postintervention (23/67). Voicemail sign-out for ED-internal medicine communication was easier than oral sign-out without any change in early ICU transfers or the perception of major adverse events. However, interaction among participants was reduced. Voicemail sign-out may be an efficient means of improving sign-out communication for stable ED admissions.
    Annals of emergency medicine 04/2009; 54(3):368-78. · 4.33 Impact Factor
  • EMS World 02/2009; 38(1):64-6.
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    ABSTRACT: Existing mass casualty triage systems do not consider the possibility of chemical, biological, or radiologic/nuclear (CBRN) contamination of the injured patients. A system that can triage injured patients who are or may be contaminated by CBRN material, developed through expert opinion, was pilot-tested at an airport disaster drill. The study objective was to determine the system's speed and accuracy. For a drill involving a plane crash with release of organophosphate material from the cargo hold, 56 patient scenarios were generated, with some involving signs and symptoms of organophosphate toxicity in addition to physical trauma. Prior to the drill, the investigators examined each scenario to determine the "correct" triage categorization, assuming proper application of the proposed system, and trained the paramedics who were expected to serve as triage officers at the drill. During the drill, the medics used the CBRN triage system to triage the 56 patients, with two observers timing and recording the events of the triage process. The IRB deemed the study exempt from full review. The two triage officers applied the CBRN system correctly to 49 of the 56 patients (87.5% accuracy). One patient intended to be T2 (yellow) was triaged as T1 (red), for an over-triage rate of 1.8%. Five patients intended to be T1 were triaged as T2, and one patient intended to be T2 was triaged as T3 (green), for an under-triage rate of 10.7%. All six under-triage cases were due to failure to recognize or account for signs of organophosphate toxidrome in applying the triage system. For the 27 patients for whom times were recorded, triage was accomplished in a mean of 19 seconds (range 4-37, median 17). The chemical algorithm of the proposed CBRN-capable mass casualty triage system can be applied rapidly by trained paramedics, but a significant under-triage rate (10.7%) was seen in this pilot test. Further refinement and testing are needed, and effect on outcome must be studied.
    Prehospital Emergency Care 01/2008; 12(2):236-40. · 1.86 Impact Factor
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    ABSTRACT: Firefighters are taught that heat, oxygen deprivation, and carbon monoxide (CO) are the primary threats to life in residential structure fires, and they are taught to search for victims on the fire floor first, and then floors above. The objective of this study was to gather data regarding oxygen, CO, and heat conditions inside a realistic house fire, to examine the validity of these teachings. During six live-burn training evolutions in a two-story wood-frame house, metering for oxygen levels, CO levels, and temperature was conducted. Except where noted, all readings were taken 24 inches off the floor, to simulate the location of a crawling victim or firefighter. Readings were hand-recorded on a convenience basis by firefighters stationed outside the building, near the meters. Of the 35 oxygen levels recorded, the lowest was 18.2%, with only 12 readings below 20%. Three of 16 first-floor readings were below 20%, whereas nine of 19 second-floor readings were below 20% (p=0.07). First- and second-floor readings were comparable (mean 20.3% vs. 19.9%, p=0.11). Except for one reading of 1,870 ppm, all CO readings at the ceiling exceeded the 2,000-ppm limit of the meters. Of the 34 CO levels recorded 24 inches off the floor, 29 (76%) exceeded the permissible exposure limit of 50 ppm, with the highest reading being 1,424 ppm, well above the "immediately dangerous to life and health" level of 1,200 ppm. None of the 20 CO levels recorded on the first floor exceeded the 30-minute exposure limit of 800 ppm, whereas seven of 14 second-floor readings exceeded this limit (p<0.001). While ceiling temperatures frequently exceeded the 1,000 degrees F limit of the meters, none of 16 readings taken 24 inches off the floor exceeded 137 degrees F. First- and second-floor temperatures were comparable (mean 88.5 degrees F vs. 90.1 degrees F, p=0.9). In residential structure fires, CO poses a greater threat to victims and firefighters than does oxygen deprivation or heat. Emergency medical services personnel should consider CO toxicity in all fire victims. Conditions on the floor above a fire are at least as adverse as those on the fire floor.
    Prehospital Emergency Care 01/2008; 12(3):297-301. · 1.86 Impact Factor
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    ABSTRACT: Emergency medical dispatch (EMD) protocols should match response resources with patient needs. We tested a protocol sending only a commercial ambulance, without fire department first responders (FR), to all non-cardiac-arrest EMS calls at a physician-staffed HMO facility. Study objectives were to determine how often FR provided patient care at such facilities and whether EMD implementation could conserve FR resources without compromising patient care. All EMS dispatches to this facility in the 4 months before implementation of the EMD protocol and 4 months after implementation were identified through dispatch records, and all FR and ambulance patient care reports were reviewed. In the "after" phase, all cases needing ALS transport were reviewed to examine whether there would have been benefit to FR dispatch. Of 242 dispatches in the "before" phase, BLS FR responded to 156 (64%), and ALS FR to 117 (48%). BLS FR provided patient care in 2 cases, and ALS FR in 17. Of 227 dispatches in the "after" phase, BLS FR responded to 10 (4%), and ALS FR to 10 (4%); all but one were protocol violations. BLS FR provided care in one case, and ALS FR in three. Review of the 93 "after" cases requiring ALS transport found none where FR presence would have been beneficial. First responders rarely provided patient care when responding to EMS calls at a physician-staffed medical facility. Implementation of an EMD protocol can safely reduce the number of FR responses to unscheduled ambulance calls at such a facility.
    Prehospital Emergency Care 01/2007; 11(1):14-8. · 1.86 Impact Factor
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    ABSTRACT: We sought to determine the ability of paramedics to inflate endotracheal tube cuffs within safe pressure limits as well as to estimate the pressure of previously inflated endotracheal tube cuffs by palpation of the pilot balloon. Using a tracheal simulation model, we conducted a prospective, observational, cross-sectional simulation study of licensed, practicing paramedics. This included evaluation of their ability to inflate the cuff of an endotracheal tube to a safe pressure, defined as < or = 25 cm H(2)O, as well as to identify excessive intracuff pressure in previously inflated ETT cuffs by palpation of the pilot balloon. Fifty-three paramedics were sampled. The average pressure generated by inflating the endotracheal tube cuff was > 108 cm H(2)O. Participants were only 13% sensitive detecting over inflated endotracheal tube cuffs (95% CI 7.3-17.8). Participants were unable to inflate endotracheal tube cuff to safe pressures and were unable to identify endotracheal tube cuffs with excessive intracuff pressure by palpation. Clinicians should consider using devices such as manometers to facilitate safe inflation and accurate measurement of endotracheal tube cuff pressure.
    Prehospital Emergency Care 01/2007; 11(3):307-11. · 1.86 Impact Factor
  • Robert J Hoffman, Vivek Parwani, In-Hei Hahn
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    ABSTRACT: Tracheal necrosis, stenosis, and rupture may result from overinflated endotracheal tube cuffs (ETTcs). We sought to determine the ability of faculty emergency medicine (EM) physicians to safely inflate ETTc as well as to estimate pressure of previously inflated ETTc. Using a previously tested tracheal simulation model, we assessed EM physician inflation of ETTc pilot balloons. Participants also palpated the pilot balloon of 9 ETTc inflated to pressures ranging from extremely low to extremely high in a random order and reported their estimate of pressure. We sampled 41 faculty EM physicians from 5 EM residency programs. Using palpation, participants were only 22% sensitive detecting overinflated ETTc. The average ETTc pressure produced by inflation was more than 93 cm H(2)O (normal, 15-25 cm H(2)O). Participants were unable to inflate ETTc to safe pressures or estimate pressure of ETTc by palpation. Clinicians should consider using devices to facilitate safe inflation and accurate measurement of ETTc pressure.
    American Journal of Emergency Medicine 04/2006; 24(2):139-43. · 1.70 Impact Factor
  • Emergency medical services 02/2006; 35(1):82-4.
  • Vivek Parwani, David C Cone
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    ABSTRACT: Teaching paramedic students venipuncture and intravenous catheterization has traditionally relied on bulky, expensive phlebotomy models. A gelatin intravenous model (GIM) costing less than 50 cents is currently being used in the training of medical students and interns. The study objective was to evaluate paramedic students' perceptions of the GIM as a training tool. GIMs are created using gelatin, psyllium, Penrose drains, food coloring, salt, and water. Penrose drains are filled with artificial blood composed of salt water and food coloring. The drains are placed in an aluminum pan with a base of hardening gelatin, with half-inch drains at the bottom of the pan and quarter-inch drains higher up in layers of mixed psyllium and gelatin to simulate deep and superficial veins respectively. A convenience, volunteer sample of 14 paramedic students who previously trained with traditional phlebotomy models each made two to five attempts at intravenous insertion using the GIM. Perceptions of the GIM were measured using a Likert scale (1, worst rating; 5, best rating). Means are reported. Study subjects rated ease of use at 4.17, realism at 4.07, and effectiveness in learning intravenous insertion at 4.28. GIM as a more effective teaching tool than the conventional rubber arm yielded a rating of 4.14. This study is limited by a small sample size, and further studies evaluating the GIMs construct and content validity are needed. Despite these limitations, given the GIMs simplicity and value, paramedic instructors may wish to consider implementation of this device in their training programs.
    Prehospital Emergency Care 01/2006; 10(4):515-7. · 1.86 Impact Factor
  • Prehospital and Disaster Medicine. 10/2005; 20(S3).
  • Prehospital and Disaster Medicine. 04/2005; 20(S1).
  • Vivek Parwani, Robert J Hoffman
    Prehospital Emergency Care - PREHOSP EMERG CARE. 01/2004; 8(1):96-96.
  • Vivek Parwani, Robert J. Hoffman
    Prehospital Emergency Care - PREHOSP EMERG CARE. 01/2004; 8(1):96-96.

Publication Stats

72 Citations
17.19 Total Impact Points

Institutions

  • 2004–2009
    • Beth Israel Medical Center
      New York City, New York, United States
  • 2005–2008
    • Yale-New Haven Hospital
      • Emergency Medicine Program
      New Haven, Connecticut, United States
  • 2006–2007
    • Yale University
      • Department of Emergency Medicine
      New Haven, CT, United States