Background Poisoning is an uncommon cause of activation of the Prehospital Emergency Services (PhEMS). There’s little evidence of the clinical features of the patients referred to the hospital with this diagnosis. Knowing these features might help emergency professionals evaluate acute situations, improving their management. Aim The objective of this study is to evaluate the features of patients diagnosed from intoxication and then referred to their reference hospitals by PhEMS as well as to objectify whether there are differences between patients referred from rural vs. urban areas. Methods Design: Retrospective, descriptive, multicenter study. Study setting: PhEMS and Emergency Services in four provinces of Spain (Valladolid, Salamanca, Segovia, and Burgos). Participants and date: We included all patients who were treated by advanced life support (ALS) units with intoxication diagnosis and referred to their reference hospitals between October 1, 2019 and April 30, 2021. Outcome variables: Sex, age, zone (rural/urban) hospital destination, intensive care unit (ICU) admission, in-hospital mortality, type of intoxication (TOI), total care time by PhEMS (TCT). Statistic methods: The quantitative variables were described as median and interquartile range (IQR) and the qualitative variables were described by absolute and relative frequencies. Student`s T-test and Mann-Whitney-U test were used in the comparison of quantitative variables if necessary. Chi-square and Kruskal-Wallis test were used to study the association of qualitative variables. A P value of <0,05 was considered significant. Results 119 patients. Women:52,9%. Median age: 43 years (IQR: 32-54). Urban 79,2% Hospitalization average: 35,3%. ICU average: 16%. In-hospital mortality average: 4,2%. TOI: average: Benzodiazepines (48,7%), alcohol (18,5%), other (12,6%), other abuse drugs (5,9%), gas/smoke (5%), antidepressants (3,4%), paracetamol (2,5%), opioids (1,7%), cocaine (0,8%), insulin (0,8%). TCT average (minutes): 52 (IQ: 44-60). Association between TCT average (minutes) and zone: Rural: 22,2. Urban 12,5 (p<0,05). Association between TOI and zone: Rural: Benzodiazepines 54,2%, alcohol 20,8%. Urban: Benzodiazepines 47,4%, alcohol 17,9% (p>0,05). Association between hospital admission and zone: Rural 29,2%, urban 36,8% (p>0,05). Association between in-hospital mortality and zone: Rural 0%, urban 5,3% (p>0,05). Association between TOI an in-hospital mortality: Antidepressants 25%, other abuse drugs 14,3% (p>0,05). Association between age (years) and in hospital mortality: < 30: 4%, 31-60: 2,4%, >60: 16,7% (p>0,05). Discussion and conclusions In our study, intoxications have shown to be high mortality diseases that often require hospitalization. Benzodiazepine and alcohol intoxication have proved to be the most common diagnose in all age-spans and in both rural and urban patients. Patients diagnosed with antidepressant intoxications were the ones who showed a higher in-hospital mortality.

Funding This trial has not received any special funding. Ethical approval and informed consent The study was approved by the Research Ethics Committee of all participating centers (reference CEIC: PI-GR-19-1258 and PI-049-19). All patients (or guardians) signed informed consent, including consent for data sharing. This research has received support from the Gerencia Regional de Salud (SACYL) with registration number GRS 1903/A/19.

Background: Caring for paediatric patients may be stressful for emergency medical services (EMS) professionals, and vital sign documentation in paediatric patients is inadequate, especially in patients ≤2 years. The study objective was to investigate if educational initiatives for EMS professionals could increase the proportion of paediatric patients for whom vital signs were documented in the prehospital medical record. Method: Prospective cohort study in the North Denmark and South Denmark Regions with a consecutive patients sample of children aged <18 years who were attended by EMS in a 15-month period from October 1, 2020, to December 31, 2021, excluding interfacility transfers and patients with cardiac arrest. The two regions have similar demographic structures; there are 29 and 28 emergency calls regarding children <18 years per 1000 inhabitants annually in the North and South Denmark Regions, respectively. Educational initiatives were conducted in one of the regions amid the study period and included video learning and classroom training based on European Paediatric Advanced Life Support principles. Virtually all EMS professionals had completed the video learning (98.6%). The primary outcome was the proportion of patients, who had their Glasgow Coma Score, peripheral capillary oxygen saturation (SpO2), heart rate, and respiratory rate documented at least once during the prehospital phase. We used a two independent samples proportions test to compare regions with a crude estimate of the proportion difference with 95% confidence intervals. Ethical approval and informed consent: The North Denmark Region Ethics Committee reviewed the study and concluded that obtaining informed consent from each individual patient was not required. Permission to collect outcome data from patient medical records according to the General Data Protection Regulation was granted by The North Denmark Region on behalf of the Danish National Health Authorities (id nos. 2020-100 and 2020-027132). Results: 15,772 patients from South Denmark and 7,682 patients from North Denmark were included. The total study population involved patients at ages <1 year (12.8%), 1-2 years (18.6%), 3-7 years (16.0%), 8-12 years (14.1%) and 13-17 years (37.9%). The proportion of patients that had all of the four vital signs documented was 0.62 [0.61;0.63] in the usual care region during both the pre- and post-educational periods. In the region that implemented the educational initiatives, the proportion increased from 0.66 [0.65;0.68] in the pre-educational period to 0.70 [0.69;0.72] in the post-educational period. Between the regions, the proportion difference of the primary outcome was 8.4 %-points [6.6;10.2] in the post-educational period. Subgroup analyses with patients <2 years (N=2,928) showed that the primary outcome was present in 56.3% [53.1;59.4] of patients following the educational initiatives compared to 32.3% [30.3;34.4] of patients in the region without the initiatives. Conclusions: The study implies that educational initiatives can increase the extent of vital sign documentation in paediatric EMS patients, especially in the youngest patients <2 years.

Trial registration: None. There was no collection or analysis of any biological material, and no interventions were introduced on patient level. Funding: VN has received a research grant from the Danish Air Ambulance.

Early warning scores (EWS) help to prevent and recognize patients presenting the first signs of clinical and physiological deterioration. Therefore, they are systems that are very helpful to prehospital emergency medical services (EMS) due to the complexity of patients and scenarios in which they must act. The aim of this study is to evaluate different EWS (National Early Warning Score 2 (NEWS2), Quick Sequence Organ Failure Assessment Score (qSOFA), Modified Rapid Emergency Medicine Score (MREMS) and Rapid Acute Physiology Score (RAPS)) to predict mortality within the first 48 h in patients with electrocardiogram compatible with atrial fibrillation (AF) at the time of care by the EMS. Observational, prospective, multicenter study. Inclusion criteria: over 18 years of age with a diagnosis of atrial fibrillation on electrocardiogram performed in the ambulance at the time of transfer by the SEMP to hospital emergency departments (ED) between October 2019 and March 2021 in 4 Spanish provinces of the same health service. Exclusion criteria: < 18 years, patients without a diagnosis of AF on electrocardiogram, patients discharged in situ, follow-up < 48 hours. Variables: NEWS2: heart rate (Fc), respiratory rate (Fr), temperature (Tª), Systolic Blood Pressure (SBP), oxygen saturation (SpO2), patient with hypercapnic respiratory failure, need for supplemental oxygen, AVPU score (alertness, verbal response, response to pain, unversponsive). qSOFA: Fr, SBP and Glasgow Coma Scale (ECG). MREMS: Fc, Fr, SBP, SpO2, GCS, age. RAPS: Fc, Fr, mean arterial pressure (MAP) and GCS. Main dependent variable: early mortality in the first 48 hours after care (EM). Statistical analysis: Normality tests. Frequencies, central measures and dispersion in standard deviation (SD) or interquartile range (IQR). Chi-square (proportions), T Student (means) Mann-Whitney U (medians). Univariate regressions using logistic regression. Odds ratio (OR) calculation. Area under the curve (AUC) of the receiver operating characteristics (ROC). Younden test to determine the cuttoff point (CP). Calculation of sensitivity, specificity, positive likelihood ratio (+LR) and negative likelihood ratio (-LR). Statistical significance: p <0.05, 95% confidence interval (95% CI). Software: SPSS. Results: N: 261. Women: 48.7%. Age: median total 80 (RIC 73.87). Men 76 (RIC 71-85) vs women 83 (77-89) (p<0.001). NEWS 6 (RIC 3-9). qSOFA 1 (0-1). MREMS 11 (9-13). RAPS 3 (2-5). EM: 11.5%. NEWS2 scale: AUC of 0.867 (95%CI 0.804-0.931) (p<0.001). CP: 8. Sensitivity 0.87 and Specificity 0.73 +LR 3.28 and -LR 0.18. OR 18.11 (95% CI: 6.07-54.06) (p<0.001). qSOFA AUC 0.870 (95% CI 0.813-0.928) (p<0.001). CP 1. Sensitivity 0.700. Specificity 0,874. +LR 5.58 and -LR 0.34. OR 16.25 (95% CI: 6.79-38.89) (p<0.001). MREMS AUC 0.800 (95%CI 0.718-0.913) (p<0.001). CP 11. Sensitivity 0.800. Specificity 0.632. +LR 2.71 and -LR 0.30. OR 6.871 (95% CI: 2.70-17.47) (p<0.001). RAPS AUC 0.817 (95%CI 0.727-0.907) (p<0.001). PC 3. Sensitivity 0.800. Specificity 0.662. +LR 2.37 and -LR 0.30. OR 7.84 (95% CI 3.08-19.99)(p<0.001). Conclusion: The score with the best ability to predict EM in patient with electrocardiogram compatible with atrial fibrillation at the time of EMS care has been the NEWS2, with an area under the curve similar to that of qSOFA but with better OR.

Background: Community First Responders (CFRs) are uniformed volunteers who respond to emergency calls and can provide life-saving interventions prior to ambulance arrival[1]. In the United Kingdom, CFRs commonly manage patients with suspected strokes before the arrival of ambulance staff. Anecdotal evidence suggests that CFRs can reduce the time spent on scene by ambulance staff with a patient, which may decrease the onset-to-treatment time in patients with true strokes. This service evaluation aimed to assess the effect of CFR presence on ambulance ‘on scene’ time in patients with suspected strokes. Methods: In this retrospective cohort service evaluation, all patients categorised by 999/111 telephone triage as suspected strokes and then attended by four UK ambulance services between 1st January 2021 and 31st December 2021 were included. Patients were stratified according to the presence of CFRs or not, which occurred depending on incident location and CFR availability. Outcome variables were CFR and ambulance staff response time (call-to-arrival time), and the time spent on scene by ambulance staff with a patient (i.e., the length of patient assessment by a clinician). As CFRs are more likely to attend incidents in rural areas, time taken for patients to reach hospital was not analysed. The study met the criteria for service evaluation so ethical approval was not required. Results: 96,312 patients with suspected strokes were identified. CFRs attended 3.9% of incidents (n = 3,763) with a mean response time of 24.52 minutes (95% CI [23.75, 25.28]). When CFRs were present, mean ambulance response time was 34.27 minutes (95% CI [33.38, 35.16]) and mean ambulance on scene time was 38.92 minutes (95% CI [38.27, 39.56]). In the remaining 91.1% of patients (n = 92,549) managed only by ambulance staff, mean ambulance response time was 28.83 minutes (95% CI [28.64, 29.03]) and mean ambulance on scene time was 40.86 minutes (95% CI [40.73 ,41.00]). CFR presence was therefore associated with a 117 second reduction in time spent on scene by ambulance staff. Discussion: In patients with suspected strokes, CFRs arrive faster than ambulance staff and are associated with a small but significant decrease in time spent on scene by ambulance staff. This may translate into a decrease in onset-to-treatment time for some patients, which has proven health benefit for even marginal improvements[2]. CFRs may decrease the time spent on scene by ambulance staff by initiating essential tasks prior to ambulance arrival (e.g., establishing time of symptom onset). It may be possible to increase this effect with specific training. As patients were included based on telephone triage, this sample is unlikely to be fully representative. References: 1 - Phung, et al. ‘Community First Responders and Responder Schemes in the United Kingdom: Systematic Scoping Review’. Scand J Trauma Resusc Emerg Med, vol. 25, no. 1, 2017, p. 58 2 – Meretoja, et al. ‘Stroke Thrombolysis’. Stroke, vol. 45, no. 4, 2014, pp. 1053–58

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Objectives This study aimed to investigate the effect of operating designated team response (DTR) on the favourable neurological outcome for out-of-hospital cardiac arrest (OHCA) patients. Methods A cross-sectional observational study was conducted for emergency medical service (EMS)-treated adult OHCA with cardiac aetiology from July 2019 to December 2020. In July 2019, a DTR pilot study was implemented to provide EMS providers with 3-day advanced cardiac life support (ACLS) training and to dispatch them to suspected OHCA patients first. Exposure was whether or not the DTR was dispatched; DTR and non-DTR. The primary outcome was favourable neurological outcome. Eligible OHCA patients were classified as shockable/non-shockable group according to the initial rhythm assessed by EMS providers. For each rhythm population (non-matched cohort), a matched cohort for DTR cases was constructed by the propensity score matching (PSM) method (matching variable: age, sex, quarter of year, and urbanization level of arrest location) and a total of 4 study populations were constructed. A multivariable logistic regression analysis was conducted for each population to investigate the effect of DTR on study outcome adjusting for confounding factors. Results Among 19,052 eligible patients, 2,946 (15.5%) were shockable (DTR 1,009, and non-DTR 1,937) and 16,033 (84.2%) were non-shockable rhythm (DTR 5,424 and non-DTR 10,609). Shockable to matched cohort was 1,062 cases, and non-shockable to matched cohort were 694 cases. In all 4 study populations, DTR provided more ACLS such as intravenous line insertion, epinephrine administration, and advanced airway management and showed longer scene time than non-DTR (all p-value < 0.01). In the final logistic model, compared to non-DTR, the DTR had a lower probability of favourable neurological outcome in all populations (AOR (95% CI): shockable unmatched 0.73 (0.61-0.87), shockable matched 0.58 (0.44-0.77, non-shockable unmatched 0.50 (0.33-0.76), and non-shockable matched cohort 0.58 (0.44-0.77)). Conclusion The operating a designated team response for OHCA did not associate with better favourable neurological outcome in despite of higher provision rate of ACLS. Further research is needed to find the optimal population in which DTR can be effective to improve survival outcome.

Background: Globally, 37 million falls are severe enough to require medical attention annually, with adults >60 years of age having the greatest number of fatal falls. Western Australia’s (WA) increasing population has resulted in high demand for emergency ambulance attendances to falls. The aim of this study was to describe the characteristics of ambulance attended patients who fall in WA. The specific objectives of this study were: 1) to describe the characteristics of patients; 2) to estimate the crude and age-standardised incidence rates of ambulance attended falls; and 3) to identify the frequency and describe: injuries sustained from falls; interventions used and patient disposition. Methods: A retrospective cohort study was conducted of electronic patient care records (ePCR) for adults (>18 years) who fell and required St John Western Australia (SJWA) ambulance attendance between 1st Jan 2015 – 31st Dec 2021. Data collected from the ePCR were: patient characteristics (e.g. age, sex and observations), injuries sustained (i.e. injury location and type), prehospital interventions (i.e. medication and treatment delivered) and disposition (e.g. transported to hospital). Falls were identified either by dispatch code or through examination text, before excluding injuries resulting from motor vehicles, assault, syncope or suicide. Age was summarised as median with interquartile range and categorical variables as count and percentage. Results: There were 188,720 patients (female = 107,811, 57%) attended by ambulances after falls, 139,857 (74%) within Perth metropolitan region and 48,863 (26%) in rural WA. Median age was 80 years [IQR 67-87]. The age-standardised incident rate of ambulance attended falls increased from 1,011 in females and 743 in males per 100,000 person-years in 2015, to, 1315 in females and 1015 in males per 100,000 person-years in 2021. The overall age-standardised incidence rate of ambulance attended falls increased from 876 to 1165 per 100,000 person-years from 2015 to 2021. Of the cohort, 89,140 (47%) patients sustained a suspected injury, 45% of patients reported pain, 31% had tenderness recorded, 27% had lacerations recorded, and 12% had suspected fractures. Regarding interventions, 50,372 (27%) patients received >=1 medication e.g. analgesia, and 31,203 (17%) patients received >=1 treatment e.g. oxygen. Following assessment and treatment, 148,050 (78%) patients were transported to hospital and 40,670 (22%) were not transported. Patients were transported via the following urgency level (time-critical emergency level): 2,371 (2%) were transported via the highest urgency with lights and siren (urgency one), 27,882 (19%) via urgency two, 93,447 (63%) via urgency three and 22,929 (15%) via urgency four-Six, (<1% unknown urgency). Conclusions: The majority of patients who fell were female, and the proportion in rural WA was in keeping with the distribution of WA’s population. Nearly half of injuries resulted in pain, many involved lacerations or suspected fractures, and a quarter of patients were given analgesia. After treatment 2% of patients were transported to hospital via the highest urgency with lights and sirens, reflecting the seriousness of their condition. The frequency and incidence rates of falls requiring ambulance attendances have increased over time.

Trial registration/Funding: NA Ethical approval: Curtin University [HR128/2013-85, 09/Mar/2022] and SJWA Research Governance Committee approval [11/Mar/2022].

Background Early prediction of serious outcome is important in emergency care - the earlier, the better - ideally as soon as the vital signs are taken on scene by the paramedics. Triage and early warning scores based on vital signs were designed for use in the emergency department and have only to some extent been tested in prehospital use and with various conclusions. The aim of this study was to investigate the standard clinical score’s ability to predict serious outcome in prehospital use among all ambulance patients. Methods The was a historic observational study based on the prehospital electronic medical record data from North Denmark Region 1 July 2016 to 31 December 2020, linked to regional administrative registries of hospital admissions and date of death. In Denmark, patients call the emergency number 112 or, in less severe cases, the general practitioner. We included patients aged 18 years or older stratified into 112-patients/non-112 patients. We calculated the RETTS-Swedish triage score, NEWS2-National Early Warning core, mNEWS score (modified NEWS score without temperature), DEPT-Danish triage score, and qSOFA. For each score, the highest score during before arrival at hospital was used as a predictor. Missing data were assumed to be normal. Outcomes were 30-day-mortality and admission to intensive care unit. Descriptive statistics grouped according to 112-call status. Receiver operating characteristic (ROC) and precision-recall curves (APR) were plotted using standard clinical scores and discrimination assessed using Area under the ROC curve (AUROC) and Average Precision (APR). Ethics: As patients’ consent to achieve medical record data was not possible, we, according to Danish Law, applied for and got permission to analyzing medical record data from the regional authority (2021-012621) Results We included data from 106.926 unique patients with 218,972 medical records, 54.5 % concerned 112-patients. Among 112-patients 46.0 % were women versus 49.7% among non-112 patients. There were three age peaks: at 1 year (infants), 21 years (young adults) and 73 years (elderly). 112-patients were younger, median (IQR) 64 (47-77) years versus 74 (61-83) in non-112-patients. The clinical scores performed similarly concerning 30-day mortality, with AUROCs of 0.75-0.80 in 112-patients and 0.62-0.66 in non-112-patients, and low APRs of 0.15-0.21 and 0.16-21, with no differences between NEWS, mNEWS and DEPT. All scores also performed similarly for prediction of admission to intensive care unit with AUROCs from 0.71-0.77 in 112-patients and 0.63-0.69 in nin-112 patients with low APRs of 0.05-0.12. Discussion and conclusion In this largescale population-based prehospital study, the RETTS, NEWS2, mNEWS, the DEPT, and qSOFA score all performed almost similarly in prediction of serious outcome. Especially, NEWS and mNEWS performed similarly, which suggests the temperature component of the score has little predictive value for mortality in this population. However, all scores performed poorly in accuracy due to the high number of false positives. The next step is to investigate whether machine-learning methods may improve prediction and accuracy. Acknowledgement: Thanks to Thomas Mulvad, North Denmark Region for assisting with data management.

None – this was a registry-based study based on medical record data. As patients’ consent to achieve medical record data was not possible, we, according to Danish Law, applied for and got permission to analyzing medical record data from the regional authority (ID 2021-012621). Funding: The European Union’s European Fund for Regional Development through Life-Science Innovation North Denmark’s programme “Sundhedsteknologisk Serviceprogram (SSP)”. projectID 036.

Background: On many occasions, the presence of pelvic fractures or unstable pelvises is associated with significant blood loss, with the consequent resulting hypovolemic shock. Sometimes it is very difficult to discriminate which patients may potentially present a pelvic fracture in prehospital care, so a high level of suspicion, the study of the injury mechanism and the use of early warning scores can help practitioners to identify high-risk cases. The goal of this report is to analyze the relationship between the use of the prehospital pelvic belt and blood administration, emergency surgery and 2-day in-hospital mortality. evaluate the ability of the Rapid Acute Physiology Score (RAPS) to predict the necessity of prehospital pelvic belt. Methods: Prospective, multicentric, EMS-delivery, ambulance-based, pragmatic cohort study of adults with prehospital pelvic trauma, referred to five hospitals (Spain), between January 2020, and December 2021. Any patient treated consecutively by EMS with prehospital diagnosis of pelvis trauma and transferred by ambulance to the ED was included in the study. Patients under 18 years of age, non-traumatic patients, pregnant women, and patients discharged on site were excluded. Results: 62 patients with prehospital pelvic trauma were transferred to the ED and finally included in the study. The median age was 50 years (IQR: 39-61), between 18 to 95 years, with 33.9% females (321 cases). 31 cases required prehospital pelvic belt (50 %). Analyzing the patients by subgroups, we can observe that the cases that did not require a prehospital pelvic belt had a rate of blood transfusion, emergency surgery and 2-day in-hospital mortality of 48.4 % (15 cases), 71 % (22 cases), and 25.8% (8 cases) respectively; vs prehospital pelvic belt, 35.5 (11 cases), 54,8 % (17 cases), and 12.9 % (4 cases). Despite the obvious quantitative discrepancies, no statistically significant differences are evident, with p=0.215, p=0.311 and p=0.195, respectively for blood transfusion, emergency surgery and 2-day in-hospital mortality Conclusions: Pelvic belt use is a standard in prehospital care, which should be used in all cases of suspected pelvic trauma. However, our preliminary results did not show a significant relationship between the use of this device and an improvement in morbi-mortality. The limited sample size may be the reason for these results, but it is clear that patients with the pelvic belt had lower rates of transfusion, surgery and early mortality. These data could indicate an insufficient use of the device, or that the pelvic belt is very effective and improves the results, in both cases, in prehospital care, the use of the pelvic belt should be a routine procedure at the slightest suspicion of pelvic trauma.

This work was supported by the Gerencia Regional de Salud, Public Health System of Castilla y León (Spain) [grant number GRS 1903/A/19 and GRS 2131/A/20]

Introduction: During the first wave of the COVID-19 epidemic, emergency medical services (EMS) were suddenly overwhelmed with calls. To better control the flow of calls and reduce the workload of the staff, we experimented an Interactive Voice Server (IVS). The objective of this study was to describe the use of the IVS in an EMS during periods of call influx and to determine whether it contributed to reducing the workload of operators. Methodology: Between March 19th, 2020, and April 26th, 2020, an IVS was activated daily from 8:00 AM to midnight. After dialing the emergency number, the caller was connected to an IVS with a message suggesting to "press zero" if their call was about COVID and they did not have a life-threatening distress. If the caller made this choice (IVS Yes), the call was directed to a specific "COVID crisis" control room, staffed by operators specially trained to handle COVID cases. In the opposite case (IVS No), the call was distributed to the operators of the usual circuit who received all the emergency calls. All Medical Regulation Records (MRRs) with a single call during IVS hours were included. Reason for call, IVR use, age and gender of the patient, caller’s profile (patient or third party), and number of operators required to fully process the call were recorded. Results 23534 MRR were included, of which 19793 (84%) were during IVS hours. Of these calls, 9044 (45.70%) had a suspected COVID infection as the reason for the call. 2846 (14.38%) patients were “IVS Yes”. The age of “IVS Yes” was 41.35 years (SD 23.08) and “IVS No” 44.81 years (SD 23.65) p<10-3. The sex ratio was 0.8 for both groups. 2340 (82.31%) of the “IVS Yes” were the subject himself vs 9681 (57.13%) for “IVS No” (p<10-3). 2513 (88.3%) of IVS Yes” were handled by a single operator vs 989 (5.84%) for “IVS No” which required up to 8 callers. Conclusion: The use of an IVS allowed, during an epidemic period, 15% of calls to be taken out of the conventional emergency call queue to be directed into a specific flow. Unlike "conventional" calls which, in our system, required the intervention of at least 2 operators, calls through an IVS can be handled by a single operator, specialized and trained specifically for the current crisis. The use of an IVS contributed to reduce the workload of a medical regulation center in case of an influx of calls.

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Background People with serious mental illness (SMI) are more likely to have multiple long-term physical health conditions, but are less likely to access primary care and preventive interventions. A 2015 Nuffield study showed that people with SMI use urgent and emergency care (UEC) services more frequently than hospital users without mental ill health. However, this study did not examine UEC usage among the general population. The aim of the present research was to compare UEC usage among people with SMI and the general population. Methods This was an observational study utilising routinely collected patient data from 2013-2016. This was taken from the CUREd research database, which holds record-level data from UEC services in the Yorkshire & Humber region. We defined two groups for each year of the study: those with SMI (anyone receiving care from Sheffield Health and Social Care NHS Foundation Trust during that year); and those without SMI (all other service users). Using ONS population estimates to approximate the local population from which the sample of non-SMI UEC service users was drawn, we calculated annual age- and sex-standardised usage rates for NHS 111 calls, ambulance callouts, A&E attendances and acute hospital admissions. We used logistic regressions to explore differences in the clinical characteristics of the SMI and non-SMI cohorts. Results During the full study period there were 256,596 NHS 111 calls by 123,315 patients; 179,786 ambulance callouts by 102,007 patients; 452,343 A&E attendances by 206,620 patients; and 211,327 provider spells by 103,099 patients. The SMI cohort made greater use of all UEC services across all study years. Usage rates per 1000 population were approximately 7 times higher in the SMI cohort for ambulance callouts, approximately 6 times higher for NHS 111 calls, and approximately 5 times higher for A&E attendance and acute hospital admissions. The proportion of the SMI group using UEC services was 3-4 times higher than the non-SMI group for all UECs. People with SMI were more likely to require a call back from NHS 111, and to be referred to a clinically trained advisor. They were more likely to receive the highest or lowest acuity recommendation from NHS 111. Patients with SMI were more likely to be admitted to a hospital bed after attending A&E, and more likely to arrive via ambulance, but were also more likely to attend with a low-acuity problem that could have been dealt with in alternative non-emergency settings. For patients experiencing an acute hospital admission, those with SMI were more likely to experience a long and/or multi-episode stay. Conclusions This study suggests that those with SMI tend to experience more serious and complex urgent healthcare problems not necessarily related to mental health, but that they also use UEC services for non-urgent healthcare needs more than those without SMI.

This is independent research funded by the National Institute for Health Research, Yorkshire and Humber Applied Research Collaborations. The views expressed in this work are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the work.

Study objective: To describe in-depth patient features in sepsis-related, in-hospital deaths. Methods: A retrospective, descriptive analysis from in-depth medical chart reviews, for all deceased adult patients within a Norwegian hospital trust, comprised of two local and one regional hospital, with a primary or secondary diagnosis of infection, during two consecutive years (2018-2019). The diagnosis of infection was identified by administrative coding supplemented by brief chart reviews for all in-hospital deaths. Premorbid function was assessed with the Clinical Frailty Scale (CFS), and number of admittances and days spent in hospital the year prior to the last hospital stay were recorded. Comorbidity was classified with Charlson’s Comorbidity Index (CCI) as well as the presence of end stage disease , immunosuppression, polypharmacy etc. The last hospital stay was assessed regarding the relevant infection, wherein Sequential Organ Failure Assessment (SOFA) was performed retrospectively, and care given, including patients’ preferences and potential restrictions in care. Ultimately, the likeliness of sepsis as cause of death was evaluated using a five-point scale, including very likely, likely, plausible, cannot be excluded and surely not sepsis as cause of death. Evaluations were performed by medical doctors in internal and emergency medicine, obtaining excellent rater’s agreement with Cronbach’s alpha. Results: Of a total of 638 in-hospital deaths among adults, 318 had a primary or secondary diagnosis of infection. Sepsis as cause of death were evaluated as very likely or likely for 178 (57%), plausible or cannot be excluded for 135 (43%), and as surely not for 5 (2%), which were excluded. Of all 313 cases of possible sepsis-related deaths, 229 patients (73.2%) were either 85 years or older, had a preexisting end stage condition or severe frailty with CFS 7 or higher, with no significant difference between sepsis likeliness groups of very likely and likely vs. plausible or cannot be excluded. Among the 84 patients (26.8%) who were younger than 85, not severely frail and without preexisting end stage conditions, there was still a high prevalence of advanced age, frailty, and comorbidity: 20 patients (6.4%) were younger than 75 years old, not frail (CFS less than 5) and without severe comorbidity (CCI less than 5). 7 patients (2.2%) where younger than 70, not frail and without moderate comorbidity (CCI less than 3). One of these 7 patients had no comorbidity. Overall, 223 (71.2%) had at least one hospital stay the year prior to the last, with means of 4.2 stays and 21.9 days in hospital, if any. 87 (27.8%) had active cancer. Polypharmacy was present in 205 cases (65.5%), immunosuppression in 54 (17.3%), and other advanced conditions, e.g., neuromuscular disease, in 53 (16.9%). Conclusion: The prevalence of advanced age, frailty and comorbidity is prominent in our cohort. This knowledge is of importance for both clinicians evaluating patients with these features, and health authorities when applying sepsis-related mortality as a metric for the quality of sepsis care in similar populations.

Funded in full by the Helse Nord, Northern Norwegian health authorities

Background: The sepsis diagnosis is based on consensus clinical criteria, and vital signs are the key elements in the criteria. Several studies have shown sub-optimal discriminative performances of the suggested sepsis criteria to identify infectious patients with an increased risk of poor outcomes (death or transfer to intensive care unit (ICU)). Consequently, patients with serious infections may present without meeting the sepsis criteria. Data on characteristics and determinants of outcomes for patients with serious infections without sepsis criteria are sparse. Aim: To describe baseline characteristics and to examine predictors of serious outcomes among emergency department (ED) patients with suspected bacterial infections without meeting the sepsis criteria on admission to the ED. Methods: A prospective observational study of patients with suspected bacterial infection admitted to the emergency department during 1.10.2017–31.03.2018. A National Early Warning Score (NEWS2) ≥5 within the first four hours in the ED was assumed to be compatible with sepsis with a high risk for serious outcomes defined as the composite endpoint (primary outcome) of in-hospital death or transfer to the ICU. Patients achieving the primary outcome were grouped according to fulfillment of the NEWS2 ≥5 criteria and compared to baseline characteristics. We used logistic regression analysis to estimate unadjusted and adjusted odds for the composite endpoint per unit increase of different covariates among patients with either a NEWS2 score < 5 (NEWS2÷) or a NEWS2 score ≥5 (NEWS2+). Results: A total of 2,055 with a median age of 73 years were included. A total of 198(9.6%) achieved the composite endpoint, 59(29.8%) NEWS2÷ patients and 139(70.2%) NEWS2+ patients, respectively. Compared to NEWS2+ patients, we found that NEWS2÷ patients were older, more likely to be female, and suffer from diabetes. The proportion with Sequential Organ Failure Assessment Score (SOFA) ≥2 and new-onset atrial fibrillation on admission was lower in the NEWS2÷ group and they also had lower values of leucocytes, bilirubin, lactate, and glucose. Urinary tract infections were more commonly the source of infection among NEWS2÷ patients. The median time to antibiotic treatment was lower in the NEWS2÷ group (4.2 vs 6.7 hours). The Do-not-attempt-cardiopulmonary- resuscitation order (DNACPR) was registered on admission among 16.9% and 27% of NEWS2÷ and NEWS2+ patients, respectively. The final regression model for NEWS2÷ patients showed that diabetes (OR 2.23;1.23-4.0%), a SOFA score of ≥2 (OR 2.57;1.37-4.79), and a DNACPR order on admission (OR 3.70;1.75-7.79) were predictive variables for the composite endpoint (goodness-of-fit test p-value 0.291; AUROC for the model 0.72). A final regression model for NEWS2+ patients revealed that a SOFA score ≥2 (OR 2.93;1.68-5.13), hypothermia (OR 2.48;1.30-4.75), and a DNACPR order on admission were predictive variables for the composite endpoint (goodness-of-fit test p value 0.62, AUROC for the model 0.70). Conclusions: Almost one-third of patients with suspected bacterial infections and serious outcomes during hospitalization did not meet the NEWS2 sepsis criteria. Our study has identified some factors with independent predictive values for the development of serious outcomes which should be tested in future prediction models.

This work was supported by Region Zealand Health Research Foundation, Naestved, Slagelse and Ringsted Hospitals Research Fund, and the Department of Emergency Medicine, Copenhagen University Hospital,Bispebjerg and Frederiksberg, Denmark.

Objectives: Low albumin concentration is known to be associated with poor prognosis in sepsis, and the effect of administration of albumin is controversial. This study was performed to investigate the effect of albumin on the outcomes of patients with sepsis or septic shock. Methods: This was a retrospective, propensity score-matched cohort study of septic patients with an initial serum level < 3.0 g/dL at an emergency department of an urban tertiary university hospital. Patients who received 20% albumin within 24 hours of emergency department (ED) admission, were compared with those who did not. We performed a 1:1 propensity score-matched analysis. The primary outcome was 28-day mortality rate and the secondary outcomes were the Sequential Organ Failure Assessment (SOFA) score at 24, 48, and 72 hours, the need for mechanical ventilation and renal replacement therapy (RRT), and admission to intensive care unit (ICU). Results: A total of 1,284 patients were included, and the overall mortality rate was 29.4%. After propensity score matching, 192 albumin group and 192 control group were included in the final analysis. There was no significant difference in 28-day mortality. The SOFA scores at 24, 48, and 72 hours were higher in the albumin group than in the control group, respectively. The rate of RRT and admission to the ICU was also higher in the albumin group than in the control group. Conclusions: In patients with sepsis with hypoalbuminemia, albumin replacement was not associated with 28-day mortality, but was associated with SOFA score, the application of RRT, and admission to the ICU.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Introduction: Infections account for 15% of the visits attended in the hospital emergency departments (ED) and the prevalence has increased in the last decade, especially in the elderly population. Beyond the severity of the infection, the comorbidity of elderly patients is a very important factor in assessing the intensity of treatment administered in the ED and the final destination of these patients. Objective: To assess the value of comorbidity at the ED visit in predicting 30-day mortality among elderly patients with acute infection. Methodology: Prospective observational multicenter cohort study of elderly patients (≥75 years) with a diagnosis of acute infection in 69 Spanish EDs over 3 seasonal periods of 2 days each (spring, autumn and winter) before the COVID outbreak. Demographic data, comorbidities, functional status according to Barthel Index (BI), clinical and analytical data, the site of infection and all-cause 30-day mortality were collected. The qualitative variables were expressed as frequencies and percentages and the quantitative variables as mean and standard deviation. For comparison, the Chi square test was used for the first, and the Student’s t test was used for independent samples for the second. The SPSS 24.0 (Inc, Chicago, IL) statistical program was used for the statistical analyses. Results: A total of 1,634 patients were included in the study with a mean age of 84.7 years and 51.7% female. Focus of infection was respiratory in 958 patients (58%), urinary in 371 (22%), abdominal in 189 (11%), skin and soft tissue in 114 (7%) and other focus in 30 (1.8%). The mortality recorded at 30 days was 10.16% (166 episodes). Patients who died at 30 days, respect to the survivors, were significantly (p < 0,05 for all) older (years ± SD 86,40 ± 6,33 vs 84,50 ± 5,83), predominantly male (12,17% men vs 8,22% women), more likely to be institutionalized (17,97% vs 8,36%), with a greater Charlson index (2,93 ± 2,02 vs 2,26 ± 1,93 points), with a history of dementia (13,83% vs 8,95%), lower BI (38,93 ± 35,73 vs 68,32 ± 36,48 points) and BI < 60 points (18,3% vs 5,32%) and lower score on the Glasgow coma scale on arrival at the ED (12,99 ± 2,47 vs 14,39 ± 1,42 points). When comparing the different infection models, we did not find significant differences between them, although the respiratory model compared to the others models had a higher mortality with a tendency towards statistical significance (p = 0,057). Conclusions: For elderly patients with acute infection, a high comorbidity on ED visit appears to be a strong predictor of mortality at 30 days regardless of the type of infection.

Introduction: The recent update in sepsis definitions have reinforced sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Because clinical signs at admission are often non-specific, sepsis biomarkers have been intensively investigated in order to improve sepsis identification and to promote the implementation of early therapeutic strategies. However, most patients with sepsis are admitted at hospitals through emergency departments. The emergency department has therefore a crucial role for the early identification of sepsis. Currently, due to complex and multimodal pathophysiological pathways, no individual biomarker of infection and/or sepsis is sufficiently discriminating to allow proper diagnosis, CRP and PCT included. Objective: To define the best combination of biomarkers for the diagnosis of infection and sepsis in the emergency room. Methods: In this cohort, prospective, single-center, non interventional study, consecutive patients with a suspicion of infection in the emergency room were included. Eighteen different biomarkers measured in plasma, and twelve biomarkers measured on monocytes, neutrophils, B and T- lymphocytes were studied and the best combinations determined by a gradient tree boosting approach. Clinical and biological data are described as frequencies and percentages for categorical variables and as means and standard deviations or medians and interquartile ranges for continuous variables, as appropriate. To identify the biomarkers which may discriminate pre-defined groups of patients (bacterial infection, viral infection, sepsis) a gradient boosting tree approach (xgbTree function from the caret R package v6.0.3.81, http://cran.r-project.org) was applied. Results: Overall, 291 patients were included from March 2016 to July 2017,and analyzed, 148 with bacterial infection, and 47 with viral infection. The best biomarker combination which first allowed the diagnosis of bacterial infection, included HLA-DR (human leukocyte antigen DR) on monocytes, MerTk (Myeloid-epithelial-reproductive tyrosine kinase) on neutrophils and plasma metaloproteinase-8 (MMP8) with an area under the curve (AUC)=0.94 [95% confidence interval (IC95): 0.91;0.97]. Among patients in whom a bacterial infection was excluded, the combination of CD64 expression, and CD24 on neutrophils and CX3CR1 on monocytes ended to an AUC=0.98 [0.96;1] to define those with a viral infection. Conclusion: In a convenient cohort of patients admitted with a suspicion of infection, two different combinations of plasma and cell surface biomarkers were performant to identify bacterial and viral infection.

ClinicalTrials.gov Identifier: NCT02707718

Objectives: Cryptococcal infection is usually diagnosed in immunocompromised individual and meningeal involvement can account for mostly cryptococcosis. Cryptococcemia indicates poor prognosis and prolonged course of treatment. This study is aimed to investigate the scoring systems and risk factors to predict the mortality risk of patients with diagnosis of cryptococcal fungemia. Methods: It was single hospital-based retrospective study on patients with diagnosis of cryptococcal fungemia confirmed by at least one blood culture collected from emergent department or during hospitalization. Patients’ characteristics, including general data, vital signs, comorbidities and laboratory investigations were collect between January 2012 and September 2020 from electronic data bank in Taichung Veterans General Hospital. The scoring systems were used to predict the mortality risk of cryptococcal fungemia. Results: Of all, 43 patients were enrolled into this study and one was excluded due to transferring to other hospital before confirmed fungemia. There were 28 (66.7%) males and 14 (33.3%) females with mean age of 63.00±19.69 years. Total hospital stay ranged from 1 to 170 days (mean 44.38 days) and 27 patients (64.28%) expired or discharged under critical condition during hospital stay. In univariate analysis, higher scores of MEWS with ROC of 0.833, RAPS with ROC of 0.842, qSOFA with ROC of 0.848, MEWS plus GCS with ROC of 0.846, REMS with ROC of 0.846, NEWS with ROC of 0.878 and MEDS with ROC of 0.905 could have good performance to predict the in-hospital mortality risk of patients with cryptococcal fungemia. In multivariate cox regression model, all of higher scores of scoring systems, older age or higher lactate, and lower MAP or DBP significantly indicated higher mortality rate. Conclusion: These scoring systems can be apply in predicting dismal outcome of patients with cryptococcal fungemia and the MEDS score has the best performance. Further large-scale prospective study will be needed for patients with cryptococcal fungemia.

Taichung Veterans General Hospital

Introduction :Acute infectious meningitis have had a various clinical presentations. The non-specificity of the clinical signs and even the power discriminating of the lumbar puncture between bacterial or viral origin, that several scores, validated in pediatrics, have been tested in the adult population. Aim of the study :To analyse the discriminating contribution of the Bacterial Meningitest Score (BMS) and the Meningitest score in determining the bacterial or viral origin of infectious acute meningitis in the emergency room. Methods:A retrospective study,from January 2017 to February 2022, including cases of acute meningitis admitted to the emergency room. The BMS and the Meningitest scores were calculated, with analyses of the ROC curve, sensitivity, specificity, PPV and VPN. Results :Seventy-one cases of meningitis with a median age of 36 years, the 25th and 75th percentiles of 22 and 54 years and a sex ratio (M/F) of 1.2. Clinical evaluation revealed fever in 84.5% of cases, neck stiffness in 67.9% of cases, vomiting in 54.7%, photophobia in 37.3%, headache in 70.4%, visual blurring in 9.4% of cases and a seizure in 5.6% of cases. Meningeal syndrome with positive Brudzinski and Kernig signs respectively in 32.4% and 22.5% of cases. Meningeal stiffness was found in 62% of cases. Lumbar puncture showed clear cerebrospinal fluid in 42 patients (59.2%), cloudy in 16 patients (22.5%) and purulent appearance in 7 patients (9.9%). Hypoglycorachia was noted in 29.6% and hyperproteinorachia in 54 cases (76%). CSF culture was negative in 43 cases (60.6%). Bacterial origin was retained in 37.3% of cases. Median BMS=1, AUC=0.730 [0.566; 0.894], median Meningitest score=2.5, AUC=0.808, [0.686; 0.930]. BMS: Specificity at 76%, sensitivity at 68.8%, VPP at 52.1% and VPN at 85.7%, Meningitest score: specificity at 78% and sensitivity at 81.3%, VPP at 52.1% and VPN at 87.7%. Conclusion :The AUC scores, especially the Meningitest score, were good, but they lacked specificity. Negative scores have better predictive value.

Background: The Surviving Sepsis Campaign recommends performing pretreatment blood cultures for all patients hospitalized with suspected sepsis, providing it does not delay the start of antibiotics. Nevertheless, the literature has shown an overall low yield in the emergency department and less than 15% were used to guide the treatment, regardless of the source of infection. Study objectives We aim to analyze the impact of systematic blood cultures drawn to screen for bacteremia on adjusting antibiotic prescription and patient-level exposure to antibiotics. Furthermore, we aim to identify predictors for blood culture positivity. Methods We conducted a retrospective cohort, enrolling patients admitted to the Emergency Department with suspected sepsis between October and December 2021 in a tertiary academic hospital in São Paulo, Brazil. Patients with signs of infection were considered with suspected sepsis after a nursing triage endorsed by a first medical evaluation at the emergency room by the physician on duty. The sample was divided into two groups: positive vs. negative blood cultures. The outcomes were days of therapy (DOTs) and modification in antibiotic prescription. Data were collected through electronic medical records, and the databases were built on REDCap® software. Analyses were performed on R software version 4.1.2. Numerical variables were analyzed using the Mann-Whitney-Wilcoxon test and categorical variables through the chi-square method. A p-value<0.05 was considered significant. Results Fifty-three patients were included. Overall, patients in our sample had high in-hospital mortality (18,88%) and incidence of sepsis (92.45%), septic shock (33.96%), and need for intensive care unit admission (52.56%). Moreover, we found a much higher yield of blood cultures than previously published (37.73%). These findings might be related to a notably sicker population (11.32% of transplanted patients, 13.2% with chronic kidney disease, 15.09% with indwelling venous catheters, and 18.86% with recent hospitalization). Patients with positive blood cultures had their antibiotic prescription more often modified than those with no microorganism isolated in the bloodstream (45% vs. 6.06%; p<0.01). De-escalation of antibiotics was the most common change in prescription (82%). Notwithstanding, there was no significant association between DOTs and blood culture positivity. We could not identify useful predictors of bacteremia for clinical use at the bedside, apart from the male sex (OR 3.45; CI 1.065 - 10.7). Surprisingly, there was no statistical difference in clinical presentation, including chronic or acute organ dysfunctions, between patients with positive and negative blood cultures. These findings must be explained by the limitation of the sample size and the short analysis period. Conclusion Although the overuse of blood cultures may be costly and ineffective for most patients with community-acquired infection with documented sources, systematic collection is definitely the safest approach in an environment with such a high incidence of bacteremia. In brief, positive blood cultures are deemed associated with the need for adjustment in antibiotic prescription and don't seem to enhance the patient-level exposure to antibiotics.

Funding: FAPESP Ethical approval and informed consent: The study protocol was approved by the local Ethics Committee (opinion number 3.990.817; CAAE: 30417520.0.0000.0068), which also waived the need for written informed consent. We adhere to STROBE guidelines.

Background: The hemodynamic key feature of sepsis is cerebral microcirculation may be significant changed in cerebral blood flow (CBF). Because of this feature, sepsis patients develop brain dysfunction and increase mortality. Nevertheless, there is a lack of methods to measure and monitor CBF in the emergency department (ED). So, the aim of this study was to verify the validity as an early death prediction tool by measuring the blood flow velocity and diameter of the internal carotid artery (ICA) by Doppler imaging and to compare the mortality prediction. Methods: This study was conducted as a prospective clinical trial targeting sepsis patients who visited a one regional emergency medical center from August 2020 to February 2022 in Busan city, South Korea. A study was conducted on 1,026 out of a total of 1,071 recruited patients, excluding 45 patients. To compare early death predictions with Doppler of ICA group (331 patients), we measured quick Sequential Organ Failure Assessment(qSOFA) group (335 patients), systemic inflammatory response syndrome(SIRS)criteria group (260 patients) that a popular early death risk recognition tools were used. A primary outcome was to verify the usefulness of ICA Doppler ultrasound as a predictive tool of early mortality accuracy to assess by measuring blood flow velocity and the diameter in sepsis patients with hypotension in the ED. To compare the tools on predictive mortality accuracy, Cox proportional regression analysis was performed and hazard ratios(HRs), 95% confidence intervals were presented. Results: As a result of analyzing the mortality prediction accuracy, the HRs (95% CI) of peak systolic velocity(PSV)of ICA group was significant difference as 1.020 (1.004-1.036) (p<0.05). The HRs of qSOFA was 3.871 (2.526-5.931), indicating a significant correlation (p<0.05). HRs (95% CI) of SIRS was 1.002 (0.995-1.009), showing no significant difference. The PSV in ICA was presented receiver operating characteristic (ROC) curve of. Area under the curve (AUC) was 0.891 (95% confidence interval 0.826~0.956, p<0.001). Discussion & Conclusions: We could verify that PSV in sepsis patients by measured Doppler may be predicting mortality. So, PSV in ICA is measured using Doppler in sepsis patients who have visited the emergency department, it will be possible to predict and prevent early death from brain dysfunction. We propose using Doppler to measure PSV in ICA for sepsis patients in ED. Then it may be useful predict the risk of early mortality in sepsis patients visiting ED.

None.

Background. The PSI and CURB-65 severity scales are widely used in the assessment of community-acquired pneumonia. Its use also spread among patients infected with Covid-19. However, it is unknown if its usefulness is maintained among patients vaccinated against COVID-19. Aim Know the usefulness of the PSI and CURB-65 scales for the prognostic assessment of the patient infected by Covid-19 based on their vaccination status Material and methods. Retrospective descriptive study. Patients diagnosed with Pneumonia by Covid-19 in emergency department (ED) and admitted in hospital. Months: August 2021-February 2022 and vaccination status against Covid-19 was known (0 doses vs one or more doses). Independent variables: age, sex, Charlson comorbidity index (CCI). Dependent variable: 30 days mortality (30M). Descriptive study: quantitative variables: median and interquartile range (IQR), qualitative variables: absolute and relative frequency. Univariate study, comparison of quantitative variables: Mann-Whitney U, qualitative variables: Chi-square. Area under curve (AUC) of receiver operating characteristic curve (ROC) of scores were calculated. All statistical analyzes were performed using the SPSS 24.0. software package. p<0.05. 95% confidence interval (CI). Results N: 402; median age: 64 (IQR: 52-80); female: 40.8%. 30M: 9.2%. Vaccinated: 67.2%. 30M and Vaccinated: 8.9%, Not vaccinated: 9.8% (p>0.05). Total median PSI 30M: 130 (105-155), survivors: 67 (53-94); Total median CURB-65: 30M: 3 (2-4); survivors: 1 (0-2). 30M PSI in Vaccinated: 0-90 points: 2.1%, >90 points: 22.4% (p<0.0001), 30 PSI in Not Vaccinated: 0-90 points: 1.2%, >90 points: 38.7% (p <0.0001); 30M CURB-65 in Vaccinated: 0-1 points: 2.2%, >1 points: 20.4% (p<0.0001), Not Vaccinated: 0-1 points: 0%, >1 points: 36.1% (p< 0.0001); AUC FINE: Total: 0.885 (95% CI 0.835-0.935, p<0.0001), Non-Vaccinated: 0.952 (95% CI 0.901-1, p<0.0001), Vaccinated: 0.846 (95% CI 0.772-0.920, p< 0.0001). CURB-65 AUC: Total: 0.853 (95% CI 0.792-0.913, p<0.0001), non-Vaccinated: 0.923 (95% CI 0.872-975, p<0.0001), Vaccinated: 0.808 (95% CI 0.719-0.898, p<0.0001). Logistic regression (age, sex, PSI): Vaccinated: age and sex (p>0.05); PSI: OR: 1026 (1008-1044); Non-Vaccinated: Sex (p>0.05), age: OR: 1.218 (1.047-1416, p<0.05), PSI: OR 1.058 (1.017-1.100, p<0.05). Logistic regression (age, sex, CURB-65): Vaccinated: sex (p>0.05); Age: OR: 1062 (1009-1118, p<0.05), CURB-65: 2223 (1273-3882); Non-Vaccinated: Sex (p>0.05), age: 1.247 (1.073-1450, p<0.05), CURB-65: 4.228 (1.180-15.151, p<0.05). Discussion and conclusion Both the PSI and the CURB-65 have a similar ability to predict mortality. Both seem to perform better among the unvaccinated population than among the vaccinated, with better results on the PSI scale. Both scales can be good tools to assess the prognosis among patients infected with Covid-19.

Background: Increasing medication use could result in a higher incidence of medication errors (MEs). MEs are considered to be a global health problem and have been reported in many countries. MEs cause morbidity and mortality and affect patients, patients’ families, and health care providers. This study was performed to clarify the clinical characteristics of, outcomes of, and factors associated with medication errors (MEs) that cause harm to adult patients (>15 years of age) treated in the hospitals or health care facilities. Methods: We performed a 10-year retrospective study (2011-2020) using data from the Poison Center, Thailand. MEs taxonomy developed by the National Coordinating Council for Medication Error Reporting and Prevention, was classified into categories A to I according to the severity of outcomes. ME Results: A total of 112 patients were included in the study. Most patients (59.8%) were female. Their mean age was 50.5 years. Most MEs (89.3%) were reported from the government hospitals and most patients (53.6%) had underlying diseases. Most MEs occurred during the afternoon shift (51.8%) and in the outpatient department (85.7%%). The most common type of ME was a dose error (40.2%). Local anesthetics, antipsychotic drugs, and cardiovascular drugs were the three most common classes of ME drugs. The most common clinical effect when the ME occurred was neurologic symptoms (32.1%) such as alteration of consciousness and seizure. Eighty-one patients (72.3%) were admitted with the mean length of hospital stay of 2.4 days. Approximately half of patients had MEs categories F. Six patients died. We analyzed factors associated with MEs that caused harm including deaths (categories E–I) by comparing the clinical characteristics between patients with category C and D MEs (20 patients) and those with category E to I MEs (92 patients). The presence of underlying diseases was the only factor that was significantly different between the two groups of patients (p=0.20). The patients who had underlying diseases, had MEs that caused harm more than patients who did not. We also compared the clinical characteristics between patients aged 15-65 years and patients aged > 65 years. No statistically significant differences were found in sex, the presence of underlying diseases, the work shift that MEs occurred, type of MEs and outpatient/inpatient setting. Discussion & Conclusion: MEs could cause harm and deaths in some adult patients. Local anesthetics were the most common drug that caused MEs in this study. A preventive measures and safety system should be emphasized and implemented to prevent or decrease the occurrence of MEs, especially in patients who had underlying diseases.

The study was not registered trial registration because of no patients involved and this is retrospective analysis. This study did not receive any specific funding.

Introduction: Carbon monoxide (CO) poisoning is one of the most common causes of poisoning death and its diagnosis is based primarily on the blood dosage of carboxyhemoglobin (COHb). Non-invasive pulse CO oximeters (SpCO) have been available since 2005, but their accuracy in determining blood COHb level is controversial. Our objective was to perform a meta-analysis to determine this accuracy. Methods: MEDLINE, Embase, CENTRAL and OpenGrey databases were searched in January 2022. All studies published from 2000 evaluating the accuracy and reliability of SpCO measurement compared to blood COHb levels were included. The primary outcome was the sensitivity and specificity of SpCO for estimating COHb by blood sampling, and the secondary outcome was to estimate the limits of agreement (LOA). This systematic review was conducted according to the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) 2018 guidelines and has been registered on PROSPERO (CRD42020177940). We included studies evaluating the accuracy and reliability of multiple wavelength pulse CO oximeter (SpCO) measurement in human volunteers or ill patients, including children, compared to blood COHb levels. The analyses were performed using R software version 4.0.3 (2020-10-10). The meta-analysis was performed using the mada package version 0.5.10 (mada: Meta-Analysis of Diagnostic Accuracy), focusing on Se and Sp measures. LOA analyses were based on the method described by Tipton and Shuster (23). The analysis of publication bias was performed using a Deeks' funnel plot. Results: Nineteen studies were eligible for the systematic review; 11 could be included for the quantitative analysis of the primary endpoint and 13 for the secondary endpoint. Three different devices were used to measure SpCO: Rad-57® (Masimo, Inc., Irvine, CA), Radical-7® (Masimo, Inc., Irvine, CA), and V-Spec™ Monitoring System (Senspec, Germany. The patient selection was the principal source of bias and concerns regarding applicability. No publication bias was found. The area under the summary ROC curve, estimated using the Rutter and Gatsonis method, was equal to 86%. The pooled sensitivity and specificity were 0.77, 95% CI [0.66–0.85] and 0.83, 95% CI [0.74–0.89], respectively (2089 subjects and 3381 observations). The mean bias was 0.95%, 95% CI [-5.16–7.07] and the LOA were -6.08% to 8.00%, 95% CI [-8.29; 10.19] (2090 subjects and 3942 observations). Discussion & Conclusions: The false negative rate with SpCO was too high (23%) for the triage of subjects suspected of intoxication. Moreover, the consensus is that the acceptable LOA values are ±5%. Non-invasive measurement of COHb (SpCO) by current pulse CO oximeters is not accurate enough to estimate the blood COHb level and should not be used in clinical practice. Trial Registration: PROSPERO (CRD42020177940) Funding: This study did not receive any specific funding Ethical approval and informed consent: Not needed

Trial Registration: PROSPERO (CRD42020177940) Funding: This study did not receive any specific funding Ethical approval and informed consent: Not needed

BACKGROUND Carbon monoxide (CO) is a colourless, odourless gas produced from incomplete combustion of carbon-containing fuels. The effects of exposure to CO range from mild symptoms, such as headache, to neurotoxicity and death. When inhaled, CO binds to haemoglobin forming carboxyhemoglobin (COHb). Several methods exist to measure COHb but detection of exposure is made difficult by its short half-life. In this scoping review we aimed to establish the existing methods used in clinical practice and research to determine CO exposure and map the diagnostic cut-off values used. METHOD A scoping review was conducted according to the Arksey and O'Malley framework. EMBASE, Medline and CINAHL databases were searched for published articles in English from 2002 onwards using keywords “carbon monoxide”, “poisoning” and “diagnosis”. Reviews and papers relating to outdoor air pollution were excluded. Two reviewers independently screened published abstracts for inclusion, with a third arbiter where there was lack of agreement between reviewers. Full text papers were then reviewed, and data extracted on methods used to measure CO level, diagnostic cut-off values, and whether CO exposure was from a known or unknown source. Papers were grouped according to the diagnostic method. RESULTS The search identified 518 individual publications for which 63 met the inclusion criteria after removing duplicates. The predominant methodology of papers were single patient case studies and short case series. No interventional studies were identified. The most common methods identified for diagnosing CO exposure were blood measurement of COHb and spectrophotometrically by measuring COHb levels with a CO-oximeter. Exhaled CO levels using breath analysers and ambient CO measurement were also documented. Most papers did not describe the diagnostic cut-off values used to determine CO exposure but where present, a large variation was noted from 2% to 10%. Blood COHb measurements were predominantly taken in the Emergency Department as a screening tool when suspected CO cases were identified. Expired CO measurements and CO-oximetry were also used within the ED. DISCUSSION AND CONCLUSION Accurate diagnosis of CO exposure is an important factor in guiding treatment and in recognising patients at risk of long-term consequences of exposure. Current methods for diagnosis include carboxyhemoglobin, CO-oximetry and exhaled CO. The results of this scoping review suggest there is wide-spread variation in clinical practice in the cut-off values used to determine exposure. The differences in reported thresholds in research papers make comparison of populations across studies difficult. This scoping review highlights gaps in our current evidence base. Further research is required to identify the optimum measurement method and cut-off values for diagnosis of CO.

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Epidemiology of hydrocodone exposures reported to the U.S. Poison Centers Background: Drug overdoses are a leading cause of unintentional injury-associated death in the United States (U.S.) with 100,306 fatalities in 2021. Opioid dispensing rates continue to remain very high in certain areas across the country. According to the U.S Drug Enforcement Administration, 24.4 million individuals used hydrocodone for non-medical purposes. Emergency department (ED) visits for opioid* overdoses rose 30% in all parts of the US from July 2016 through September 2017. This study aims to examine the national trends in hydrocodone exposures reported to U.S. poison centers (PCs). The National Poison Data System (NPDS) was queried for all closed, human exposures to hydrocodone from 01/01/15 through 12/31/21 using the American Association of Poison Control Center (AAPCC) generic code identifiers. We identified and descriptively assessed the relevant demographic and clinical characteristics. Reports from acute care hospitals and hospital based EDs (ACHs) were evaluated as a subset. Trends in hydrocodone exposure frequencies and rates (per 100,000 human exposures) were analyzed using Poisson regression methods. Percent changes from the first year of the study (2014) were reported with the corresponding 95% confidence intervals (95% CI). Results: During the study period, there were 106,078 toxic exposures to hydrocodone that were reported to the PCs. The frequency of exposures decreased by approximately 50% (95% CI: 45.5%, 53.3%; p<0.001), and the rate of exposures significantly decreased by 57% (95% CI: 48.2%, 65.9%; p<0.001). Of the total hydrocodone calls, the proportion of calls from ACHs was approximately 55%, with this trend remaining constant through the study period. Multiple substance exposures accounted for 56.7% of the overall hydrocodone calls and 70.1% of calls from ACHs. Approximately 18% of the patients reporting hydrocodone exposures were admitted to the critical care unit (CCU), with 13% of patients being admitted to a psychiatric facility. Residence was the most common site of exposure (94.3%), and 62% of these cases were enroute to the hospital via EMS when the PC was notified. Cases were predominantly female (61.3%), with the most common age group being 20-29 years (16.2%) followed by 30 – 39 years (13.6%). Suspected suicides (45.2%) was the most common reason for exposure, followed by therapeutic errors (20.3%), with exposures for both reasons being higher in cases reported by ACH. Major effects and moderate effects were seen in 6.1% and 20.6% cases, respectively. There were over 600 deaths during the study. The most frequently co-occurring substances associated with the cases were benzodiazepines (17%) and alcohol (9.7%). Conclusions: PC data demonstrated a decreasing trend of hydrocodone exposures, which may in part be attributed to the reformulation of this medication with abuse‐deterrent properties. However, the high proportion of calls from the acute-care hospitals and EDs indicates higher risk of such exposures which may be mediated by several clinical and demographic factors.

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Background: Acute appendicitis is one of the most common indications for emergency surgery worldwide. Patients with severe mental illness (SMI) have a shorter life expectancy and have been considered by the World Health Organization (WHO) as a vulnerable group. A higher perforation rate has been found among patients with SMI and was considered owing to delayed diagnosis. 72-hour unscheduled emergency department revisit was considered an indicator for evaluating delayed diagnosis and suboptimal management. Thus, the aim of this study is to evaluate the association of 72-hour unscheduled emergency department revisit rate in SMI patients with acute appendicitis via the use of multi-centre database. Methods: This is a retrospective case-control study derived the data from Chang Gung Research Database (CGRD) from January 1st, 2007 to December 31st, 2017. CGRD is the largest multi‐institutional electronic medical records (EMR) collection in Taiwan collecting data from seven Chang Gung Memorial Hospitals (CGMH), including two tertiary medical centres, two regional hospitals, and three district hospitals. The diagnoses of acute appendicitis were confirmed by the ICD codes in discharge medical records combined with the national health insurance declarations data. SMI including schizophrenia, bipolar disorder and major depressive disorder were defined by the psychiatric out-patient department diagnosis at least once before the diagnosis of acute appendicitis. The exclusion criteria were below 18 years of age, not admitted through ED, transferred from other health facility and incomplete medical records. A non-SMI patient group was matched at the ratio of 1:3 by using the Greedy algorithm. The outcomes were unscheduled 72-hr ED revisit, appendiceal perforation rate, ICU admission and in-hospital mortality. Results: A total of 25,766 patients from seven hospitals over a span of 11 years were recruited; among them, 11,513 were excluded by criteria, with 14,253 patients left for analysis. SMI group was older (50.5 vs. 44.4 years, p < 0.01) and had a higher percentage of females (56.5 vs. 44.4%, p = 0.01) and Charlson Comorbidity Index. An analysis of the matched group has revealed that the SMI group has a higher unscheduled 72-hour revisit to ED (17.9 vs. 10.4%, p = 0.01). There was no significant difference in appendiceal perforation rate, ICU admission and in-hospital mortality. Conclusions: Our study demonstrated a higher unscheduled 72-hour ED revisit rate prior to the diagnosis of acute appendicitis in the SMI group was found. ED health providers need to be cautious when it comes to SMI patients with vague symptoms or unspecified abdominal complaints.

Trial Registration: Not applicable for observational study. Funding: This study did not receive any specific funding. Ethical approval and informed consent: This study was approved by the Chang Gung Medical Foundation Institutional Review Board (IRB: 202001785B0), waiving the need for obtaining the informed consent of the study participants.

Background and aim: Worldwide, many children under the age of 18 years die due to acute intoxications. Intoxications can occur unintentional or intentional. Intentional intoxications in adolescents are most common in females. Substantial underreporting of childhood intoxications and registration bias causes data scarcity and case details to be unknown. To optimise prevention strategies and training of emergency department (ED) personnel, increasing knowledge on intentional intoxications is crucial. Therefore, the aim of this study was to describe patient characteristics of children with intentional intoxications at the ED. Methods: We present preliminary data of a single-centre retrospective observational study at the Erasmus Medical Centre (Erasmus MC). We consecutively included all children under the age of 18 who were admitted at the ED for (a suspicion of) intoxication between 2015-2019. Exclusion criteria were ingestion of button cells, smoke, carbon monoxide, or natural gas. The total study population was divided into non-intentional and intentional intoxications (non-suicidal self-harm (NSSH) and suicide attempts (SA)). The outcome variables concerned patient characteristics (including vital signs), location of ingestion, intoxicant (type, dosage, intention), diagnostics, treatments and outcome. For descriptive statistics the chi-squared test and Fisher’s exact test were used. Results: 305 patients with non-intentional (n=228; 74.8%) and intentional (n=77; 25.2%) intoxications were included. The median age was 14.0 years (SD 6.6; IQR 2.0-16.0). Intentional intoxications were divided into two subgroups: NSSH (n=19; 24.7%) and SA (n=58; 75.3%). In the group of intentional intoxications, 67 patients (87.0%) were female, and all patients (n=77; 100%) were over eleven years old. Most intoxications occurred at home (NSSH: n=11; 57.9% and SA: n=36; 62.1%). Therapeutic drugs were the most common intoxicant in both NSSH (n=67; 87.0%) and SA (n=52; 89.7%). In NSSH and SA, 33.8% (n=26) did not receive any treatment at the ED compared with 54.0% (n=123) in the non-intentional group. Most patients with an intentional intoxication were hospitalised (n=38; 49.4%). No death due to an intentional intoxication occurred. Conclusion: In our population, the majority of intentional paediatric intoxications concerned SA and occurred more often in female patients at home with therapeutic drugs as the most used intoxicant. Patients with intentional poisonings were more often severely ill than patients with non-intentional poisonings. As we performed a small single centered study, in order to gain more insights on this topic and further improve prevention programs and training of ED personnel, data should routinely be collected and monitored.

Funding: This study is part of a larger study which received funding from the “Spoedeisende Geneeskunde Onderzoeksfonds” and Stimuleringsprogramma Gezondheidsonderzoek (SGO).

Background: Misuse of prescription opioids continues to be a significant public health crisis globally. According to the Centers for Disease Control and Prevention (CDC), there were more than 72,000 overdose deaths in the United States (U.S.), with 49,068 involving an opioid. Preliminary reports from states and cities indicate that overdose death rates are further increasing during the COVID-19 pandemic. The present study sought to evaluate the recent trends in the severe outcomes to single substance opioid exposures (SSO) reported to the U.S. poison centers (PCs). Methods: The National Poison Data System (NPDS) was queried for all closed, human exposures to opioids from 01/01/15 through 12/31/21 using the American Association of Poison Control Center (AAPCC) generic code identifiers. We identified and descriptively assessed the relevant demographic and clinical characteristics. Reports from acute care hospitals and hospital based EDs (ACHs) were evaluated as a subset. Trends in opioids exposure frequencies and rates (per 100,000 human exposures) were analyzed using Poisson regression methods. Percent changes from the first year of the study (2014) were reported with the corresponding 95% confidence intervals (95% CI). Results: During the study period, there were 458,285 toxic exposures to opioids that were reported to the PCs. The frequency of exposures decreased by approximately 28% (95% CI: 25.5%, 30.4%; p<0.001), and the rate of exposures significantly decreased by 26% (95% CI: 23.2%, 31.7%; p<0.001). Of the total opioids calls, the proportion of calls from ACHs was approximately 56%, with this trend remaining constant through the study period. Multiple substance exposures accounted for 51.7% of the overall opioids calls and 59.9% of calls from ACHs. Approximately 17% of the patients reporting opioids exposures were admitted to the critical care unit (CCU), with 10% of patients being admitted to a psychiatric facility. Residence was the most common site of exposure (88.3%), and 66% of these cases were enroute to the hospital via EMS when the PC was notified. Cases were predominantly female (53.6%), with the most common age group being 20-29 years (18.2%) followed by 30 – 39 years (17.1%). Suspected suicides (33.2%) was the most common reason for exposure, followed by intentional abuse (20.3%), with exposures for both reasons being higher in cases reported by ACH. The proportion of cases reporting intentional abuse as the reason for exposure increased significantly during the study (12% to 22%). Major effects and moderate effects were seen in 11.6% and 23.2% cases, respectively. The case fatality rate was 1.3% and the proportion of fatalities increased significantly during the study period (491 to 792). The most frequently opioid was hydrocodone while benzodiazepines were the most commonly reported co-occurring substances. Conclusion: opioid exposures reported to the poison centers during the study period decreased but exposures reported from ACHs increased significantly. Mortality due to opioid exposures also demonstrated an increase. The impact of COVID-19 on the opioid crisis needed further attention.

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Introduction : L’ « Aide Médicale d’Etat » or State Medical Aid (SMA) is a social protection system In France allowing foreigners in irregular situation in France to access healthcare. This plan cristallizes regularly the public debate, intermixing politics questions about migration and health policies. In 2019, a report by the « General Inspectorate of Social Affairs » about the comparison of European systems for access to healthcare for this population was published. He reported a rate of abuse and fraud at the SMA of more than 25%, considering that the existence of a pre-existing pathology was at the origin of the migration project. This report, witch was politically commissioned, had significants methodologicals bias. Our study aimed to analyze, for foreign patients in an irregular situation in France, the rate of emergency consultations for a pathology preexisting to migration. Method : We conducted a retrospective single-center observational study in a University Hospital Center in a department with a large migrant population. All emergency consultations in 2019 were included. The data collected were : socio-demographics, comorbidities, reasons for consultation, emergency care, discharge procedures. The primary endpoint was the rate of consultations linked to a pre-existing pathology on arrival in France among patients receiving SMA or without social protection. Results : 592 consultations in 2019 concerned 409 patients benefiting from SMA or without social protection. 72% had no history. The hospitalization rate for these precarious patients was 7.9%. 7 consultations (2%) were motivated by the existence of a pathology pre-existing the migration, particulary chronic renal failure (3 consultations) and tumor pathologies (2 consultations). Conclusion : The reasons for consultation in the emergency departements of beneficiaries of the SMA or without health insurance are very rarely linked to a pathology existing before the migration.

Introduction. Falls combined with subsequent complications (injuries, fractures) are a common clinical phenomenon among vulnerable elderly patients. Polypharmacy in the elderly often leads to increased prescription of potentially inappropriate medications (PIMs), which are significant contributors to increased risk of falls in patients over 65. This study aimed to identify the percentage of patients over 65 years of age who visited the Emergency Department (ED) of a secondary hospital in Greece with a fall diagnosis, the prevalence of fractures in these cases, and the risk factors that lead to a fall with a concurrent fracture. We also studied the relation between polypharmacy and prescription of PIMs, with the incidence of fracture after a fall as an indicator of mechanically more dangerous accidents. Another question that we studied was whether ED physicians identify cases related to the prescription of potentially inappropriate medications and whether they intervene. Materials and Methods. This was a prospective observational study in patients over 65 years of age who presented to the ED of Venizelio General Hospital of Heraklion after a fall and provided consent to participate. The period studied was from 1/12/2020 to 30/3/2021. A questionnaire was used to record demographic data, medications, frailty score, Activities of Daily living performance score, and disease outcomes. The use of PIMs was defined based on the revised 2019 Beers criteria of the American geriatric society. Results. A total of 143 patients were included in the study, with a mean age of 79.5 ± 8 years. Forty-one patients were men, and 102 were women. Significantly more women experienced a fracture after a fall compared to men (74.5% vs. 43.9%, p = 0.001).In accordance with previous studies, fractures were more prevalent in patients with lower body weight and lower BMI. When patients had a fall with a fracture, physicians tended to more often identify PIMs as potential causing agents of the fall compared to patients that had no fractures. (86% vs. 54.8%, p <0.001). A significantly higher Frailty score was also associated with an increased possibility of a fracture after a call. Conclusions. The ED could be an important health unit for reviewing polypharmacy in the elderly. Such a policy could reduce the risk of adverse drug reactions from PIMs and decrease ED visits and hospitalizations for fall-related trauma.

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Background and Objectives: This study aimed to compare the characteristics and short-term outcomes of Turkish and American adolescents with suicide attempts and determine the difference in the management and used resources among two different emergency departments in Turkey and the United States of America. Methods: This retrospective observational study was conducted between October 2017 and September 2018. Characteristics and other information of 217 (131 American and 86 Turkish) suicide attempter adolescents were retrieved from medical records. Results: Overall, 78% of adolescents were female. Abuse history (physical/sexual) was more common among American adolescents (p = 0.005, odds ratio [OR] 3, 95% confidence interval [CI]: 1.4–4.8), whereas uncontrolled psychiatric diseases were more evident in Turkish cases (p <0.001, OR: 5.3, 95% CI: 2.3–8.6). Proportions social worker assessment and hospitalization were significantly lower, with shorter mean follow-up duration after discharged among Turkish than American adolescents (respectively, p <0.001, OR: 9.2, 95% CI: 5.8–14.6; p<0.001, OR: 16.6, 95% CI: 8.3–33.3; and p=0.002, mean difference: –12.6; 95% CI: –20 to –5). Repeated suicide attempts were significantly higher in Turkish than American patients within 3 months after discharge (29% vs 8%, p < 0.001, OR: 4.9; 95% CI: 2.2–10.9). Social worker assessment, hospitalization, and longer mean duration of emergency department observation reduced the incidence of repeated suicide attempts (respectively, p < 0.001, OR: 4; 95% CI: 1.9–8.6; p= 0.003, OR: 3.3, 95% CI: 1.5–7.2; and p = 0.012, mean difference: − 6.2; 95% CI: −11.5 to −1). Conclusions:Turkish adolescents had shorter observation time, with less social worker assessment, and hospitalization. Therefore, their high suicide re-attempt rate following discharge was related to the health care deficiencies.

Background The Osaka prefectural government has publicized a damage estimation for a Nankai Trough quake, with a recurrence probability of about 70% in the next 30 years. Although there are designated “disaster coping” hospitals in Osaka Prefecture, it remains unclear whether the city’s medical care system can manage the high number of casualties. As the burden on medical systems differs markedly depending on individual hospitals’ capacities, which reflect factors such as bed numbers and operating rates, and earthquake and tsunami victims’ behaviors, we investigated manageability of the disaster medical care system in Osaka City by using the inpatient care capacities of each disaster coping hospital, and casualty distributions for cases of high and low tsunami evacuation rates. Methods There are seven disaster base hospitals (DBHs) and 94 disaster cooperative hospitals (DCHs). In this geographic information system (GIS)-based analysis, we calculated the number of available beds based on total number of beds and monthly operating rates and displayed inpatient care capacities on a map. Subsequently, we calculated detailed distributions of severely and moderately injured patients based on damage estimations in two conditions: high and low evacuation rates from the tsunami-affected zone. We ran a simulation in which severely injured patients were assigned and transported to DBHs directly, and moderately injured patients were transported to DCHs. Moderately injured patients who could not be accommodated in DCHs were then transported to the nearest DBHs (Scenario 1) or were transported to DCHs with available beds in the same region first, and then surplus patients were transported to DBHs (Scenario 2). Results In the low evacuation rate condition, 16,528 severely injured patients were transported to DBHs (minimal 22-maximal 4,506), with the highest number being admitted to a DBH in northeastern Osaka City. In Scenario 1, 59,316 excess moderately injured patients were transported to DBHs (0-16,015) versus 32,411 (61-22,739) patients in Scenario 2; again, the highest number were admitted at a DBH in the northeastern area. In the high evacuation rate condition, 839 severely injured patients were transported to DBHs (22-288), whereas 1,367 excess moderately injured patients were transported to DBHs (0-636) in Scenario 1 versus 550 (0-294) patients in Scenario 2. Discussion & Conclusions A GIS allows visualization of the manageability of the disaster medical care system in Osaka City and provides directions for improving the medical care system. To date, countermeasures against a major Nankai Trough earthquake are focused mainly in coastal areas, but this study revealed that any problems in medical care would most greatly impact the northeastern area. Our results showed that the burden on medical systems differed markedly depending on whether the evacuation rate was high or low, thus underscoring the importance of providing sufficient education to citizens. To decrease the burden on DBHs, moderately injured patients should be transported to DCHs with available beds in the region first by using an Internet of Things system such as the Emergency Medical Information System in Japan.

This work was supported by JSPS KAKENHI Grant Number JP20K09292.

Background Traumatic brain injury (TBI) is a frequent cause for admission to the pediatric intensive care in young children. Over a quarter of the hospitalizations and half of the deaths due to TBI are caused by abusive head trauma (AHT). The effects of AHT on neurocognitive, motor and psychological development are especially detrimental. Differentiating between AHT and non-abusive head trauma (nAHT) is important to ensure appropriate care. The aim of our study is to describe the differences in characteristics of AHT and nAHT and examine the use of ancillary diagnostics in screening for inflicted injury. Methods Retrospective data on presentation, history, examinations and outcome were collected on children aged 0-24 months who were admitted with TBI to the pediatric intensive care unit of the Erasmus Medical Center (Rotterdam, the Netherlands) from 2011 through 2021 and had no previous history of brain- or skull injury. Cases were categorized as AHT or nAHT according to Hymel’s criteria. The data were analyzed descriptively and tested using Fisher exact tests. Results 60 children (median age 4.0 months, 65% boys) were included. AHT was identified in 27% (n=16). There was no statistical difference in symptoms at presentation or delay of presentation between AHT and nAHT. Children with AHT did present more often without history of trauma (50% =8/16 vs 7% =3/44, p-value 0.001) and when accidental trauma was reported this more often was a fall from height <1m (63% =5/8 vs 14% =5/36, p-value 0.009). Skin abnormalities in the urogenital area (31% =5/16 vs 9% =4/44, p-value 0.048) and on extremities (56% =9/16 vs 14% =6/44, p-value 0.002) were significantly more frequent in AHT compared to nAHT. An abnormal fontanel (50% =8/16 vs 18% =8/44, p-value 0.021) and abnormal tonus (31% =5/16 vs 4% =2/44, p-value 0.011) were also found more often in AHT. All children underwent imaging of the brain by CT (n=56) and/or MRI (n=21). No differences in types of injuries on imaging were found between AHT and nAHT. An initial skeletal survey was performed in 37% (n=22) of children and fundoscopy in 52% (n=31). Not all children categorized as AHT by Hymel’s criteria underwent complete top-toe examination (n=13/16) or had a skeletal survey (n=11/16) performed. In 63% (n=10) of AHT cases advise from the Dutch Expertise Center for Child Abuse was sought. In 42% (n=25) of all children suspected child maltreatment was reported to the Safe at Home centre (national child safety organization). Mortality was higher in AHT compared to nAHT (25% =4/16 vs 4% =2/44, p-value 0.038). Conclusion This study shows that differences in presentation, physical symptoms and outcome between AHT and nAHT in children admitted to the pediatric intensive care unit can help to identify inflicted injury. Screening for signs of inflicted injury with top-toe examination and skeletal survey should be performed in children with possible AHT. Strict adherence to protocols and assistance by a child abuse expert team could improve the recognition of child maltreatment in young children with TBI.

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The Antwerp metropolitan region is at risk for disasters. It hosts the world second petrochemical port including a nuclear power plant. It’s on a traffic crossroad for transport on the road, by train, by air or on the water. It hosts a huge Jewish community and an important show arena with great international stars performing. Are the hospitals in this city prepared to deal with these kind of incidents. To evaluate this preparedness in 5 acute hospitals from the 2 major hospital associations we used the Hospital Emergency Response Checklist of the World Health Organisation. This checklist evaluates 92 subsets of 9 major components of hospital preparedness scoring each item from 0 (absent) over 1 (to work on) to 2 (completed). A total score between 0 and 64 out of 184 results in an unacceptable situation. Between 65 up to 129/184 gives a certain preparedness but is insufficient for a good reaction on incidents. A score of 130 and higher states a sufficient overall preparedness. The checklist was completed by one of the authors in cooperation with 2 respondents per hospital (a disaster coordinator and a responsible of the Emergency Department. 2 hospitals scored 150/184 given a good preparedness level , 1 scored 128/184 and 2 scored 126/184 giving some work to be done in the latter 3 hospitals. Sections with the highest need on improvement were surge capacity (4/5 hospitals), human resources (3/5 hospitals) and command and control, continuity of essential services and post disaster recovery (2/5 hospitals). With a sufficient score in only 2 hospitals and an intermediate score in the other 3 hospitals there is some work to be done to optimize the hospital disaster preparedness in Antwerp. As the responsibles know the key points they can act on it and a re-evaluation should be planned. In conclusion we can state that the studied Antwerp hospitals aren’t optimally prepared to possible disastrous situations.

No funding for this study

Introduction In cranial trauma patients, a lack of monitoring can be responsible for Secondary Cerebral Aggression of Systemic Origin which is harmful for the patient. In addition, the post-trauma transport period is a delicate moment which could conditioning immediate mortality or even the subsequent prognosis. The objective of our study was to evaluate professional practices concerning the prehospital management of severe and moderate traumatic brain injury and to assess their influence on the prognosis of patients at 3 months and 6 months. Material and method We carried out a monocentric and retrospective descriptive study. Between October 1, 2016 and December 31, 2020, we included all adult patients treated by the pre-hospital emergency medical service of a university hospital for severe or moderate head trauma. Results Of the 129 patients included, 87 (67%) had severe head injuries and 40 (31%) died. The mean age was 50+/-22 years old. Road accidents accounted for half of the causes of death, 24% of patients had a positive blood alcohol level and 19.4% benefited from antiplatelet or anticoagulant treatment. The median duration of prehospital treatment was 39 minutes (IQR: 29-56). Of all treatments, 41% of patients had no blood sugar value and 76% had no temperature value. Regarding ventilation, 95% of patients were adequately oxygenated with saturation > 90%. Of the 35 patients who showed signs of cerebral involvement, 10 (28.6%) did not benefit from osmotherapy. Blood pressure was controlled for 66% of the population in our study, but only 18% of patients had normal temperature and blood sugar values. The Glasgow Outcome Scale was overall more unfavorable for patients whose Secondary Cerebral Aggression of Systemic Origin had not been corrected and/or monitored. Conclusion These results should encourage us to find solutions to optimize the management of head trauma (improvement of procedures, computerization, checklist) during the prehospital time, as we shows an impact of the pre-hospital management of Secondary Cerebral Aggression of Systemic Origin on morbidity and mortality.

Advancing age is a well-known risk factor for poor outcomes in trauma. Thus, strategies and policies to prevent and minimise injuries must be developed. There has been a rapid increase in the elderly population over the last century with the number under 65 tripling and that over 65 increasing by a factor of 11. Although the number of dependent elderly have increased; many still maintain active independent lifestyles requiring assessment and care in the event of trauma related injuries. Many elderly patients live alone in large double storey homes, many have multiple co-morbidities and are on multiple medications, often these have not been reviewed. Increasing age puts a trauma patient into a higher risk category. It is known that elderly who sustain major trauma have a higher complication and mortality rate; minor injuries should not be overlooked. This retrospective audit of consecutive patients 65 and over presenting to the Emergency Department with trauma over the period of October to December 2021 showed the need to improve preventative strategies against trauma, the need to ensure a robust system of medication review and that strategies should include means that would be more patient centered and there should be improvement of community-based care focused on minimising travel to access healthcare. More study around accessible primary care and planning for life after 65 is warranted with the increased demands on health care and rising costs.

Background Disability and death due to low falls is a growing problem worldwide which disproportionately affects older adults. Optimising the management of these patients carries significant implications for the health of individuals and the performance of healthcare systems. However, studies concerning the benefit of higher-level trauma centre care have not yielded consistent, high-quality evidence of the role of higher-level care in patients injured by falls. This study assessed the effectiveness of major trauma centre care in adult patients injured by low falls in England and Wales. Methods Data were obtained from the Trauma Audit and Research Network (TARN) on adult patients (age over 16 years) injured by falls from <2 metres between 2017-2019 in England and Wales. Binary logistic regression and Cox Regression were used to control for casemix. 30-day survival, length of hospital stay and discharge destination were compared between major trauma centres (MTCs) and trauma units or local emergency hospitals (TU/LEHs). Results 127,334 patients were included of whom 35,175 (27.6%) attended an MTC. The median age was 79.4 years (IQR 64.5-87.2 years), and 74.2% of patients were aged >65 years. Unadjusted 30-day survival was lower in MTCs (odds ratio [OR] 0.69, 95% confidence interval [CI] 0.66-0.73). After adjusting for casemix, MTC care was not associated with improved survival (adjusted odds ratio [AOR] 0.91, 95% CI 0.87-0.96). Transferred patients had a significant impact upon the results. After excluding transferred patients, the AOR for survival in MTCs was 1.056 (95% CI 1.001-1.113). The association between improved survival and MTC care was greatest in patients who suffered major trauma (AOR 1.126, 95% CI 1.044-1.215) and was absent in patients aged >65 (AOR 1.038, 95% CI 0.982-1.097). MTC care was associated with longer length of hospital stay (adjusted hazard ratio 0.906, 95% CI 0.894-0.918) and higher odds of discharge home (AOR 1.066, 95% CI 1.033-1.101). Conclusion TU/LEH care is at least as effective as MTC care due to the facility for secondary transfer from TU/LEHs to MTCs. In patients who are not transferred, MTCs are associated with greater odds of 30-day survival in the whole cohort and in the most severely injured patients. There is no association between MTC care and improved 30-day survival in patients aged >65 years. Future research must determine the optimum way to identify patients in need of higher-level care, the components of care which improve patient outcomes, and develop patient-focused outcomes which reflect the characteristics and priorities of contemporary trauma patients.

Dr Michael Tonkins was supported by a grant from the National Institute for Health Research (NIHR). The NIHR played no role in the design or conduct of the study.

Introduction: Trauma is a major contributor to disease burden especially in the younger population. Traumatic brain injury (TBI) has notable impact in patient’s autonomy and life expectancy. It is possible to reduce trauma burden with good quality care and a systematic approach. In 2003, the Portuguese general medical council (GMC) published the standards of good practice in trauma, defining quality indicators (QI) for TBI. Aim: To audit the quality of care provided to TBI patients admitted to the emergency room (ER) of a tertiary hospital according to the QI defined by the Portuguese GMC. Methods: Retrospective cohort study including all trauma patients admitted in our ER between January 1st and December 31st, 2021. Demographic data, type and mechanism of injury, trauma and physiological severity, probability of survival, pre-hospital medical approach, destination after ER and early and late mortality were evaluated. The QI analysed were: patients with Glasgow coma scale (GCS)<9 received endotracheal intubation, patients with GCS<13 had a CT-scan in less than 4 hours, patients with surgical lesion were transferred to the operating room in less than 4 hours after hospital admission and patients with GCS <9 had placement of an intracranial pressure (ICP) sensor. Results: During the study period there were 135 trauma patients admitted to the ER, 87 (64%) presented with TBI. The median±SD age of the TBI group was 57±20 years-old and 70 (80%) patients were male. According with the type of trauma, 38 (44%) presented as isolated TBI being 72 cases of blunt trauma. The most frequent cause of TBI was falls in 47 patients (54%) followed by road traffic accidents in 29 cases (33%). Injury severity score (ISS) median±SD was 15±11 and 48% of the cases had an ISS ≥16 with an overall mortality rate of 16%, with similar rates for early and late in-hospital mortality. Considering de QI, 94% of patients with GCS < 9 received endotracheal intubation, 98% of the patients with a GCS<13 had a CT-scan in less than 4 hours, 75% (9 in 12) were transferred to the operating room in less than 4 hours after hospital admission, 35% patients with GCS <9 had placement of an ICP sensor. In this group, patients not submitted to ICP sensor placement presented an ISS average of 20 and an in-hospital mortality rate of 45%. Discussion&Conclusion: Like in most series, TBI comprised the principal type of trauma admitted to the ER. Blunt trauma was the most frequent type of injury as the falls were the most common cause as described in medical literature. The compliance to TBI QI was extremely high in our hospital except the indicator related to the placement of the ICP sensor in patients with GCS<9. Patients that did not had an ICP sensor placed had a severer TBI and higher mortality. This study identifies an area of improvement in TBI, an internal protocol will be developed along with the neurosurgery to improve this parameter.

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Background Vitamin D may be important for neuroprotection after traumatic brain injury (TBI) by modifying inflammatory responses. The objective of this study was to evaluate the association between vitamin D deficiency and functional/survival outcomes among TBI patients with intracranial injury. Methods This study was a prospective multicenter cohort study, conducted on adult TBI patients admitted in 5 participating emergency departments (EDs) from December 2018 to June 2020, and who had intracranial hemorrhage or diffuse axonal injury confirmed by radiological examination. The study outcomes were good functional recovery at hospital discharge and survival at 6-months after injury. The main exposure was serum vitamin D deficiency (0–10 ng/ml). Multilevel logistic regression analysis was performed to estimate the association between vitamin D deficiency and study outcomes. Results Among 606 patients, 101 (16.7%) patients had vitamin D deficiency at the time of ED arrival. Good functional recovery was observed in 65.2% (395/606) of total population, and the proportion was significantly lower in the vitamin D deficiency group than the non-deficiency group (56.4 vs. 66.9%, p=0.04, adjusted OR (95% CI): 0.56 (0.37–0.84)). Overall survival rate at 6-months after injury was 79.5% (434/546), and patients with vitamin D deficiency had significantly lower likelihoods of survival at 6-months than patients without deficiency (75.0 vs. 80.3%, adjusted OR (95% CI): 0.58 (0.39–0.86)). Conclusions Vitamin D deficiency is associated with poor functional outcomes at hospital discharge and mortality at 6-months after injury for TBI patients with intracranial hemorrhage or diffuse axonal injury.  

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Abstract Background: Intimate partner violence (IPV) is a widespread, often unidentified and hidden public health problem, which has serious consequences. The purpose of this study was to describe and compare the clinical characteristics of women’s violence inflicted physical injuries, as presented at Iceland’s largest Emergency Department (ED). Three groups were created based on registered reason of injury: (1) IPV, (2) community violence (CV) with a history of IPV (HIPV), and (3) CV with no history of IPV. Methods: Data was collected retrospectively by using the Nomesco classification system of external causes of injuries. Participants were adult women, residing in the capital area, visiting the ED during 2005-2019. Results: IPV inflicted ED visits declined by 45% during the research period and CV visits declined by 61%. Women in the IPV group had the highest prevalence of repeated new ED visits per 1,000 women in the capital area. The majority of IPV occurred in residential areas (86.4%), inflicted by a current partner (54.7%), and included only one perpetrator (95.3%). Women involved in CV were most likely to visit the ED on weekends (p=0.003) and IPV women were most likely to visit between 08:00-16:00 (p<0.001). The most common type of injuries resulting from IPV were superficial injuries (69.4%) with IPV women being twice as likely (7.1%) to have injuries on their neck than CV women (3.5%). IPV women were most likely to be admitted (3.0%). Conclusion: Time of ED visit, number of perpetrators and location of assault can be indicators of IPV inflicted injuries, as opposed to otherwise inflicted injuries. Repeated visits, superficial injuries and neck injuries might also be an indicator of IPV, however wounds and sprains and injuries on head and upper limbs are more likely to be non-IPV inflicted

Landspitali University Hospital Science Fund [A-2021-071, 2021]. University of Iceland Research Fund [2020]. The Icelandic Gender Equality Fund [2018]. Reykjavík City Council’s Human Rights and Democracy Office [R15060027, 2015].