Background Nightshift workers have decreased cognitive capacity, vigilance, sleep deprivation and feel tired due to circadian dyssynchrony. To deliver excellent care and assure good wellbeing for nightshift workers, it is important to limit fatigue and sleepiness. Powernaps during nightshift might reduce these negative effects. The primary aim of this study was to assess the effect of powernapping during nightshifts on fatigue and vigilance. Methods A crossover design study was performed between March and April 2021. Candidates in this study were nurses, residents and emergency physicians working in a large, Dutch, hospital. After voluntary inclusion participants were followed during two nightshift blocks. They were randomly assigned to start with either the control condition, or the intervention condition and crossed over to the other condition during their next nightshift block. In the control condition no powernaps were allowed. In the intervention condition, they performed a 20-minute-powernap between 2-4 AM. Vigilance and sleepiness were tested three times during both conditions, before and after the powernap and at the end of the nightshift. Vigilance was tested using a 5-minute psychomotor vigilance test (PVT). Karolinska sleepiness score (KSS) measured sleepiness. For between-group comparisons estimated marginal means corrected for baseline measurements were used. Results 56 healthcare workers were included in the study. 59% of the participants worked at the emergency department. 24% percent was able to complete all tests in both conditions. 16% of participants tested the intervention only and 14.5% the control condition only. 17% of participants tested more than one shift in both conditions. Overall, 91 nightshifts were analyzed with even distribution between the conditions. The mean KSS increased from 3.3 to 6.0 in the control condition comparing to 3.4 to 4.8 in the intervention condition. This increase was 1.3 points lower compared to the control group, which is statistically significant. The mean reaction time in the control group started at 459 milliseconds (ms) and increased to 468 ms in the powernap condition starting reaction time was 449ms and increased to 532ms at the end of the shift. This difference was not considered statistically significant, p-value 0.07 compared to control situation. Conclusions and discussion Performing a powernap during a nightshift can be difficult due to working demands. However, when performed between 2-4 AM, it can improve subjective feeling of sleepiness. The increased reaction time at the end of a nightshift after a powernap might be due to sleep inertia. It is the feeling of grogginess people experience after awakening lasting between 15-30 minutes. The reported decrease of sleepiness after a powernap however contradicts this hypothesis. This might be due to a reporting bias in the KSS since the powernap chairs in this study were a trial installation in all of the participating departments except the ED. Evidence on the occurrence and timing of sleep inertia after a nap is inconsistent in current literature. The timing of the powernap as well as the timing of the last measurement isn’t registered in this study therefore these data cannot predict the timing or duration of sleep inertia.

Funding for this research was provided by the SGO-fonds. It is a foundation that supports scientific research by Emergency Physicians in The Netherlands. www.SGOfonds.nl

Acute pain is one of the most common complaints concerning referral to the emergency department. Pain remains misdiagnosed and mistreated despite all current pain evaluation measurements (pain scales, physiological parameters). Cortisol is identified as stress and pain-marker during acute pain. The aim of this study was to evaluate any changes in cortisol and if there were any changes during the pain stimulus experiment in healthy volunteers. Methods: a prospective experimental study was performed, and healthy volunteers were included in the study. All volunteers underwent a specific controlled-pain experimental procedure. The first phase (10min) – calm sitting followed by cold-water stimulus (2min, left hand, 7℃ water); recovery phase (5min) – calm sitting followed by a second cold-water stimulus (2min, left hand, 10℃ water); recovery phase (10min) followed with a deep breathing (1min) phase and 5min calm sitting. Saliva samples were collected at 8 time points as follows: at 0 (1) 10 (2), 12 (3), 17 (4), 19 (5), 29 (6), 30 (7), and 35min (8) respectivelly. All samples were stored at -80℃ until tested with the cortisol ELISA kit. Statistical analysis was performed using SPSS 27.0; p-value <0.05 was considered significant. Results: Twenty-nine (10 female and 19 male) volunteers from 25 to 53 years (mean 25.86y) participated in the study. In all saliva tested samples, changes in cortisol levels were observed. The peak cortisol level was measured in the last time point (189.57+/-30.1 (158.9-261.8pg/ml)) with statistically significant changes compared to the initial values (timepoint 1–156.6+/-23.2 vs. timepoint 8–189.57+/-30.1pg/ml, p=0.0044). The final value (time point 8) was significantly higher compared to the 2nd, 3rd, and 4th time points (161.4+/-23.4, p=0.011; 160.4+/-17.6, p=0.006; 162.1+/-20.8, p=0.01, respectively). There was a tendency to increase cortisol levels through other time points; however, it was not significant compared to the final point. No association was observed between gender, age, and cortisol levels. However, body mass index (BMI) was correlated with the cortisol level at the 1st point of the cold stimulus (12th min) – the cortisol level was higher with the higher BMI (r=0.58, p=0.048). Pain level was directly correlated with the cortisol level at the 4th time point (r=0.900, p=0.037) as well as in the 5th and 6th time points (r=1, r=0.9 respectively, p=0.037). No changes were observed between HR, systolic or diastolic arterial blood pressure, and cortisol levels. Discussion and Conclusions: Despite the recovery (when the painful stimulus was stopped) and the deep breathing phases (when the parasympathetic system started to act), the cortisol levels continued to increase. One minute of deep breathing could not be enough, and longer time intervals should be tested. Moreover, it was observed that those who did not identify a clear reduction in pain had higher cortisol levels. It is clear that a higher cortisol level can be associated with a higher pain level. However, some studies show that higher cortisol levels can change the pain threshold; thus, volunteers can define a higher pain level. Therefore, more studies with the later testing time points must be performed.

Background The COVID-19 pandemic has generated an unprecedented pressure on healthcare, including frontline health care workers in emergency medical systems. Prolonged shifts, lack of protective measures, providing care despite the fear of infection, ethical dilemmas due to the lack of resources and increased stigma and violence pose a high risk of worsening mental health. We aimed to assess factors associated with moderate to severe depression of health care workers during the COVID-19 pandemic in the Czech Republic. Methods The COVID-19 HEalth caRe wOrkErS (HEROES) Study is a global prospective cohort study with the aim to evaluate the impact of COVID-19 pandemic on mental health of healthcare workers in 26 countries across 4 continents. The data collection in the Czech Republic was initiated in June 2020 (wave 1: June 24th to August 2020; n=1,795; 76.3% female; 39% nurses and 26.5% physicians), with the first follow-up conducted in spring 2021 (wave 2: 15th February 31st of April; n=1,845; 75.2% female; 31.9% nurses and 41.6% physicians). Participants were recruited through hospital administrators, scientific societies, professional bodies and associations. All participants gave informed consent prior to survey completion. The organizations were asked to confirm distribution to the study team to estimate response rates. Data on demographics, mental health, support needs and provision were collected via an online questionnaire. Information on moderate to severe depression was derived from the Patient Health Questionnaire (PHQ-9). Demographic comparison across waves was conducted using chi-square tests (categorical variables) or t-tests (continuous variables). Logistic regression was used to assess the association of several predictors with moderate to severe depression. Results 1795 and 1845 respondents initiated the survey in wave 1 and wave 2, respectively, and 621 (46%) answered both. Demographic factors in both cohorts were similar, the only difference was the number of participating physicians (26,5% in wave 1 and 41,6% in wave 2). The presence of depression was associated with working at COVID-19 unit (ORwave2= 2.50), redeployment or assigning new tasks (ORwave1=1.25 and ORwave2=1.86) and contact with patients with COVID-19 (ORwave1=2.23 and ORwave2=2.05). The need of any type of support (economical, psychological or with care of children/relatives) was associated with 3.5 greater odds of depression in both waves. The frequency of depression doubled between wave 1 and wave 2 (10.2% vs. 20.2%). Suicide ideation in professionals had also increased from 5.9% to 7% between waves. Discussion and conclusions The data supports the hypothesis that COVID-19 worsened mental health and well-being of health care workers. Identification of the main stressors and needs as seen by professionals themselves can help to prepare for the future and establish targeted supportive programs for workers with the highest risk. Ethical approval and informed consent: Ethical approval was obtained from the Ethics Committee of the Czech Ministry of Health (MZDR-23393/2020-1/MIN/KAN) and Ethics Committee at the 2nd Faculty of Medicine (EK-753.3.6121).

Funding: The research has been funded by the Ministry of Health of the Czech Republic (grant NU22J-09-00064)

Background – Demands for hospital-based emergency care have significantly expanded in Emergency Departments (EDs). Since ED providers pursue to safeguard high-quality care, we need to determine strategies to establish work system solutions for resilient delivery of care under increasing workloads and persistent constraints. To date, there is a lack of empirical evidence and synthesis from large-scale investigations into ED providers’ work life surveys across European countries. Hence, our study aimed to identify and compare relevant work factors for ED providers’ well-being on the job and respective intervention practices in and across European ED settings. Methods – A mixed-methods survey study was set out. Ethical and data protection approval were obtained prior to start. A purposive sample of 18 subject matter experts (i.e., ED physicians) was selected via snowball sampling from six EUSEM-member states (i.e., Belgium, Finland, Germany, Italy, Romania, UK). From each nation, three interviewees were drawn, equally selected across basic-, general- and maximum-care level hospitals; further selection criteria were: senior physicians, profound ED expertise, active professional practice, and sufficient English language skills. A two-round Delphi study with semi-structured interviews (~90 Min average duration) followed by semi-quantitative online surveys was conducted. Consensus was achieved by qualitative content analysis (round 1) and standardized approval metrics (round 2). Key survey contents were sociodemographic/contextual characteristics, ED work conditions, provider and patient outcomes, respective intervention approaches, and COVID-19-related challenges. Further analyses included comparisons among nations and care levels. Results – Concerning adverse work conditions, our results showed that utmost detrimental influences on organizational level were Time pressure (Mean rank: M=3.11, SD=2.16), Workflow interruptions & multitasking (M=3.39, SD=2.14), and Overcrowding (M=4.0, SD=2.56). Most mentioned personal influences were Lack of coping mechanisms (M=5.53, SD=3.85), Medical errors & adverse effects (M=5.94, SD=3.87), and Task overlap (M=6.11, SD=3.57). Most frequent patient-related influences were Verbal & physical violence (M=2.33, SD=1.97), Ungrateful feedback (M=3.94, SD=2.22) and Excessive claims (M=4.0, SD=1.28). Concerning provider outcomes, a spectrum of physical (including Fatigue: n=14, 77.8%; Musculoskeletal pain: 61.1%), mental health (including Burnout: 83.3%; Exhaustion: 72.2%; Depression: 44.4%), and psychosomatic complaints (including Insomnia: 100%; Hypertension/tachycardia: 50%; Digestive disorders: 38.9%) as well as behavioral outcomes were mentioned (including Drop-out: 55.6%; Intentions to leave: 50%; Substance abuse: 44.4%). Frequent intervention practices were Skills training (83.3%), ED modernization (77.8%), Roster redesigns (66.7%), as well as Performance evaluations (66.67%). Predominant COVID-19-related provider outcomes were Anxiety (72.2%), Infections (66.7%), PPE discomfort (61.1%), and Skin/respiratory irritation (50%). Round 1 findings serve as base for round 2 to confirm expert appraisals and establish consensus. Discussion & Conclusions – Our study provides the first cross-European investigation into ED physicians’ work conditions and respective intervention approaches. Our results emphasize the significance of work-related influences on ED provider health and well-being as well as ensuing patient care outcomes. It further sheds lights on current status of improvement measures. Our study serves as base for future policy and practice recommendations as well as intervention studies for effective improvement approaches to ameliorate ED providers’ well-being on the job, and thereby promoting quality and safety of patient care.

Trial was not registered due to: no appropriate register, non-clinical work, no patients involved. This study did not receive any specific funding.

Background Evidence suggests that a substantial number of emergency department attendances from care homes could be classed as avoidable. There is a great deal of interest in how new technologies in care home settings can reduce avoidable hospital attendances. HealthCall is a technology that aims to reduce Emergency Department (ED) attendances by upskilling staff to use app-based technology whereby care home residents with new clinical presentations and their observations are recorded electronically using a structured SBAR approach. Information is automatically fed to a Single Point of Access, where clinical staff triage referrals. This study assessed the effectiveness of the HealthCall technology across the North East of England to safely reduce ED referrals and attendance. Methods The study involved 123 care homes across the North East covering a study period of 2018-2021. Routinely collected NHS secondary care data from County Durham and Darlington NHS Foundation Trust was obtained and linked with clinical data from the HealthCall technology. Pseudonymised NHS number linkage was used to identify the residents in the secondary care data. We describe the change in ED attendances over the period before, during and after the introduction of the technology to the care home cohort. We fitted a resident level, Poisson generalised linear mixture models to fit counts of emergency attendances for each resident each month, accounting for seasonality and external factors such as the effect of COVID-19. The impact of HealthCall technology being used on each resident’s expected number of monthly ED attendances is tested as both a ‘step’ change and an additional gradual ‘slope’ change over time after intervention. Results Our cohort included 8702 care home residents in 123 care homes. Preliminary models trained on a sample of 1000 residents include a yearly seasonal cyclic harmonic pair, COVID-19 bed days in the local Trust hospitals each month, a care home level random intercept and an individual level random intercept. The preliminary models suggest the use of the HealthCall technology shows a ‘step’ reduction of expected monthly ED attendances for care home residents by 19%, 95% CI [7, 30], p = 0.0036. There is currently insufficient evidence in the preliminary modelling to support an additional gradual decrease in attendances for each resident over time, p = 0.78. Discussion This study finds that the implementation of the HealthCall technology in care homes reduces the expected number of monthly emergency department attendances for residents. The technology also allows for ongoing monitoring of resident health alongside providing more convenient and timely access to clinical advice that promotes more appropriate and resident-focussed decision making leading to fewer unnecessary ED attendances.

This project was funded by HDRUK as part of the Learning Care Homes project.

Background: Patients often suffer from pain and have feelings of uncertainty and worries while waiting for acute surgery in the Emergency Department. Evidence shows that music has a positive effect on pain reduction, relaxation, and general well-being in other healthcare settings. However, knowledge of providing music interventions for patients during the acute preoperative nursing care is limited in the setting of Emergency Departments. The aim of this study was to (1) examine the association between music and pain, relaxation, and well-being and (2) explore the patients’ experience of using a music pillow during the waiting time for an acute surgery. Methods: A mixed-method pilot study was carried out in the Emergency Department at Odense University Hospital. Participants were purposely sampled. Patients scheduled for any acute operation were offered a music pillow for 30 minutes during the waiting time. The primary outcome was the participants’ self-reported pain, relaxation, and well-being by a visual analog scale (VAS) ranging from 0 to10 conducted before and after the music intervention. Field observation during the music session followed by a semi-structured interview was carried out in the qualitative part of the study. Statistical analysis was performed using a Wilcoxon signed-rank test and the qualitative analysis was structured using Systematic text condensation. Ethical approval and informed consent: The study is registered with the Danish Data Protection Agency (20/56891). Oral and written consent was given by the participants. Results: The quantitative part included 30 participants with 14 men and 16 women. The age ranged from 18 to 93. The Wilcoxon signed-rank test showed that music had a positive statistically significant association with reduced pain, relaxation, and well-being (P < 0.001). The qualitative part of the study included 15 participants. Two themes were derived: 1) Feelings of physical and mental well-being and 2) A break from the acute preoperative context. Discussion & conclusion: A statistically significant association was found between the music and acute preoperative patients’ self-reported reduced pain, relaxation, and well-being. Participants experienced that listening to music provided physical and mental well-being as it made them feel relaxed and took their minds off pain and worries. The study suggested that for the music to successfully promote mental and physical well-being patients should be undisturbed while listening to the music, which appeared as the main challenge in the current organizational structure in the Emergency Department. Perspectives: This pilot study provides knowledge of the significance of music interventions and the potential of implementing music in preoperative nursing care. The results provide insight into improvements in the implementation of music in acute nursing care. For future research, it is relevant to include perspectives from nurses, patients, and caregivers to have a wider understanding of the implementation of music in acute preoperative nursing care.

Funding: This study did not receive any specific funding.

Background: Emergency departments care for patients with life threatening or urgent medical conditions. They also serve as a provider of last resort for health-related demands that are not provided for elsewhere. Analysis of use-patterns of emergency departments may not only serve to develop more efficient care models within hospitals, but also to assess unfulfilled needs in health-care outside the hospital system. Primary care is often regarded as fulfilling a gatekeeper role to protect emergency departments from unnecessary use, fending of patients that can be cared for on an out-patient basis. Primary care physicians, however, may also use emergency departments for diagnostic and therapeutic support in less acute cases not requiring hospital admission. We investigated hospital admissions and diagnostic and therapeutic resources used in the management of patients who presented to ED after being assessed in primary care. Methods: A computer-generated random sample out of all 80845 patients cared for in emergency< departments of two metropolitan general hospitals during 2019 (pre-covid) was analyzed. Patient demographic and medical data was extracted from the hospitals’ medical data mainframe system and documents provided by the patients upon presentation. Results are presented as Proportion (%), Mean ± SD or Median (25th – 75th) percentile for categorical, or not normally distributed or normally distributed continuous data, respectively. The study protocol was assessed by the Berlin Board of Physicians and need for informed written consent was waived. Results: 1500 patients were analyzed. Age was 56.0 ± 22.8 years, 50.9% female. 34.7% presented by emergency ambulance, 47.7% were self-presenters, 13.1% arrived by patient transport services. 32 patients were referred by other hospitals and were excluded from further analysis. 183 (12.5%) patients were referred by primary care physicians. Referrals were older (61.2 ± 20.8 vs 55.1 ± 23.0 years, p < .001) and had a higher Charlson Comorbidity Index (CCI) ( 3 (1 – 5) vs 2 (0 – 4); p < .001). They had more often laboratory investigations (79.9% vs 60.6%; p < .001) more often imaging by ultrasound (27.6% vs 15.7%; p < .001) and more often ECG investigations (50.0% vs 37.5%); p < .001. There were no differences in sex, Manchester triage System classification or pain-scale values. Referrals presented by emergency medical transports less often (8.7% vs 38.8%; p < .001). Admission rates were 61.4% in referrals and 33.4% in non-referrals (p < .001). Th following parameters were independently associated with outpatient treatment as compared to hospital admission: Referral (OR .220 (95%CI interval: .135 – .361); resources used per case (OR .502 (.449 – 562); any abnormal vital parameters (.617 (.443 - .859); CCI (.797 (.751 – .845); parenteral medication 1.419 (.969 – 2.078); lower MTS-class (1.387 – 2.128). Conclusion: Assessment by a primary care physician before presentation to an ED reduced the probability of hospital admission. Perceive acuity of most of the referred patients was low, as evidenced by MTS classification and the low proportion referred by emergency medical transport. A proportion of patients was probably referred for technical assistance despite being out-patient cases

no registration / no funding

Background: Among healthcare staff, especially employees in emergency departments (EDs) are affected by violence and aggression. The majority of employees regularly experiences violence caused by patients and their relatives. Measures to prevent violence can be taken on organizational, technical/architectural, or individual-focused levels. Overall, little is known on how employees perceive the implementation and effectiveness of respective measures. Thus, the aim of the current study is to explore which measures for violence prevention in EDs are known and perceived as effective, as well as which barriers exist regarding their implementation. Methods: Due to the explorative nature of the research questions, a qualitative approach was chosen to reflect the participants’ perspectives and gain profound knowledge on advantages and disadvantages of available preventive measures. Thus, telephone interviews based on a semi-structured interview guide were conducted. A purposeful sampling technique was applied supplemented by snowball sampling. The sample comprised participants from all emergency care levels in Germany and included both employees and supervisors working in EDs. Inclusion criteria were employment in the current ED for at least 6 months and also immediate contact to patients in a medical or nursing position. Transcribed interviews were analysed using Mayring's approach to qualitative content analysis. Ethical approval was granted by the Local Psychological Ethics Committee of the University Medical Centre Hamburg-Eppendorf, Germany. Results: 27 interviews were conducted between June and September 2021. Slightly more than half of participants were female (f = 56%, m = 44%), while 13 participants were doctors and 14 had a nursing profession. Furthermore, 16 participants worked as medical or nursing supervisors in the ED. The interviewees described technical/architectural measures (e.g., design of waiting areas and treatment rooms, alarm systems), organizational measures (e.g., security service) and individual-focused measures (e.g., staff training). Security services and verbal de-escalation skills were perceived as particularly effective. However, there was a lack of guidance for ED staff, e.g., in the form of standard operating procedures (SOPs). Furthermore, incidence reporting was more common for physical assaults, while verbal aggression was often perceived as part of the job. It further became apparent that due to hierarchical structures violence prevention was highly dependent on supervisors’ awareness, knowledge and motivation to implement respective measures, and the most important barrier for violence prevention measures was financial constraints. Discussion and Conclusions: The results of this study provide an insight into the current state of implementation and perceived effectiveness of violence prevention measures in German EDs. They substantiate those of previous research indicating that many ED employees feel they could be better prepared for violent incidents. Furthermore, the results at hand allow to infer recommendations for violence prevention targeting both supervisors and employees. For instance, supervisors should encourage employees to report incidents in order to increase awareness, but also to justify the need for preventive measures in front of hospital managements. In this way, occupational safety and thus mental and physical health of ED staff could be improved in the long term.

This research was funded by the Institution for Statutory Accident Insurance and Prevention in the Healthcare and Welfare Services, Hamburg, Germany (grant number: ext FF_1524).

Background In Denmark, out-of-hours emergency healthcare use (i.e., out-of-hours general practitioner/medical helpline and emergency medical services (EMS)) is associated with certain sociodemographic- and economic factors. Low education, low income, and employment were some of the most important factors related to emergency healthcare use, particularly EMS use. Studies indicate that such characteristics could be explained by comorbidity. Therefore, this study aimed to investigate sociodemographic/-economic characteristics and emergency healthcare use for patients with and without comorbidity. Methods An observational study, including all citizens aged 18 and above in the North Denmark Region and Capital Region of Copenhagen during 2016. Contacts were identified in the prehospital databases and in the National Health Service Registry. The unique personal identification number was used for linkage to numerous registries containing the characteristics: age, sex, residence, family type, ethnicity, education level, income, and employment. Comorbidity was established using Charlson Comorbidity Index based on each patient’s diagnoses five years prior to the study period. We calculated the proportions of selected sociodemographic and -economic characteristics in patients with emergency contacts compared to patients without contact and reported it overall and for both patients with and without known comorbidity. Results We included 1,899,468 citizens, 23.8% with an emergency healthcare contact. Overall, the proportion of low education was significantly higher among patients with contacts compared to patients without (37.2% vs 29.5%) as was the proportion of low income (27.7% vs 23.2%), whereas employment proportion was higher for patients with no contact compared to patients with contact (32.6% vs 23.8%). For the subgroup of patients with known comorbidity the tendency was similar: higher proportions of low income among contacts compared to no contacts (27.9% vs 22.5%) and higher proportions of low education (39.0% vs 31.2). Employment was higher for those without contacts (25.9% vs 17.7%). Likewise, in patients without comorbidity, low income was more prevalent among contacts compared to those without (27.4% vs 24.5%). As was low education: (33.6% vs 26.6%). Employment was higher among those with no contact (44.8% vs 35.9%). All reported differences were of statistical significance. Discussion and conclusion These preliminary results show that certain characteristics indicating low socioeconomic status are significantly more prevalent among patients with emergency healthcare contacts compared to patients without contacts. This applies to both patients with and without known comorbidity. Going forward, we aim to investigate if higher degrees of comorbidity increase the use of emergency care for patients with the reported sociodemographic- and economic characteristics.

None

Background The COVID-19 pandemic has a significant impact on the health and well-being of health care professionals. However, insight for ambulance care professionals is limited. Reported prevalence rates in the pre-COVID-19 era were 15% anxiety, 15% depression, 11% post-traumatic stress disorder (PTSD) and 20-27% insomnia. Insight in the health and wellbeing of ambulance care professionals is needed to develop targeted preventive and curative interventions to cope with the impact of COVID-19 and to prevent drop-out. The aim of this study was to gain insight in the prevalence of anxiety, depression, PTSD, need for recovery after work and insomnia among ambulance care professionals in the Netherlands. Methods A national cross-sectional study was performed. An online survey was distributed by national EMS organisations to all ambulance care professionals in the Netherlands, participation was voluntary. Data were collected from March 14th until April 15th 2022, three reminders were sent. The impact on health and well-being was measured with internationally validated instruments. For anxiety and depression the Hospitality Anxiety and Depression Scale (HADS -A and HADS-D) were used, for PTSD the Impact of Event Scale (IES), for work fatigue the Need For Recovery after work (NFR) and for insomnia the Insomnia Severity Index (ISI). Also, demographic (age, gender) and workrelated (area of working, work experience in years) characteristics were collected. Surveys with at least one completed outcome measure were included in the analysis. Descriptive statistics were calculated: mean and standard deviation [SD], median and first and third quartile (IQR) for continuous variables, or as number and percentage for categorical variables. Results In total 783 ambulance care professionals completed at least one outcome measure in the survey. Participants had a mean age of 47 years (SD ± 9,4), 38,6% is female and there was an average work experience of 13,6 years (SD ± 9,4). Prevalence rates of symptoms of anxiety were 19% (N=149, median 4, IQR 2-7), for depression 16,2% (N=127, median 3, IQR 1-6) and for PTSD 10,5% (N=78, median 3, IQR 1-7). Of the respondents 32,2% (N=236, median 3, IQR 0-7) scored positive for need for recovery after work. 39,3% (N=285, median 5, IQR 2-11) of the respondents scored positive for insomnia problems (27,8% light problems, 9,9% moderate problems and 1,5% serious problems). In the total sample 51,5% of the respondents scored positive on at least one of the outcomes. Discussion & Conclusions COVID-19 had high impact on Dutch ambulance care professionals, as 51,5% of the ambulance care professionals scored positive on at least one outcome. Especially need for recovery after work and insomnia were highly prevalent,and seem higher compared to literature from the pre covid era. Our results indicate a need to systematically develop and test interventions aimed at recovery and work fatigue and insomnia.

Funding This study was funded by the Taskforce for Applied Research SIA (part of the Dutch Research Council NWO), funding: RAAK.PUB08.044. Ethical approval and informed consent There is a letter of approval from the ethical research committee of the HAN University of Applied Sciences (ECO 334.03/22). The respondents give there consent to participate before starting with the survey.

Introduction The diagnosis pathway for small bowel obstruction (SBO) in the Emergency Department (ED) usually includes abdominal CT which has excellent performances. However, its access could be difficult in some ED and the waiting time before its realization important. Point-of-Care Ultrasound (POCUS) has been investigated and has demonstrated interesting performances. However, the ability of POCUS to rule-out SBO in ED patients with a clinical suspicion remains currently unknown but could be interesting, in particular in ED with limited resources. The goal of this study was thus to assess the ability of POCUS to exclude SBO in such patients. Patients and methods It was a prospective multicenter observational study. Included patients were a convenience sample of adults consulting in the ED for acute abdominal pain with a clinical suspicion of SBO. Exclusion criteria were patients < 18 years old and protected adults. After informed consent, a POCUS was performed. The following items were assessed in the 9 abdominal quadrants: dilated incompressible intestinal loop (>25 mm) with back and forth fluid movements. The main objective was the ability to rule-out the diagnosis of SBO (sensitivity). The secondary objectives were the other diagnostic performances, duration of POCUS, operator’ experience, delay between POCUS and CT. The study was approved by an ethic committee and registered on clinicaltrial.gov (NCT04848415). For a 95% sensitivity with 5% confidence interval, 145 patients were needed. Results 152 patients were included, 2 secondarily excluded (no CT performed) leaving 84 women and 66 men (mean age 69 + 20 years old). A SBO was excluded by CT in 67 patients (55% [95%CI 47-62%]). There was a false negative case with POCUS. The sensitivity was 99% [95%CI: 93-99%]. Other diagnostic values were: specificity 84% [95%CI: 73-90%], positive predictive value 88% [95%CI: 80-93%], negative predictive value 98% [95%CI: 91-99%], accuracy 92% [95%CI: 87-95%]. The operator’s experiences were beginner for 28 patients, intermediate for 61 and experienced for 61. The duration of POCUS were <5 min for 118 patients, 5-10 min for 30 and >10 for 2 patients. Delay between POCUS and CT was 120 min [60-182] (median [1st - 3rd quartiles]). Discussion The performances of POCUS to rule-out SBO were excellent even when performed by Emergency Physicians without major ultrasound experience. POCUS was achieved in a short amount of time. This rule-out ability was concordant with a recent meta-analyse [1] but the rule-in (specificity and positive predictive value) was less efficient. This could be related with the lake of Ultrasound experience of the Emergency Physicians. In conclusion, POCUS could save time and radiation for patients with a suspected SBO in the ED. 1 Gottlieb M et al. Utilization of ultrasound for the evaluation of small bowel obstruction: A systematic review and meta-analysis. The American Journal of Emergency Medicine 2018;36:234–42.

clinicaltrial.gov: NCT04848415

Background: Lung ultrasound (LUS) has been established in intensive care medicine as a bed-side routine tool for the assessment of pleural conditions, effusions, consolidation and interstitial edema. Due to its availability and ease of use, LUS is increasingly used in emergency medicine in the differential diagnosis of dyspnea and thoracic pain, among others. During the Covid-19 pandemic there was a need for a screening tool for pneumonia in patients with suspected Covid-19 disease. Methods: We performed a prospective method comparison trial in patients suspected or known to have Covid-19 or other indications for pulmonary imaging. The setting was a medium sized metropolitan general hospital with an emergency department caring for about 40000 patients per year. All patients received LUS by an emergency physician (EP), thoracic CT and rtPCR for SARS-CoV-2. EP and radiologists were blinded to the respective images and reports of their counterparts. Enrollment was between April 2020 and march 2021. During shifts with presence of an EP with skills in LUS consecutive patients where included if they fulfilled the following inclusion criteria: dyspnea and/or age > 60 years and/or relevant comorbidities and either lymphopenia or temperature > 37.3°C or if chest CT was indicated for another reason. A LUS diagnosis of Covid-19 pneumonia (B-Profiles, no large consolidation, no large effusion) was compared to the final adjudicated diagnosis of Covid-19 pneumonia. Most chest CTs were performed as low-dose CT. Results: 220 patients were included (mean age 67,6 ± 16,5 years, 42,8% female). 133 (60%) had a final clinical diagnosis of Covid -19 pneumonia. Over the whole cohort, patients with covid-19 pneumonia compared to patients without covid-19 pneumonia, were significantly less likely female (36.8 vs. 51.7%; p = .048), had a lower oxygen saturation (95% (91 – 97) vs. 96% (93 – 98); p = .046), lower lymphocyte counts (0.89 G/L (0.66 – 1.24) vs 1.23 G/L (0.70 vs 1.68); p = .006 and higher CRP (65.0mg/L (37.5 – 114.2) vs 31.6mg/L (9.2 – 113.8); p = .001). 27 patients were treated as outpatients. Hospital mortality was 10.4%, 3.4% in patients with and 17.3% in patient without Covid-19 pneumonia (p < .001). SARS-CoV-2 PCR was positive in 144 patients (64.9%). 163 (73.4%) patients had any infiltrates on LDCT, 134 (60.6%) had bilateral infiltrates. In 120 (54.1%) pulmonary infiltrates were judged typical of Covid-19 pneumonia (CORADS 4 or 5). LUS had an accuracy of 0.7387 (95% CI: 0.6757 – 0.7952) predicting a final diagnosis of SARS-CoV-2 pneumonia in that patient. Sensitivity and specificity were 0.8346 and 0.5955, respectively. Positive predictive value in this cohort was 0.7551, negative predictive value 0.7067. Positive and negative likelihood-ratios were 2.06 and 0.277, respectively. Cohen’s Kappa was 0.4416. 5 cases were classified as false negative LUS. On CT, these had small patchy central infiltrates in 4 cases and a large consolidation possibly due to superinfection in one case. Conclusion: In this cohort of undiagnosed emergency department patients with respiratory/thoracic symptoms we found a moderate accuracy of LUS in predicting Covid-19 pneumonia.

DRKS00021585 / no funding was received

Aim: SARS-CoV-2 is prone to genetic evolution, which resulted in the emergence of multiple variants with different characteristics. With Delta and Omicron being the last two leading variants, we aimed to compare the need for respiratory support in patients treated in two different eras of the SARS- CoV-2 pandemic. Materials and methods: We retrospectively enrolled consecutive adult patients treated in the Emergency Department, University Hospital Centre Zagreb in November 2021 (presumed Delta era) and January 2022 (presumed Omicron era). The patients were not tested for specific variants and the cohorts are based upon epidemiological reports of variant prevalence. Data on 839 SARS-CoV-2-positive patients (409 in the Delta era and 430 in the Omicron era) included demographics, relevant comorbidities, vaccination status, vitals upon admission, initial laboratory parameters and administration of oxygen support. Zou´s modified Poisson regression was used to compute relative risks (RRs) for the need for oxygen support (any method) and advanced oxygen support (non-invasive ventilation, high-flow nasal cannula or mechanical ventilation). Result and conclusion: The cohort from the Omicron era was significantly younger (median age 64 vs. 67.1, P=0.021) and had more fully vaccinated patients (39.5% vs. 29.6%, P=0.011). They also had significantly higher oxygen saturation of the arterial blood upon initial presentation, lower C-reactive peptide (P<0.001) and high-sensitive cardiac troponin T levels (P=0.002). The need for oxygen supplementation and advanced oxygen supplementation was significantly lower for patients in the Omicron era relative to the Delta era both at univariate analysis and after adjusting for age, sex and vaccination status (RRadj 0.8, 95% CI 0.7 – 0.9; P valueadj <0.001 for total oxygen supplementation; RRadj 0.2, 95% CI 0.1 – 0.4; P valueadj <0.001 for use of advanced oxygen supplementation). Increased prevalence of the Omicron variant in our population seems to have reduced the number of patients presenting with more severe forms of COVID-19 requiring respiratory support.

Background: COVID-19 has highlighted that nasopharyngeal swab (NPS) has high diagnosis accuracy, including in ICU patients. However, little data are available on the consistency of detecting other viruses’ between NPS and bronchoalveolar lavage (BAL) among adults. The objective of this study was to compare NPS and BAL results for non-SARS-CoV-2 viruses in case of suspected pneumonia. Materials/methods: A retrospective analysis was performed in one Parisian academic hospital using data from 276 adults with suspected pneumonia from 2012 to 2018 and tested within 48h by multiplex-PCR in both NPS and BAL. The consistency in pathogen detection between the paired NPS and BAL was evaluated. Results: Patients were primarily male (65%), with a median age of 59.7 (IQR: 50.9-67.8). One hundred sixty-nine patients (61%) were admitted to ICU for acute respiratory distress. One hundred and eight patients have a chronic respiratory disease (38%), 109 were immunocompromised (39%), and 38 died during their hospital stay (14%). We detected at least one respiratory virus in 95 NPS (34%) and 80 BAL (29%). Two or more viruses were detected in 7 NPS (3%) and 6 BAL (2%). Compared to a positive BAL, NPS had a sensitivity of 71.6%, specificity of 93.4%, and a Kappa coefficient of 0.67. The same pathogen or pathogen combination was observed in 231 patients (84%) positive in NPS and BAL. Influenza B, parainfluenza, coronaviruses HKU1, NL63, 229E had the highest agreement (100%) between NPS and BAL, while coronavirus OC43 and rhinovirus had the lowest agreement (33% and 67%, respectively). In a multivariate regression model adjusted on age and immunodepression, we observed that samples from patients with a chronic respiratory disease showed a poorer agreement between NPS and BAL (aOR 0.5, 95%CI [0.25-0.97], p=0.043). Conclusions: There was good consistency between NPS and BAL in detecting respiratory viruses among patients with suspected pneumonia. However, these data still encourage performing a BAL when available for a more precise diagnosis.

No funding

Backgrounds The need of palliative and end-of-life (EOL) care is growing, but not much attention is paid to the emergency departments (ED). Although death in the ED is unavoidable, information on who dies in the ED is insufficient. This study aimed to investigate the size and characteristics of ED death using the representative national data. Methods Retrospective observational study was conducted for all ED visits between 2016 and 2019 using the National Emergency Department Information System (NEDIS) database. Except for death on arrival and cardiac arrest at ED arrival, the patients who died during the ED treatment was included as study population. The primary outcome was reason of ED visit. The secondary outcomes were length of stay (EDLOS) and provision of life-sustaining treatment (LST) in the ED. The patient characteristics and ED treatment were compared according to the reason of ED visit. For patients who died of disease, most common diagnoses and whether they had palliative care eligible disease were investigated. Results Among the 36,538,486 ED visits for 4 years, 34,086 patients were died in the ED during the treatment. Only 9.9% (3,370) died from non-disease, and 90% (30,716) died from disease. For disease patients, the most common ED diagnoses were cardiac arrest (22.1%), pneumonia (8.6%), and myocardial infarction (4.7%). The median EDLOS was 4.5 hours (IQR, 1.9-11.7), and 34.0% (10,452) stayed in the ED over 8 hours. 44.2% (13,562) received cardiopulmonary resuscitation (CPR) at the EOL time. Patients with palliative care eligible disease were cancer 16.9% (5,187), liver disease 3.8% (1,176), heart failure 3.5% (1,076), and chronic respiratory disease 1.4% (416), accounting for a quarter of the disease death. Cancer patients received less CPR and had longer EDLOS than other disease patients (CPR rate 23.4% and EDLOS 7.3 (3.2-15.9)). Conclusion Over the past 4 years, 30,000 people, including 5,200 cancer patients, died in the ED during the treatment. More than 30% stayed in the ED over 8 hours and half did not received CPR at the end-of-life time. It is time to discuss about need of palliative and EOL care in the ED.

Contrast Induced Acute Kidney Injury (CI-AKI) refers to the elevation of serum creatinine from baseline by ≥25% or ≥0.5 mg/dl (44 μmol/l) within 48 hours of receiving a contrast medium. While NICE guidelines recommend mitigating strategies for patients at increased risk of CI-AKI, it is stressed that this should never delay emergency imaging. The clinical impact of CI-AKI has come under considerable scrutiny, with recent data suggesting that patients come to greater harm from our attempts to prevent CI-AKI than the nephrotoxic effects of contrast medium itself. Any delays to urgent imaging and subsequent management, particularly emergency surgery, can have significant clinical consequences for patients. The aim of this study was to determine the incidence of CI-AKI in patients who had contrast enhanced CT scans in the ED. Of those who developed renal impairment, data was reviewed to determine the proportion of patients requiring dialysis as a result. Given the risks associated with imaging delays we also wanted to determine whether precautions to prevent CIAKI (including waiting for U+E result) led to delays in CT scanning for emergency patients. We reviewed retrospective data for all CT imaging with contrast performed in the ED of a DGH from 01/11/2020 to 19/05/2021. We excluded CTPA and CT cerebral angiogram as these investigations tend to be performed on an inpatient basis at our site. Renal function pre- and post-scanning (where available) was reviewed against patient case notes to determine if renal function became impaired and if the patient required dialysis. 370 CT scans with contrast were reviewed. Findings revealed no patient with previously normal renal function (n = 292) required dialysis following CT with contrast in the ED. 1 patient required dialysis in ICU post-contrast. This patient had pre-existing renal impairment and was critically ill on presentation. 16 patients had an elevation in serum creatinine consistent with CI- AKI post-contrast imaging. However almost all had significant findings on CT imaging which could also contribute to pre-renal causes of renal impairment. Over half of this cohort of patients were for end-of- life care as a result of CT findings and clinical presentation. 46.5% of patients in this study waited over an hour for CT imaging in the ED. There was very little documentation regarding causes of scan delays. Waiting for U&Es and providing pre-emptive treatment against CI-AKI should not delay patients receiving urgent CT imaging with IV contrast. The incidence of CI-AKI, or even the need for subsequent renal replacement therapy, is low and delays to definitive management poses a greater potential risk to the patient. We can support patients thought to be at risk of CI-AKI in the ED by following NICE guidance: oral hydration where possible, IV fluids considered if – eGFR <30, renal transplant, large volume contrast, or intra-arterial use. In doing so we will be managing a range of factors known to precipitate AKI and providing more holistic care. While further studies would be required to support large scale change in practice these results demonstrate safe practice within our department.

Introduction: An emergency stock (ES) allows emergency-release transfusion of labile blood products in life-threatening situations. In particularly for haemorrhagic shock, current guidelines recommend early transfusion. This demand to deliver RBC without delay. Is the access to an ES pertinent for ED? Background: Actually, emergency physicians (EP) of the university hospital of Rennes use the ES for the management of haemorrhagic shock (medical and traumatic origin; exempted trauma centre for massive transfusion managed by anaesthetists). A new architectural project is considering the removal of access to the ES for EP. The primary outcome of this study is transfusion delay after the prescription of RBC, comparing the path coming directly from the « Etablissement Français du Sang » (EFS) (on the site, but not in the same building) and that using the ES next to ED (floor under). Methods: In this retrospective single-centre observational study, we assessed all emergency-release prescriptions of RBC in the shock room between the Jan 1, 2018 and Dec 31, 2020. The primary outcome is prescription – connection delay between de RBC issue of de ES and the EFS. Path was chosen by EP. Secondarily, were compared the 1 day and 1 month survival, clinical characteristics and the respect of national guidelines of transfusing D negative RBC in the 2 groups. Statistical analysis utilized Wilcoxon and Fisher exact tests by using R v. 4.0.2 software (R Core Team, 2019) and p-value < 0,05 was considered significative. Results: In 3 years, 99 patients were included. 64 patients received RBCs directly from the EFS and 35 patients from the ES. Delays were significantly shorter by the ES path with 86% of RBCs connected < 15 minutes after prescription, vs 9% by the EFS path (p = 5.286 x10-12). Patients benefiting from the ES were younger (median = 62 years [IC 48-75] vs median = 73 years [IC 61-84], p = 0.03434), with a more severe hypotension (systolic blood pressure median = 84mmHg [IC 71-93] vs median = 91mmHg [IC 80-110], p = 0.01978). Survival was not different either at 24 hours or at 1 month. National guidelines were respected in 74% with no difference between groups. Discussion: The existence of an ES allowed a significant reduction in prescription-connection times without impact on survival in this study. The necessity of an ES in proximity of the ED depends on architectural and logistic organization in the hospital, also if it is mutualized by different structures (ED, trauma centre, UCI, emergency operating room). Other stages of the classic EFS path could also be optimized to accelerate the prescription-connection process. New prospective studies have to prove the impact on delay and on survival. Progress is possible concerning the overuse of O Rhesus D negative RBCs in our ED. Conclusion: In emergency-release transfusion, the existence of ES allowed a significant reduction in prescription-connection delay without impact on survival in this study.

Trial Registration: no appropriate register Funding Information: This study did not receive any specific funding.

Background: Metformin is one of the most prescribed drugs in the world. This makes it especially important to pay attention to the possible adverse effects among which the possible induction of lactic acidosis stands out by severity. In some series the mortality of this picture is very high. However, it is believed that the true incidence is unkown, as well as practical transcendence. To know the characteristics of patients with lactic acidosis induced by metformin is very important to diagnosis and treatment. - Material/Methods: It is a descriptive analysis de all cases diagnosis of “ Lactic acidosis secundary by metfomin were diagnosis in Emergency Department from January 1, 2014 until March 1, 2017, in a third level hospital. Being a retrospective search, informed consent was not requested. Results:Sample was composed of 20 cases, of which 10 were males(50%) with an average of 76.7 ± 8.6 SD years. The number of drugs per day was 10.15 (7.25-12.5). The consumption of metformin in 35% of the patients, was carried out together with another antidiabetic, although the most frequent pattern was in solitary (65%): in 9 cases with 850 mg every 8 h (45%) and 3 of them each 12 hours (15%) Only in one case was it overdosed at home (3000 mg/day). Charlson was 3.94 ± 1.81 SD, and only 20% had diabetes with organ involvement. Symptoms on arrival in 40% were confusional, followed by vomiting (30%), diarrhea (20%) and dyspnea (5%). The situation of patients upon arrival at the emergency room presented Glasgow 12.29 ± 3.22 SD, and a respiratory rate The renal function was reviewed in hospital clinical history, only in 2 cases there were data of chronic kidney disease, being its Basal Glomerular Filtration > 60 mL / min. 80% had acute kidney failure at the time of assessment, with mean creatinine values 6.5 ± 2.9 mg/dl, Urea 191 ± 74.5 mg/dl and potassium levels 6.1 ± 1.34 mEq/L. A total of 7 patients (35%) required admission to the ICU compared to 13 (65%) that was not required, were admitted mostly in the nephrology service in 10 of the cases (50%). In 12 cases required purification treatment, 9 cases required hemodialysis ( 45%). The number of sessions was 3.2 ± 2.9 SD. Continuous venovenous hemofiltration (HFVVC) is applied in 3 cases (15%). The duration of the hemodialysis sessions carried out by the Nephrology service was scheduled in l 4-6 hours. The average of the days that were admitted until the time of discharge or the moment of success was 12.60 days (5-13.75). Only 5 cases (25%) the patient died during admission - Conclusions: All our cases were older with acute renal failure and polymedicated. Patients must be warned about the most common lactic-acidosis inducing situation, especially dehydratation and gastrointestinal syndrome if they continue taking the drug at such times. Mortality was similar to what was published.

Background: In the early 1990’s a group of volunteer Intensive Care doctors, proposed a change in the Emergency Medicine Services in Romania based on existing models from fellow European states and the United States. The proposed model continued to develop under faculty guidance, from these countries and by 2008 it became an integral part of Romania’s Healthcare System continuing to develop since. In 2019 our department took steps to implement Point-of-Care-Ultrasound (PoCUS) in pre-hospital. We started with a PoCUS course under EUSEM faculty guidance, acquired two portable ultrasounds for pre-hospital ground and helicopter crews and conducted several seminars. Methods: An 11-question anonymous survey was emailed in early 2022 to the doctors that practice pre-hospital medicine within our university and local level 1 trauma centre. The survey has been done as an overview of the current state before the start of a prospective study. Descriptive statics are reported. The doctors involved are from their final year of speciality training up to consultant level. We documented how they are utilizing PoCUS in pre-hospital care and how having it on hand is impacting the decisions they make in patient care and case management. No incentives were provided for completion of the questionnaire. Results: 23 answered within the allotted time. 5 (21.7%) stated that they don’t use PoCUS in pre-hospital, the main reason is the lack of legal framework and lack of experience with PoCUS. 18(100%) stated they use it for trauma and cardiac arrest patient, 14 (77.8%) use it in non-differentiated shock and 11 (57 %) use it for invasive procedures. 16 (88.89%) have used PoCUS for evaluation of Pulseless Electrical Activity. All of the participants consider that PoCUS has increased in clinical importance since the start of the pandemic and 10 (55.56%) state that the use of PoCUS changed their management of the patient, reporting an improvement in their care decisions. 23 (100%) stated that bi-annual, experience based, workshops and the need to introduce ultrasound in the training curricula of future residents is necessary in order to make PoCUS common use. Discussion & Conclusions: The last two years of COVID have brought PoCUS up front, with an increased use due to a lack of repeatable imaging in a resource scarce, COVID isolated environment. Bringing PoCUS to pre-hospital has helped it become more ingrained in the arsenal of local emergency physicians becoming a common thing. Although a positive progression has been made with workshops and ultrasound availability there is still a lot to do in terms of standardizing use, standardization and implementation of training and supervision of trainees and the creation of a legal framework where non-radiologists ultrasound targeted findings, be it from the Emergency Department or Intensive Care, can be recognised. Further observation and working in collaboration with other medical systems could hold the key to a smoother implementation

Background: Dyspnea is a common symptom for admittance and evokes anxiety. Serial point-of-care ultrasound (PoCUS) has the potential for improving acute patient care through modifying the treatment to the dynamic ultrasound findings. The objective was to investigate if treatment guided by serial PoCUS of the heart and the lungs in patients admitted to an emergency department (ED) with acute dyspnoea could reduce the severity of dyspnoea compared to usual care. Methods: The study was a randomised, controlled, blinded-outcome trial in one ED in Denmark between Oct 9, 2019, to May 26, 2021, with a follow-up period of 30 days. In a convenience sample, patients > 18 years admitted with a primary complaint of dyspnoea and no trauma were included and allocated 1:1 to a serial ultrasound and control group. Patients in both groups received standard care within one hour from arrival, including a single cardiopulmonary PoCUS. In the serial ultrasound group, additional two extra PoCUS was performed with two hours interval. The primary outcome was a reduction of dyspnoea on a verbal dyspnoea scale (VDS) from 0-10, where 10 was worst, registered at inclusion and after two, four, and five hours. Outcome assessors were blinded, whereas the treating physician and patients were not. The secondary outcomes in both groups were length of stay, 7- and 30-days mortality, number of readmissions, and the proportion of patients with a correct presumptive diagnosis in agreement with a final audit diagnosis. The sample size was calculated based on the primary outcome. The primary outcome was analysed with a mixed-effect model. Results: We included 102 patients in the serial ultrasound group and 104 in the control group. Median age was 76, sex was even distributed, many were previous smokers, and had chronic obstructive pulmonary disease or arterial hypertension as the most common comorbidities. The mean difference in VDS between patients in the serial ultrasound and the control group was -1·09 (95% CI -1·51 to -0·66) and -1·66 (95% CI -2·09 to -1·23) after four and five hours, respectively. The treatment in the two groups differed, with a larger proportion of patients receiving diuretics in the serial ultrasound group. No differences were observed between the two groups regarding the secondary outcomes. No adverse events were present. Discussion and conclusion: Serial PoCUS-guided treatment can, together with standard care, reduce the severity of dyspnoea compared to standard care alone because it gives the ED physician the possibility to tailor the treatment according to ultrasound findings. PoCUS could therefore be considered for routine use to aid the physician in stabilising the patients and thereby handling crowding and flow.

Trial registration number: ClinicalTrial.gov, NCT04091334. Funding: Department of Emergency Medicine, Slagelse Hospital; Naestved, Slagelse, and Ringsted Hospitals’ Research Fund; Research Fund of Region Zealand and Region of Southern Denmark; and the University of Southern Denmark.