Introduction

Acute vascular disease such as deep vein thrombosis (DVT) requires oral anticoagulants to prevent progression to potentially fatal pulmonary embolism and recurrence. Approximately 1 in 1000 people are diagnosed with a DVT every year, with an annual population death from venous thromboembolism (VTE) being 0.1%. Traditionally the oral anticoagulant used is Warfarin but this is increasingly becoming superseded by direct oral anticoagulants (DOAC) as these are thought to improve the anticoagulant effect and reduce need for monitoring. Therapeutic efficacy monitoring of DOACs such as Rivaroxaban is problematic as no reliable test is currently available. A novel rheological biomarker developed at Abertawe Bro Morgannwg University Health Board/Swansea University, has focused on the measurement and quantification of clot microstructure as a biomarker of vascular disease and its treatment. Fractal dimension (d_f) has been shown to be a highly sensitive marker of changes in clot structure, quantifying acute vascular disease with both anticoagulation and antiplatelet therapy. This study aimed to investigate if d_f could quantity changes in clot microstructure in patients taking Rivaroxaban.

Methods

The prospective observational pilot study recruited patients being investigated for a DVT. Baseline blood samples were collected measuring d_f and standard markers. Upon diagnosis, a DVT and non-DVT group were created. The DVT group had three sample points in total, the baseline/pre-treatment sample and two additional sample points to measure the two different doses of Rivaroxaban. Sample points were at approximately 20 days with a dose of 15mg BD Rivaroxaban and finally at approximately 60 days following 20mg OD Rivaroxaban. The recruitment followed a strict inclusion and exclusion criteria with full ethical approval.

Results and Discussion

40 DVT patients (mean age 64 years [SD 14.8]; 23 male, 17 female) were recruited. Mean d_f on admission was 1.72 (SD 0.059). Rivaroxaban therapy reduced d_f to 1.69 (SD 0.051) after approximately 20 days, and subsequently increased to 1.71 (SD 0.061) at approximately 60 days. The non-DVT group of 178 patients (mean age 61 [SD 16.6]; 67 male, 111 female) had a mean d_f of 1.71 (SD 0.055). Despite the absence of significance in the differences in mean d_f at the three DVT timepoints, the trend observed suggests a measured and quantifiable reduction in clot strength associated with DOAC. Interestingly and of equal importance, analysis suggests a potentially gender based and personalised response to the DOAC. No difference between the DVT and non-DVT group suggests first time DVT may not be due to systemic clot microstructure changes. Furthermore, given the large potential difference in clot mass that changes in d_f represent, further studies with greater numbers are required to elucidate the effect of d_f during DOAC therapy in thrombotic disorders and its relationship to haemostasis and clot strength.

Background: Migraine is a primary headache disorder that presents in the emergency department (ED). Trials show that low-dose ketamine (0.1-0.5 mg/kg) provides analgesia for acute pain in the ED, but headache patients have been excluded from these studies. We sought to investigate analgesic efficacy of ketamine for treatment of acute migraine.

Objective: To evaluate and compare analgesic efficacy and safety of low-dose ketamine to saline placebo for treatment of acute migraine in the ED.

Methods: This prospective, randomized, double-blinded, placebo-controlled trial evaluated patients aged 18 to 65 in the ED with acute migraine. Patients were randomized to receive 0.2 mg/kg ketamine or normal saline intravenously. Subjects were assessed at baseline and at 30 and 60 minutes post-treatment for Numeric Pain Rating (NRS) scores, categorical pain, functional disability, side effects, and adverse events. The primary outcome was reduction in NRS score at 30 minutes. Secondary outcomes include categorical pain and functional disability improvement, rescue medication request, patient satisfaction, and adverse events. Side effects were evaluated using the Side Effects Rating Scale for Dissociative Anesthetics (SERSDA) model. 

Results: 35 subjects were enrolled (ketamine=17, placebo=18). The average subject was 35 years old (SD=12), Caucasian (66%) and female (77%). There were no statistically significant differences in demographics except age (ketamine=39 vs placebo=31, p=0.032). There was no statistically significant difference in NRS score reduction between arms. Median NRS score reductions at 30 minutes for ketamine and placebo arms were 1 [interquartile range (IQR: 0,3.00)] and 2 (IQR: 0,3.75) (p=0.590), respectively. Categorical pain and functional disability each improved at 30 minutes in 6 (35%) ketamine subjects, while 9 (50%) placebo subjects improved in categorical pain and 7 (39%) in functional disability. Rescue medication was requested at 30 minutes with similar frequencies in ketamine and placebo arms (71% vs 78%, p=0.820). Treatment satisfaction was similar in both arms (69% vs 65%, p=0.909).  Ketamine subjects had significantly higher SERSDA scores at 30 and 60 minutes for generalized discomfort with median scores of 4 [(IQR: 2,4) vs 2 (IQR: 0,3) in placebo arm, p=0.032] and 3 [(IQR: 2,4) vs 1 [(IQR: 0,2) in placebo arm, p=0.007], respectively. Ketamine subjects had significantly higher SERSDA scores for fatigue at 60 minutes with a median score of 2 [(IQR: 1,4) vs 0.5 (IQR: 0,1.75) in placebo arm, p=0.040]. All other differences in SERDA scores were statistically insignificant. No serious adverse events occurred.

Conclusions: IV ketamine at 0.2 mg/kg did not produce a greater reduction in NRS pain score compared to placebo for treatment of acute migraine in the ED. Generalized discomfort was significantly greater in the ketamine arm at 30 and 60 minutes, as well as fatigue at 60 minutes, but no other side effects showed significant difference.

Background: Emergency department (ED) overcrowding is a common problem in many countries and impacts on patient safety, quality of care, staff morale and cost. In England, many hospitals regularly fail to meet the national performance target of admitting or discharging 95% of patients attending ED within 4 hours. Existing evidence shows that factors external to ED (e.g. bed capacity within the hospital) can limit ED performance against this target. Our objective was to assess, for a UK hospital, the relative extent to which different external factors hinder performance against the 4-hour target and identify the scope for improving performance by reducing the time associated with key processes in the ED.

Methods: This study was conducted by a multidisciplinary embedded research team at University College London Hospitals (UCLH). Staff within the ED and related departments were interviewed and shadowed to identify key processes and flows of patients through ED and factors external to ED that were hindering performance. This informed the development of a mathematical model, based on a queuing network, that related the external factors to measures of ED performance (e.g. the 4 hour target). The model was used to determine the time evolution of the system (i.e. number of patients in each step of the ED process at any given time) and to measure performance against the 4-hour target under different scenarios of interest.

Results: The following external factors of interest were identified: patient arrival rates (number of patients arriving, and at what time during the day); delays due to unavailability of hospital beds for patient admission; delays due to unavailability of specialist clinicians from the main hospital to visit ED patients. The mathematical model was parametrised using data routinely collected in the ED and expert clinical input, and the impact on ED performance of these external factors and of reducing the time associated with key ED processes were quantified. For instance, we determined the extent to which delays accessing specialist clinicians and/or hospital beds currently limit ED performance and quantified performance gains attainable by shifting specialist/bed requests earlier in the patient journey. We studied the relationship between ED delays due to bed unavailability and the current pattern of inpatient discharges from the hospital during the day and used the model to quantify the gain in performance achievable by shifting inpatient discharges to earlier in the day.

Conclusion: The mathematical model enabled a better understanding of reasonable expectations for ED performance at UCLH given external factors that cannot be controlled by ED staff. The model results are being used to help ED staff prioritise interventions aimed at reducing the effects of overcrowding in the department. The study suggests that an improved synergy between different areas of the hospital could potentially lead to substantial gains in ED performance.

Objective: Ileus usually presents with acute abdomen and patients with ileus frequently need operation and hospitalization. High white blood cells (WBC) levels are associated with acute abdomen. The purpose of this study is to analyze the relationship between Neutrophil/Lymphocyte ratio and the time of hospitalization and the prognosis of the disease.

Material and Methods: The patients who applied to the Emergency Medicine Department of University of Health Sciences Ümraniye Research and Education Hospital between January 1st 2013 and December 31st 2015 with abdominal pain, diagnosed with ileus and hospitalized were scanned retropectively. The leukocyte, hemoglobin, neutrophile and lymphocyte counts, the time of hospitalization, the imaging technique used for diagnosis, the presence of malignity, and mortality rate were recorded. The relationship between NLR and the duration of hospitalization and the rate of mortality were studied in the patients who were diagnosed with ileus. 

Results: 251 patients were included in this study. 143 (57%) were male. WBC levels were studied in patient's presentation to the ED. The median WBC value of the deceased patients were 13 (9.07-15.90), and it was 10.90 (8.74-13.77) in patietns who survived which was statistically insignificant (p=0.201). Mean NLR of the patients who passed was 11.65 (3.29 - 18.83), and it was 5.21 (3.30 - 8.38) for patients who survived which was statistically significant (p=0.03, Man-Whitney U Test). A multiple linear regression was calculated to predict mortality. Age and NLR were significant predictors of mortality (p=0.014 and p=0.045, respectively). (Table 1) Clinical utility of NLR is shown in (Table 2).  In our study, the NLR was significantly higher in deceased patients (p=0.03). 

Discussion: Leukocyte level usually increases in the patients with acute abdomen but it is not specific and can be effected from other inflammatory diseases (1).Neutrophile and lymphocyte values in peripheral blood sample show variability in systemic imflammatory conditions (2). In recent studies, NLR is found useful for evaluating the degree of  the imflammatory response (3). In our study, the NLR was significantly higher in deceased patients (p=0.03). Also, mortality and duration of hospital stay was correlated. These results show correlation with other studies in the literature.

Conclusions:  NLR is a cheap and widely accessible laboratory test and can be used for predicting mortality in patients with ileus. More randomised studies in larger populations are needed for getting stronger evidence.

Background: Bone fractures are one of the three most important complications during accidents that fixation
and pain control are the most important management for these complications. The aim of this study was to
compare the effect of intranasal ketamine versus intravenous morphine in the treatment of pain in patients
with bone fractures.
Materials and Methods: In this double-blind clinical trial, 104 patients with bone fractures recruited from
the emergency department (ED) from 2015 to 2016 were randomly divided into two groups. Patients in the
ketamine group received 1mg/kg intranasal ketamine and patients in the morphine group received 0.1mg/kg
intravenous morphine. Then the severity of pain, hemodynamic parameters and side effects in the both
groups were measured for each 5 minutes.
Results: Results showed that the mean of pain score at different time intervals (from first 5 minutes until 20)
in the ketamine group were lower than the morphine group, of which in the 5th minute, in morphine group
was 5.19 and in ketamine group was 3.51 (P<0.001). Moreover, the analgesic effect of ketamine was started
faster, which was 2.36 min, hence in the ketamine group was 5.09 min (P=0.0034). Finally, we found that the
complications such as nausea and vomiting were significantly lower in patients receiving intranasal ketamine
(9.6% vs. 44.2%, P<0.001, and 3.8 % vs. 32.7 %, P<0.001).
Conclusion: Considering the results of our study and others’ experiences with intranasal ketamine, and its
benefits, including needle-free drug delivery, ease of use, non-opioid nature and ready access properties, this
novel medicine delivery method merits further research in patients with acute pain due to limb fracture.
Early application of low doses of ketamine following trauma-induced pain such as limb fracture may provide
acute pain relief and reduce the probability of chronic pain and merits further study.

Background

Cardiopulmonary arrest is rare in children, but the survival rate is poor (0-27%). Training parents is of pivotal importance, especially for babies with high risk of cardiopulmonary arrest due to prematurity, congenital heart defects or chronic pulmonary disease. Our project aims to teach parents of high-risk babies admitted to our NICU on cardiopulmonary resuscitation (CPR) and foreign body ingestion maneuvers, before their infant's discharge.

Methods

Parents of high-risk babies, defined as prematurity, severe congenital heart defects, chronic pulmonary disease (including pulmonary hypoplasia due to congenital diaphragmatic hernia), gastrointestinal anomaly (including esophageal atresia), apnea spell, and need for tracheostomy, discharged from the DNMC of the Bambino Gesù Children’s Hospital between February and November 2016 were educated to perform CPR and foreign body ingestion maneuvres by certified instructors, following ILCOR 2015 guidelines, during weekly 2-hour courses. In a group of parents of babies with tracheostomy, home ventilation, airway management and tracheostomy care were also explained.  Parents completed a questionnaire to test attitudes towards CPR before and after training. The questionnaire was proposed again, by telephone call, 3 to 6 months after the course.

Results

Over the 10 month-period, 135 caregivers (71 mothers, 48 fathers, 9 grandmothers/grandfathers, 7 uncles/aunts) of 97 high-risk neonates were educated. Babies were affected by prematurity (62%), congenital heart defects (41%), chronic pulmonary disease (32%), gastrointestinal malformations (12%), apnea (10%), tracheostomy (6%). Parents were highly motivated to learn CPR. Among them, only 15% had previously performed a CPR course.  During the practical sessions, parents demonstrated good performances, in particular to heart massage with adequate depth and rate of the compressions faced to the foreign body ingestion maneuvres. The correct questionnaire rate was 30% and 85% before and after the course, respectively. In a subset of 60 parents, the survey was proposed again, by phone, 3 to 6 months later (average 4.5 months) to test skill retention. The prevalence of  correct answers decreased from 85% to 65%.

Conclusion

Based on our results, and consistently with other reports in the literature, a program of CPR for parents of babies with high risk of cardiopulmonary arrest should be planned in Neonatology and Neonatal Intensive Care Unit when the baby is going to be discharged home. Considering the decrease of the right answers to the delayed questionnaire, further evaluation should be done to establish the best interval for CPR training repetition.

Introduction: Hyperlactatemia has been found to be a risk factor for mortality in critically ill patients. Until now, no definitive research has been carried out into whether serial measurements or lactate clearance over time can be used as a prognostic marker in a clinically unwell population in the emergency department (ED).

Objective: To evaluate the predictive value of lactate clearance and to determine the optimal cut-off value for predicting short-term mortality in critically patients admitted in ED.Methods:  A prospective observational study was performed over 10 months. Inclusion of adult patients whose blood level of lactate was measured. Serial lactate levels in ED admission and 6 hours later were measured. Lactate clearance, percent decrease in lactate level in 6 h ((lactate admission – lactate 6 hours) x 100/lactate admission) was calculated. The main outcome measure was 7-day mortality.

Results: Inclusion of 170 patients. Mean age was 59 ± 21 years. Sex ratio = 1.53. The overall mortality at the seven day was 22%. The median admission lactate was 3 mmol/L [2,5]. Survivors compared with nonsurvivors had a lactate clearance of 30.2 ±69.9 vs. 21.8 ±40.6%, respectively (p=0.01). Based on Area Under the Curve in receiver operating characteristic analysis, lactate clearance have a significant inverse relationship with short-term mortality (0.65, 95% CI [0.47 to 0.81]), with a cut-off at 20%. Patients with a lactate clearance >20%, relative to patients with a lactate clearance <20%, had a lower short-term mortality rate (p =0.05).

Conclusion: Lactate clearance early in the hospital course may is associated with decreased mortality rate. Patients with higher lactate clearance after 6 hours (>20%) of ED intervention have improved outcome compared with those with lower lactate clearance.

Background: Procedural Sedation rates are rising exponentially in the Emergency Department and consequently measures have to be taken to stratify risk and avoid adverse events. Provision of safe sedation is an area of practice which benefits particularly from standard operating procedures and therefore the Royal College o Emergency Medicine (RCEM) published 7 standards in 2015. 

Aims: To ascertain whether the introduction of a mandatory sedation checklist and electronic database (Bamboo) following the 2015 audit has improved our documentation rates so far as to demonstrate high levels of compliance with the seven RCEM standards.

Methods: In 2015, data was collected from the procedural sedation logbook resulting in 50 consecutive patients between 27/07/2015 and 12/11/2015. 46 patients were included in the audit due to full data set availability. In 2016, data was extracted from all entries on the new trust electronic database resulting in 50 consecutive patients between 01/09/2016 and 13/11/2016. 

Results: ASA grade, anticipation of difficult airway and fasting status rose from 8.7%, 10.6% and 32.6% to 84%, 96% and 98% respectively. Consent was recorded in 98% of cases up from 21/7% the previous year. All team members were recorded as present 76% of the time, an increase from 56.5%: The most common missing member of the team on record was nurses. Patients were monitored with the required ECG/Capnography?NIBP and pulse oximetry in 98% of cases up from 39%. No specific information was recorded to demonstrate use of oxygen to the point of discharge. Fulfillment of discharge criteria was only documented in 39% of cases, down from 41% in 2015. 

Conclusions: Our documentation rate has significantly improved over the last year and consequently we are not far from adhering to the RCEM standards 100% of the time. 

Recommendations: All procedural sedation must be recorded on the electronic database with specific improvements to ensure extra details are documented: Patient consent, monitoring (specifically that it includes ECG/Capnography/NIBP and pulse oximetry and that nursing staff are present. As a matter of safety, we must add in the discharge criteria for all patients being considered for discharge and that we ensure that we meet these. 

Abstract

IMPORTANCE Use of calcium channel blockers (CCBs) has been found to improve sepsis outcomes in animal studies and one small clinical study. Whether the pre-admission use of CCBs would confer beneficial effects to patients with sepsis requires validation by a large population-based study.

OBJECTIVE To determine whether the use of CCBs is associated with a reduced risk of mortality in patients with sepsis.

DESIGN, SETTING, AND PARTICIPANTS We conducted a population-based cohort study using the National Health Insurance Research Database of Taiwan. From 1999 to 2011, hospitalized sepsis patients were identified by ICD-9 codes compatible with the sepsis-3 definition.   

EXPOSURES Use of CCBs or beta blockers. Beta-blocker was used as an active comparator, to examine the influence of healthy user bias. Propensity score (PS) adjustment and matching were used to adjust for unbalanced covariates between users of specific medication of and nonusers.

MAIN OUTCOMES MEASURES The primary outcome for the analysis is 30-day all-cause mortality. The secondary outcomes are 90-day all-cause mortality, septic shock, and acute respiratory failure.

RESULTS Our study identified 51,078 patients with sepsis, of which 19,742 received CCB treatments prior to the admission. Use of CCB was associated with a reduced 30-day mortality after PS adjustment (HR 0.94, 95% confidence interval, 0.89-0.99), and the beneficial effect could extend to 90-day mortality (HR, 0.95, 95%CI, 0.89, 1.00). In contrast, use of beta-blocker was not associated with an improved 30-day (HR, 1.06, 95%CI, 0.97, 1.15) or 90-day mortality (HR, 1.00, 95%CI, 0.90, 1.11). On subgroup analysis, CCBs tend to be more beneficial to patients with male gender, aged between 40 and 79, with a low comorbidity burden, and to patients with cardiovascular disease, diabetes, or renal diseases.

CONCLUSIONS AND RELEVANCE In this national cohort study, preadmission CCB therapy before sepsis development was associated with a 6% reduction in mortality when compared to patients who have never received a CCB. 

Background: In recent years lecture based learning (LBL) compared to Problem and case based learning (PBL-CBL) have been proven to be methods that improve training of residents. There are still not enough studies that analyze the importance of these methods in the medical Emergency area.

This study had as purpose to analyze the improvement in training given by the grades obtained in the Medical ER rotation of first year residents of family medicine comparing 2 course methods LBL group vs. PBL-CBL group.

Methods: Study type: Historical Cohorts. Universe of study: we analyzed the grades of the total of first year residents of family medicine that started their Medical ER rotation In HGUGM in the years 2012, 2013, 2014, 2015, 2016. We analyzed specifically the grades in the variable acquisition of theoretical knowledge, doctor-patient relationship, and rational use of resources. Statistical analysis was done with Excel, and SPSS (Pearson’s Chi-squared).

Results: In the years 2012, 2013, 2014 70 first year residents of family medicine received the LBL course, in the years 2015, 2016 50 first year residents received the PBL-CBL course.

In the grade variable of theoretical knowledge acquisition 88% of the residents in the PBL-CBL course obtained a grade of 2 (1-3 grading scale, being 3 the highest grade) compared to 60% in the LBL group. Being this difference statistically relevant (p < 0,01). In the Variable doctor-patient relationship 44% of the PBL-CBL course obtained a grade of 3 compared to 4.3% in the LBL group. Being this difference statistically relevant (p < 0,003). In the variable rational use of resources 68% of the residents in the PBL-CBL course obtained a grade of 2 compared to 39.1 % in the LBL group. Being this difference statistically relevant (p < 0,03)

Discussion: There was statistically relevant difference between the PBL-CBL group compared to the LBL group in the grades of the variables of theoretical knowledge acquisition, Doctor-patient relationship and rational use of resources. In this study we observed that the methodology of the PBL-CBL course had a favorable impact in the grades on the medical ER rotation, in the variable mentioned previously compared to the LBL course. The PBL-CBL group had an improvement probably due to the practical application of the theoretical knowledge, the simulation of real situations and how to overcome problems in doctor patient relationship, and due to the application of that knowledge to rationally use the resources they have for the purpose of solving problem and cases related to real patients. 

Objective: To develop a standardized high fidelity medical simulation (HFMS) training curriculum focusing on specific assessment and treatment of disaster-related severe injuries presenting to the emergency department.

Background: Evidence suggests that most prehospital and hospital providers are inadequately prepared to manage a multiple-casualty incident. For hospital healthcare providers, it is critical for them to develop competency in managing patients injured from disaster events. Unfortunately, some of these patients could be really critical, and understanding the pathophysiology of the injury progress is important for good quality care for the patients. Although existing disaster training systems emphasize non-technical skills, there has not yet been an in-depth analysis in identifying the competency of clinical skills for disaster personnel. HFMS is being used in rare but critical clinical events to enhance the competencies of healthcare providers.

Methods: The curriculum was developed using Kern’s 6-step approach. Problem identification, targeted needs assessment, goals, objectives, and educational strategies were developed according to evidence references and focused survey results. Five components of construct validation were used to validate the program: Content, Response process, Internal structure, Relationship to other variables, and Consequences. Contents were developed after reviewing all the related evidence references. And educational environment, setting, methods, instructor, and assessor were standardized. All checklists for assessment were validated using content validity index. And consequences were validated using pre- and post-intervention differences. The educational intervention consisted of a half-day workshop (lecture-HFMS-debriefing) for selected 24 emergency residents (6 teams). The objective of the scenario was to develop performance competency in managing critically injured patients in a disaster events, specifically, blast, radiation, and crush injuries. A checklist was developed to assess the performances of the participants. All pre-to-post differences within subjects were analyzed with paired t tests. The statistical level of significance was set at 0.05.

Results: The content validity index of performance checklist was 0.90. Pre- and post-intervention differences (percentage) for the 6 team performances were 67.7 to 84.6, 58.1 to 80.8, 51.6 to 84.6, 61.3 to 80.8, 51.6 to 65.4, 61.3 to 76.9, respectively. All results were statistically significant.

Conclusion: HFMS training program focusing on critically injured disaster victims positively affected performances of the participants.

Background: Evidence suggests that most hospital providers are inadequately prepared to manage a critically ill patient, especially patients in shock conditions. As the care of patients become more specialized, training the residents for general care of patients is becoming more difficult. The working hour limits of residents has restricted them to be exposed to critically ill patients. The objective of this project is to develop a standardized high fidelity medical simulation training curriculum, focusing on specific assessment and treatment of shock patients. Participation of healthcare providers in this program using self-assessment tools would positively affect knowledge, skills, and attitudes toward managing patient in shock conditions.

Methods: The educational intervention consisted of a full-day course for all new residents entering following departments: Internal medicine, General surgery, Pediatric, Obstetric, Chest surgery, Emergency medicine, and Anesthesiology. The day was composed of a summary lecture, followed by session comprised of learning psychomotor skills necessary for saving shock patients, which included airway management, and ultrasound-guided central line insertion. Simulation session consisted of 5 scenarios: Anaphylactic, Septic, Cardiogenic, Hemorrhagic, and Obstructive shock. To identify the differences in knowledge and self-confidence before and after course, all participants responded to the survey with a Likert scale. Paired t-test was used to compare the knowledge and self-confidence level on pre- and post-course. A descriptive analysis was performed to determine the general characteristics of subjects and the level of awareness of the importance of clinical competency in shock management.

Results: A total of 68 residents participated in the session (25 internal medicine, 9 general surgery, 12 pediatrics, 6 obstetrics, 1 chest surgery, 6 emergency medicine, 9 anesthesiology). All self-assessment questionnaires were scored out of 10 points. The mean score for overall course satisfaction was 9.3. For the face validity, the participants’ scoring for ‘realism of the setting environment’, and ‘realism of the scenario’ were 8.0, and 8.6, respectively. The score differences in pre-and post-course scores for competency in shock recognition, differential diagnosis, stabilization, intervention, skills, and crisis management were 4.5 to 7.6, 4.2 to 7.6, 4.3 to 7.5, 4.1 to 7.6, 4.5 to 7.5, and 4.4 to 7.5, respectively. The results were statistically significant.

Conclusion: The pilot course was satisfactory to the participants. The simulation session was able to improve the confidence and knowledge of the participants in managing shock patients. The scenario and simulation environment was able to assist the participants in recognizing the importance of patient in shock conditions, and also to self-assess competency in knowledge, skills, and attitudes towards shock patients.

Introduction

Acute bacterial skin infections are a usual cause of sepsis in the Emergency Department (ED). Mostly, the diagnosis is clinical. Globally, the most common pathogens are Streptococcus pyogenes and S. aureus. Our primary concern should be the use of a adequate antimicrobials therapy under guidelines. Before the spread and diffusion of bacterial resistances, empiric antiobiotics therapy (with a large spectrum β-lactam) was favoured. The rational is now to adapt the use of antibiotics to the local ecological situation. Monotherapy should be attempted (depending on the severity), Gram-negative coverage is mostly not empirically indicated, oral antibiotics are very effective and should be preferred if possible. The aim of this study was to evaluate the management of acute skin infections in an urban ED and the adherence to clinical guidelines.

Methods

We present here, a one-year (2015) retrospective and monocentric study conducted in a french teaching hospital. During the period of the study, we included all adult patients with the diagnosis af erysipelas. We collected and analyzed all clinical, biological, treatments and evolution datas during the stay in the ED. In fine, 127 patients have been included for statistical analysis.

Results

In the study population, mean age was 73.8±11.6 years old and the sex-ratio was 1.14. Penicillin G and Amoxicillin + Clavulanic Acid were the two most prescribed antibiotics (both 32%). Pristinamycin (15%), Amoxicillin (11%), Clindamycin (6%), Cloxacillin (4%) and others (2%) were the other used antimicrobials. Mean duration of therapy was 11.6±4.2 days. More than three quarter (77% (CI95%: [66-88%])) of them were hospitalized. IV administration was mostly used (78%) in the ED. Blood cultures came back positive in 14% of cases (mostly with S. pyogenes: 42% and S. areus: 14%). Antimicrobial therapy was given with a average time of 4.6±2.7 hours after ED admission. There was no difference in term of treatment duration (p=0.7), neither in term of antibiotics used (p=0.59) between out-patients and hospitalized patients. The mortality at Day28 was 2.3% (95% CI: [0.5-5%]) in this cohort.

Conclusion

Our study highlights the poor adherence to current guidelines. The management of acute skin infections in our ED remains heterogeneous. Penicillin G remains as a good choice in this indication but Amoxicillin + Clavulanic Acid should be preserved in the absence of bacteriological justification. As well as curbing the additional cost of non-guideline prescription, adherence to guidelines is essential in order to suppress growing resistances to antibiotic treatment. Pristinamycin and clindamycin could be appropriate alternative of Peni G in this area. The choice of antibiotic therapy should take in account various factors, including safety, interactions, patient profile (age), and possibility of permitting an early discharge (early switch-therapy, IV to oral at 48 hours) and thus minimizing the costs of hospitalization.

Emergency medicine (EM) was ranked the highest specialty in the 2016 GMC survey¹ for workload, intensity and fatigue. College surveys² have found that as many as 1 in 4 trainees may leave the specialty. Billions a year are spent on locums in the NHS.³

The 3 big questions to ask are : How can we recruit junior doctors into EM training posts and retain them? How can we inspire medical students into an EM career? And how can we deliver a cost effective service whilst providing quality training?

There is one solution: Fellows.

From August 2016, Brighton and Sussex University Hospitals (BSUH) created EM fellow posts. Each post consisted of 66% clinical time and 33% project time. The aim was to offer a better work-life balance and allow time to pursue other EM related interests. Applicants were required to be post foundation years. Fellowships were offered in education, simulation (both with a funded postgraduate certificate), leadership, trauma, toxicology and major incidents.

What do the fellows think of the job and does it make them want to do EM? We surveyed the fellows and 11/22 responded. 81% (n=9) agreed or strongly agreed that they had a good work-life balance and enjoyed the job. 91% (n=10) agreed or strongly disagreed that they had more time to participate in projects. 100% (n=11) would recommend the job to others. 72% (n=8) would consider a career in emergency medicine. Both of the registrar fellows who are EM trainees are continuing their training.

Every medical student on placement at BSUH ED this year was attached to an educational fellow. We aimed to encourage final year medical students to pursue careers in EM by providing a supportive and inspiring learning experience. How likely were they to consider emergency medicine as a career? We asked the students this question at the beginning of their EM placement and we asked them the same question after their placement with their dedicated educational fellow. The results were very positive. Answers were recorded on a 0-10 scale. Response rate was 100% of 39 students. The mean average before the placement was 5.3 and the mean average after the placement was 7.4. This is a difference of 2.13 (confidence interval 1.60-2.66).

And to answer the final question, these additional posts have enabled us to save £375,000 on locum spend already in the first half of this year.

We have shown how fellows can be a solution to recruitment, to retaining doctors whilst being cost effective. We are keen to explain the process further and share our successes and experiences with an international audience.

References in attachment

Background

UK ambulance services do not routinely receive information about what happens to patients following pre-hospital care. This impacts the ability of ambulance services to measure patient outcomes or evaluate care quality and performance. Measuring patient outcomes for ambulance service users has been identified as important through our consensus work with service users, service providers and service commissioners. In a Delphi study and patient and public consensus workshop, one of the highest priorities was to develop new indicators for measuring patient survival following ambulance service care. We present new survival indicators to measure survival for patients with serious emergency conditions, at multiple time-points.

Methods

We linked six-months patient level call and clinical data from one UK ambulance service with Hospital Episode Statistics (HES) Emergency Department (ED), admitted patient data and national mortality data. We identified a cohort of people who were admitted or died from one of 16 serious emergency conditions (conditions where death could potentially be prevented by a good emergency system). Multi-variable models (adjusting for age, condition and hospital effects) were created to calculate two survival measures. 1) Survival to hospital admission, within 7 days of the ambulance call; 2) For patients admitted to hospital, survival to 7 days from admission.

Results

Indicator 1: To identify the proportion of people with a serious emergency condition who survive to admission (within 7 days of ambulance contact). 11,264 of 187412 patients in our dataset met the inclusion criteria and had a serious emergency condition. Of these, 617 (5.5%) died and 10,647 survived to admission. The majority of pre-admission deaths occurred in older people and were within 1 day of the ambulance contact (87.8%). Pre-admission deaths were more likely for people with conditions such as ruptured aortic aneurysm, asphyxiation and meningitis.

Indicator 2:  For patients admitted to hospital, survival to 7 days from admission.

10,647 patients were admitted to hospital and 94% survived. The rate of survival decreased with age. People with septic shock, cardiac arrest, ruptured aortic aneurysm and heart failure were more likely to die, whereas people with falls age >75, road traffic accidents and asthma were more likely to survive. Most deaths occurred within one day of admission (47%).

Discussion

These indicators are part of a set of indicators developed by the Prehospital Outcomes for Evidence Based Evaluation (PhOEBE) project, to measure ambulance service quality and performance. The indicators presented here are system indicators that monitor pre-hospital and post admission survival rates for people with a serious emergency condition and can be used to assess trends over time and differences between geographical areas.  For example, survival may improve through service developments, such as taking the right patients to the right specialist care.

Background

The Prehospital Outcomes for Evidence Based Evaluation (PhOEBE) project is a five year NIHR funded research programme, which aims to identify, develop and test new ambulance service quality and performance indicators. During our 3 stage consensus research study, an important topic identified by patient and professional research participants was quality and safety of non-transport decisions. For example death or hospital admission following a non-transport decision. This is also important because the number of non-transported calls is increasing and there is huge service level variation for non-transport rates for different localities. Using our study patient-level linked ambulance and subsequent health event dataset, we developed a quality and performance indicator to identify potential missed opportunities to improve care related to prehospital non-transport decision making.

Method

Data for 6 months of 2013 was provided by one UK ambulance service and linked to national datasets (ED, hospital admissions, mortality) using NHS Digital’s data-linking service.  We excluded calls transported to ED, people who were dead on scene, untraced calls and end of life care calls. Calls were categorised into those receiving a paramedic response and not transported and calls receiving telephone advice only. We identified hospital admissions or deaths within 3 days of the original call as being potential missed opportunities to improve care. We calculated crude and standardised rates of admission or death within 3 days of the call and created predictive models to adjust for age, condition, call outcome and deprivation.

Results

84% of calls receiving a paramedic response and not transported were traced (42796/50894). Of these 6.3% were admitted to hospital within 3 days and 0.3% died within 3 days. Low tracing rates for telephone advice only calls (24%, 2514/10634) resulted in the possibility of bias, therefore we conducted a sensitivity analysis to identify a range of hospital admissions (2.5% – 10.5%) and deaths (0.006 – 0.24%) within 3 days of the original call. Using predictive models we assessed the results by county, clinical commissioning group, condition, in and out-of-hours calls, using traced and non-traced calls in the denominator, and presented standardised rates using funnel plots. We also assessed the impact of excluding hospital admissions < one day.

Conclusions

Quality and safety of non-transport decisions is important to service users and service providers, and can be measured using linked prehospital and subsequent health event data. We developed and tested a potential prehospital non-transport quality and performance measure. This can be used to monitor deaths and admissions following prehospital non-transport decisions and to provide information about the safety of non-transport decision making. This has potential as a system level indicator for all emergency and urgent care services where patients are not-transported to hospital.

Introduction: Syncope in the Emergency Department (ED) presents a dilemma between accurate diagnosis, recognition of risk-factors, and cost-effective management. Approximately 50% of the UK population will experience at least one syncopal episode in their lifetime, accounting for 3% of all ED attendances and up to 6% of hospital admissions. A comprehensive, evidence based pathway to aid decision making on whether to admit or safely discharge a patient with syncope could improve patient management and resource utilisation^.

Objectives: To collect data regarding the outcomes and risk characteristics of patients presenting to the emergency department with syncope to determine whether patients would benefit from the implementation of a syncope management pathway or dedicated syncope outpatient clinic.

Setting: Royal Alexandra hospital, Paisley, Scotland.

Results: 159 patients were included in the study after 12 were excluded according to set criteria. 99 (62.3%) were discharged and 60 (37.7%) admitted. The mean age was 35.7 years for those discharged and 71.4 years for those admitted. The two groups of most interest in relation to the aims were those stratified high-risk and discharged (HRD) and those stratified low risk and admitted (LRA). Of those discharged 23 (23.2%) were stratified as high risk, of those admitted 24 (40.0%) were stratified as low risk.

 When comparing these two populations LRAs were, on average, older than the HRDs (mean age 69.0 to 44.7). LRAs were more likely to attend hospital within 6 months for reasons other than syncope (29.2% to 13.0%), more likely to receive follow-up than low risk discharged patients (45.8% to 23.7%) and LRAs were more likely to receive head CT scans than HRDs (12.5% to 0%).

Conclusions: This study shows that there are patients presenting to the ED with syncope who are inappropriately admitted or discharged. Figure 1 outlines an example pathway helping to guide clinicians in decision making. Further research is required to identify exactly which patients would most benefit from referral to a specialist syncope clinic or from a management pathway to aid ED clinicians in assessing and directing care and whether its implementation is effective in real-world use.

TITLE A comparison of the timeliness and efficiency of two triage systems, the Manchester Triage System and Emergency Severity Index, in Midland Regional Hospital Tullamore and Royal Liverpool University Hospital

INTRODUCTION An effective triage system can ensure that an emergency department (ED) runs smoothly during periods of time where patient numbers are high and resources are sub optimal. The Emergency Severity Index (ESI) assessment is shorter than that of Manchester Triage System. The MTS is in use in the Midland Regional Hospital Tullamore (MRHT) and the ESI in the Royal Liverpool University Hospital (RLUH).

The aim of this study was to determine

1 the extent of the triage assessment used in each hospital.

2 the time elapsed between;

• patient arrival in the emergency department and time to triage.
• triage and patient information being available to the ED staff.
• patient information being available and first consultation with a Doctor.

3 if the availability of an advanced triage system improves waiting times

METHODS

A prospective observational study was undertaken in both EDs in Summer 2016. The time a patient entered triage was recorded and the process they underwent observed. The tasks undertaken by the triage nurse was noted. The time for notes to enter the boxes for doctor/ANP review was noted. The observed time and the duration of the  triage process as recorded on the IT system was compared if feasible. The advanced triage process (ie Bloods, ECGs etc) in each ED (formal in RLUH, adhoc in MRHT) was also observed and impact noted.

RESULTS

Data was collected on 217 and 204 patients in MRHT and RLUH respectively. The mean time for triage was 7mins 8secs and 9mins 36secs for MRHT and RLUH respectively. In both EDs, 1 in 5 patients needed no additional tasks at triage (19.8% and 20.6% respectively). A mean of 1.4 and 1.3 additional tasks were performed respectively at triage. 12.8% patients were discharged direct from triage to alternative services in RLUH. Availability of ED cards to medical staff was longer in RLUH than MRHT but time to medical review was longer in MRHT (113.9mins in MRHT vs 88.6mins in RLUH for Cat 3 patients)

CONCLUSION

In theory, the ESI should result in a shorter triage process than the MTS. In practice, this was not observed. Both systems require additional tasks to be performed at triage in the majority of patients, commonly recording vital signs and provision of analgesia. The formal advanced triage process in place in the RLUH resulted in longer delays to availability for doctor/ANP review. Due to the lack of IT systems recording the ED transfer of care to other specialties in RLUH, it is not possible to evaluate if the advanced triage process had benefits further along the patient journey.  Time until review by doctor/ANP for category 3 and 4 patients was longer in MRHT despite the longer advanced triage process in the RLUH, reflecting other factors that impact on efficient ED function eg lack of doctors or lack of cubicles.

Background:

The SAMe-TT₂R₂ score has been proposed to identify patients with non valvular atrial fibrillation (AF) who maintain a high average time in therapeutic range (TTR) on vitamin K antagonists treatment (VKA). This score has been validated in several studies; either monocentric or including very selected populations in a specialized setting. Our aim was to validate this score in patients attending an Emergency Room (ER). To our knowledge this is the first report describing this score in an Emergency Room setting.

Patients & Methods:

From January 2014 to June 2014, we included in this study patients with AF on VKA consecutively seen in our ER. The SAMe-TT2R2 score was calculated for each patient and so was the TTR using the Rosendaal method, following the international normalized ratio (INR) six months, after the admission in ER. Patients with SAMe-TT₂R₂TTR

Data Collection:

We enrolled 394 patients with AF seen in the ER for any reason. In 271 (68.7%) cases were on AVK thromboprofilaxis.

Results & Discussion:

A number of 271 (68.7%) cases were on AVK thromboprofilaxis. The mean SAMe-TT₂R₂ score was 1,6(0.70 SD) points. In 202(74.5%) patients the score was 0 or 1 points and 69(25.4%) patients received 2 or more points. Up to 211(77.8%) patients were followed 6 months with mean 4,25(4,75 SD) INR determinations in this period. A total of 79 (37.4%) patients had a TTR ≥65%. Comparing high TTR vs low TTR groups (table I) we found no differences bettween demographic and clinical variables. Comparing SAMe-TT₂R₂ groups with TTR values we found: SAMeTT₂R₂=0 43%, TTR(interquartile range(IQR)26-51). SAMeTT₂R₂=1 40%, TTR(IQR30-49). SAMeTT₂R₂=2 33% TTR(IQR23-48). SAMeTT₂R₂=3 31% TTR(IQR19-45). SAMeTT₂R₂=4 NA.

A linear correlation was found in the prediction of good TTR control with the SAMeTT₂R₂ scale. (Fig 1). A statistically level of significance (p <0.05) was observed for SAMeTT₂R₂ to predict good control by the Rosendaal method grouping the patients into a “likely to achieve a high TTR” group (SAMeTT₂R₂ <2) and “unlikely to achieve a high TTR” SAMeTT₂R₂ ≥2.

Conclusion & perspective:

In a "real-world" cohort of patients attending the ER we have meassured the value of the SAME-TT2R2 score for the identification of patients who would have poor-quality anticoagulation. Higher values have been significatively associated with worse TTR control.  Thus, rather than imposing a "trial of vitamin K antagonists" for such patients (and exposing such patients to thromboembolic risks), we can a priori identify those patients who can (not cannot) do well on a vitamin K antagonists. Such patients would benefit from additional strategies for improving anticoagulation control with vitamin K antagonists or alternative oral anticoagulant drugs.

Objectives: Previous animal studies reported that acute anticholinesterase pesticide (organophosphate and carbamate) poisoning (ACPP) may affect thyroid hormones. There is no human study investigating the association of hypothyroidism and ACPP, and therefore we conducted a retrospective nationwide population-based cohort study to delineate this issue.

Methods: We identified 10372 ACPP patients and matched 31116 non-ACPP patients between 2003 to 2012 in a 1:3 ratio by index date from Taiwan’s National Health Insurance Research Database for this study. We compared cumulative incidence of hypothyroidism between two cohorts by following up until 2013. Independent predictors for hypothyroidism were also investigated.

Results: In total, 75 (0.72%) ACPP patients and 184 (0.59%) non-ACPP patients were diagnosed with hypothyroidism during follow-up. Cox proportional hazard regression analysis showed that ACPP patients had higher risk for hypothyroidism than non-ACPP patients (adjusted hazard ratio: 1.47, 95% confidence interval [CI]: 1.11-1.95) by adjusting age, sex, hypertension, malignancy, liver disease, renal disease, atrial fibrillation and flutter, thyroiditis, goiter, endocrine disorder, and mental disorder. Stratified analysis showed that ACPP patients had higher risk for hypothyroidism than non-ACPP patients in the subgroups of 40-64 years, female, past history of goiter, and follow-up of < 1 month. ACPP patients without atropine treatment had higher risk for hypothyroidism than non-ACPP patients (incidence rate ratio: 1.66, CI: 1.20-2.30), but ACPP patients with atropine treatment did not. Female gender, malignancy, renal disease, thyroiditis, goiter, mental disorder, and ACPP without atropine treatment were independent predictors for hypothyroidism in the all patients.

Conclusions: ACPP might increase the risk for hypothyroidism. We suggested that early evaluation of thyroid function for ACPP patients is needed, especially in the patients of 40-64 years, female, and past history of goiter. Further studies are warranted for the detail mechanisms.

Background

Ultrasound plays a significant role in emergency medicine protocols worldwide. It has proven to be a valuable tool, especially in patients subjected to blunt abdominal trauma. In a prehospital setting, ultrasound of the chest, abdomen, and pericardium is considered a valuable addition to physical examination and it guides patient management. Nevertheless, recent reviews conclude that a positive contribution remains controversial. We aim to determine the impact of prehospital abdominal ultrasound on treatment decisions in a Dutch physician-staffed helicopter emergency medical service (HEMS).

Methods

We conducted a retrospective review of patients who underwent abdominal ultrasound examination from 1 January 2007 through 31 December 2016 performed by the HEMS of Nijmegen, The Netherlands. It services an area of 10.088 square kilometers inhabited by 4.5 million. Physicians record data on every scramble and patient treated in a dedicated electronic database. The retrieved data included patient demographics, type of incident, abdominal ultrasound findings, impact on treatment decisions, and the physicians’ narrative report. Detection of hemoperitoneum with ultrasound was compared to computed tomography (CT) scan and laparotomy. Outcome parameters were: impact of ultrasound on treatment decisions, incident types leading to ultrasound examination, and its performance.

Results

Of 17077 recorded scrambles and 8699 patients treated, 1583 underwent 1631 abdominal ultrasound examinations. Male to female ratio was 3.54:1. Most suffered from traffic accidents and falls from height. After eliminating missing data, 1539 examinations lead to 193 (12.5% - CI 10.8-14.2%) impacted treatment decisions. Alterations were related to information provided to the receiving hospital (40%); mode of transportation, including physicians escorting patients (29%); choice of receiving hospital (13%); fluid management (13%); converting to a ‘scoop-and-run’ strategy (2%); administrating or withholding drugs (1%). Sensitivity of prehospital abdominal ultrasound for hemoperitoneum was 31.3%, specificity 96.7%, and accuracy 82.1%.

Discussion

Ten years of data on prehospital abdominal ultrasound showed management alterations in 12.5% of cases. Although comparable studies are scarce, a similar study showed a significantly higher impact on patient management but had an entirely different design. Sensitivity is low, likely due to the prehospital setting with many detrimental environmental factors, high stress, and time pressure. Also, accumulation of intraperitoneal blood is time-dependent and will be negligible at first. Furthermore, CT detects small quantities of free fluid, also in the retroperitoneal space associated with pelvic injury. In conclusion, prehospital abdominal ultrasound in our setting alters patient management significantly. It, therefore, is a valuable tool in the Dutch HEMS setting, and probably beyond.

The aim of this evaluation was to explore the impact, views and experiences of implementing an on-going initiative in Yorkshire Ambulance Service (YAS), utilising specialist triage by mental health nurses in the YAS Emergency Operations Centre (EOC).

An exploratory evaluation involved interviews with a range of staff (n=12) and analysis of computer aided dispatch (CAD) data.

Preliminary impressions of the intervention derived from this evaluation indicate that the triage nurses are increasingly managing patient’s issues over the phone to deliver ‘hear and treat responses’, thereby reducing unnecessary ambulance dispatch and conveyance to ED. Specialist mental health triage appears to deliver benefits from a patient and organisational perspective. These include improved responses that meet the needs of ambulance service patients experiencing a mental health crisis, reduced usage of ambulance resources and reduced conveyance to ED where not wholly appropriate.

Initial implementation was conducted quite rapidly and the approach was still evolving at the time of the evaluation. Perceived effectiveness of the mental health nurse triage scheme is attributed to the nurses’ established contacts and their ability to communicate inter-professionally with staff in mental health services. Staff reported an enhanced awareness of mental health issues, as well as improved working relationships and morale amongst those directly involved in managing patient calls since the introduction of mental health nurses. Staff in the frequent caller programme acknowledged the role that the nurses play in helping to manage patients with complex mental health needs.

The majority of the 3983 calls triaged by the mental health nurses (April - December 2015) were from Advanced Medical Priority Dispatch System (AMPDS) card categories 23 (overdose/poisoning) and 25 (psychiatric/ suicide).  As the number of calls triaged increased over the nine month period, the proportion of card 23 and 25 calls decreased, with more calls originating from across 22 ‘other’ AMPDS card categories. Analysis of available computer aided dispatch (CAD) data indicates that rates for (a) ambulance dispatch and (b) total cases conveyed were lower for calls triaged by the mental health nurses.

Further evaluation and research is needed to examine this intervention in more detail, including service user experiences and cost-benefits of implementing a mental health triage nurse intervention.

Full report available at: https://www.shef.ac.uk/polopoly_fs/1.647212!/file/YAS_Mental_Health_Triage_Report.pdf

Backround: The North Estonia Medical Centre is one of the top health care providers in Estonia. Each year, around 145,000 patients receive specialist medical care, a total of 36,000 of them are assigned to the hospital`s 1200 beds. The annual volume in the emergency department (ED) is approximately 80,000 visits. The number of ED visitis is constantly increasing over the past years. The causes for unscheduled returns to the emergency department (ED) within 72 hours of discharge at our hospidal are unclear.

Objective: To determine rate, common initial presentation and cause of unscheduled emergency department return visits within 72 hours at the North Estonia Medical Centre.

Methods: The study was conducted between 1 September 2016 and 30 November 2016. Data were abstracted from hospital electronic patient records, abstracted data included variables related to patient information, reason for visit, injury/poisoning, diagnosis and medications. The previous care variable was revised to collect data that includes three types of return visits; scheduled, unscheduled returns that are unrelated to the initial visit and unscheduled return visits related to the initial visit. For revisited patients, we identified the cause of the revisit, changes in diagnosis and/or treatment, diagnosis mistakes,  and final destination of the patient.

Results: There were 806 patients who had at least one scheduled or unscheduled 72 h return visit to the ED. These 806 patients made a total of 1781 initial and return visits, which accounted of 9.55 percent of the total number (18,655) of ED visits during the studied period.  Unscheduled visits constitute broadly half of these visits, which is comparable rate to ohter similar studies conducted in Europe and North America. The 72-hour return for admission rate, which is considered to be more critical measure was up to one third of unscheduled visits.

Discussion: The revisit rate in our ED is similar to other hospitals in Europe and North America. A relatively high percentage of revisited patients require to be admitted to the hospital. Further data analysis is needed to identify factors associated with unscheduled 72 h returns in the ED to serve as a basis for development of interventions to decrease unscheduled returns and improve quality of care and safety of patients.

More detailed data will be presented in tables and graphs.

Background: Mild knee trauma is a common reason for consultation in Emergency Department (ED). The Ottawa Knee Rules are used to determine if X-rays of the knee should be performed to find a fracture. Apart from bone injury, ligament and meniscal injury should be investigated. The diagnosis of ligament and meniscal injury of the knee is essentially on the questioning that allows to appreciate the mechanism of the trauma. As well as the clinical examination of the knee which makes it possible to test ligament and meniscal structures. In practice, evaluation of a knee trauma in the acute phase is difficult because of the painful phenomena, the functional impotence and often incomplete questioning about the fall. The objective of this study was to evaluate the initial and 1-month management of patients who had consulted for mild knee trauma in ED in order to improve their initial and post-discharge overall management. Methods: We conducted a prospective study in the Lariboisière hospital ED in Paris between February 2016 and June 2016. The patients included were any patient consulting for a mild knee trauma in ED who did not require initial surgical management or hospitalization. Patients had an initial evaluation when they were in the ED and were contacted by phone 30 days after discharge from ED for a final evaluation. The primary outcome was diagnostic concordance between initial diagnosis in the ED and final diagnosis 30 days after discharge from ED. Results: During the study period, 70 patients were analyzed. They came by their own means to the ED in 63% of the cases, following a fall (78%) with direct (50%) or indirect (50%) shock. Knee testing was performed in 69% of patients with laxity in 13% of cases. The only radiological examination performed was a radiograph of the knee in 98% of the patients. Emergency diagnosis was contusion (41.5%), ligament injury (47.1%), and meniscal injury (7.1%). Some patients were discharged from the ED with an external MRI prescription (51.4%). A clinical revaluation with a general practitioner, traumatologist or orthopedic surgeon was requested for 92.8% of patients. Finally, 75% patients were revaluated and 24% completed knee MRI. Knee MRI was justified for 60% patients showing ligament or meniscal injury. Thirty days after discharge from ED, diagnostic concordance was 52% for knee contusions, 27% for meniscal injury and 17% for ligament injury. Conclusion: Diagnostic concordance between initial diagnosis and diagnosis 30-days after discharge from ED was poor. A systematic revaluation could be beneficial for patients consulting with mild knee trauma in ED, especially when ligament or meniscal injury is suspected. The prescription of a MRI could be useful after discharge from ED if meniscal or ligament injury can not be eliminated.

Background: Antibiotic overuse has enabled growing rates of antimicrobial resistance and unneccessary adverse events. Antimicrobial stewardship programs (ASP) are effective in reducing antimicrobial use in inpatient setting. But Emergency Department (ED) is unique environment lends itself to challenges for succesful antimicrobial stewardship for outpatients. So, We want to evaluate the impact of our ASP.

Materials/methods: We performed a monocentric retrospective comparative study of all antibiotic prescriptions of patients who have been admitted to the adult ED without being hospitalized (or hospitalized les than 24H) before (Nov 2012-Nov 2013)/ after (june 2015-june 2016). Patients' files were rewied by 2 independant evaluators: an infectious disease specialist (IDS) and an ED physician. They assessed compliance of antibiotic prescriptions with national and international guidelines. Our ASP was driven by an IDS and ED physician, it included:

1) Educational course outlining ASP principles was given to ED residents every 6 months.

2) The on-call IDS was made available during regular work hours for ED consultations. ED physicians were encouraged to call him/her when uncertain about antimicrobial prescriptions.

3) One ED team member was identified as referent for antimicrobial usage and was present at everyday staff meetings. He/She raised awareness about optimized antimicrobial utilization during work hours

4) The ED physician and IDS porvided guidelines on the main infectious diseases encountered in ED. Theses guidelines were given to each resident and ED physicians as a pocket handbook

We compared the relevance and volume of antibiotics prescribed in both periods to assess the impact of our ASP.

Results:Before and after ASP, we recorded respectively 34671 vs 35925 consultations at ED, 25470 vs 26208 were outpatients. The number of antibiotics prescribed for them decreased significantly, 760 vs 580 (p<0.0001). Among these prescriptions, there was a significant decrease in non-compliant prescriptions 455 (59.9%) vs 255 (44%) (p<0.0001) of which:

- 197 (40.7%) vs 101 ( 17.4%) (p<0.001) had an unnecessary antimicrobial prescription

- 95 (19.6%) vs 54 (9.3%) (p< 0.05) had a prescription with too broad spectrum

- 87 (17.9%) vs 53 ( 9.1%) (p<0.05) had a prescription with an excessive treatment duartion.

Conclusions: Antibiotic prescriptions to outpatients in the ED are often inadequate. Thanks to ASP, antimicrobial use could be widely imrpoved, especially concerning the volume of prescribed antibiotics and prescriptions generationg the most resistances.

Objective: Demand for ambulances is growing. Nevertheless, knowledge is limited regarding diagnoses and outcome in patients receiving emergency ambulances. This study aims to examine time trends in demographic characteristics, diagnoses and mortality among patients receiving emergency ambulances.

Design: Population-based cohort study with linkage of Danish national registries.

Setting: The North Denmark Region in 2007-2014.

Participants: Cohort of 148 757 patients transported to hospital by ambulance after calling emergency services.

Main outcome measures: The incidence of emergency ambulance service patients, distribution of their age, sex, hospital diagnoses, comorbidity, and 1- and 30-day mortality were assessed by calendar year. Poisson regression with robust variance estimation was used to estimate relative risk and age- and sex-adjusted prevalence ratios for Charlson Comorbidity Index (CCI) to allow comparison of mortality rates by year, with 2007 as reference year.

Results: The annual incidence of emergency ambulance service patients increased from 24.3 in 2007 to 40.2 in 2014 per 1 000 inhabitants. The proportions of women increased from 43.1% to 46.4% and of patients aged 60+ years from 39.9% to 48.6%, respectively. The proportion of non-specific diagnoses increased during the years, whereas injuries declined. Proportion of patients with high comorbidity level (CCI>3) increased from 6.4% in 2007 to 9.4% in 2014, corresponding to an age- and sex-adjusted prevalence ratio of 1.27 (95% Confidence Interval (CI): 1.18 to 1.37). The 1- and 30-day mortality decreased from 2.40% to 1.21% and from 5.01% to 4.36%, respectively, from  2007 to 2014, which corresponds to age- and sex-adjusted relative risk of 0.72 (95% CI: 0.66 to 0.79) and 0.43 (95% CI: 0.37 to 0.50), respectively.

Conclusion: During the eight-year period, the incidence of emergency ambulance service patients, the proportion of women, elderly, and patients with non-specific diagnoses increased. The level of comorbidity increased substantially, whereas the 1- and 30-day mortality decreased.

OBJECTIVES: In a group of patients with acute respiratory failure (ARF), treated with noninvasive ventilation (NIV), we tested if an early evaluation through a validated scale, using variables easily obtained at the bedside, can identify patients at high risk of adverse outcome.

METHODS: This was a retrospective study including all patients with ARF requiring NIV over a two-year period (January, 2014-July, 2016), admitted in an Emergency Department High-Dependency Observation Unit (ED-HDU). Clinical data were collected at baseline, 1 hour, and 24 hours; HACOR score (previously employed only in patients with hypoxemic respiratory failure) was calculated before NIV and after 1 and 24 hours of treatment. For prognostic analysis, the score was evaluated as continuous value and as dichotomized value (≤5 or >5, as suggested in the validation study). The primary outcome was in-hospital mortality, need of ICU admission and NIV weaning at 48 hours.

RESULTS: The study population includes 348 patients, mean age 77±15 years, 53% male gender; 249 patients presented an hypercapnic respiratory failure. Most frequent admission diagnosis were pneumonia in 59% of patients, congestive heart failure in 34% and sepsis in 20%, which overlapped in some patients.  In-hospital mortality was 22%; 86 (25%) patients needed ICU admission while 167 (48%) patients were weaned from NIV within 48 hours. Admission SOFA score was 4.3±2.5; after 24 hours of HDU stay it decreased to 3.7±2.2. Compared with survivors, non-survivors showed  significantly higher  HACOR score before NIV (8.1±5.2 vs 6.2±4.0, p=0.006), after 1 hour (6.7±5.3 vs 3.8±3.3, p<0.001) and 24 hours (4.7±4.7 vs 2.0±2.2, p<0.001) NIV treatment; moreover, HACOR score reduction during the first hour of NIV treatment was significantly higher in survivors compared with non survivors (-2.5±3.5 vs -1.4±3.5, p=0.021). Analysis for repeated measures showed a score reduction significantly more marked in survivors compared with non-survivors (p<0.001). Compared with patients with HACOR ≤5, patients with HACOR score >5 showed a significantly higher mortality rate at every evaluation point (before NIV: 27 vs 16%, p=0.019; 1-hour: 36 vs 17%, p<0.001; 24-hour: 44 vs 17%, p=0.001).  When we took into account the end-point ICU admission and early weaning (<48H), only HACOR score after 24 hours was significantly higher in patients who were admitted to ICU (3.3±2.8 vs 2.3±3.1, p=0.021) or who needed a prolonged ventilation (3.0 ±2.1 vs 2.1±3.0, p=0.011).

CONCLUSIONS: HACOR score incorporates several variables easily obtainable at the bedside; in a population of unselected patients with acute hypoxic or hypercapnic respiratory failure, treated with non-invasive ventilation, from the beginning of treatment in-hospital non survivors showed significantly higher score values compared with survivors.    

Background:

Traumatic brain injury (TBI) is a major cause of morbidity and mortality. Hence severity scales are important adjuncts to trauma care to predict the prognosis in order to improve triage decisions and identify patients with unexpected outcomes. Traumatology scores have been investigated and found to be useful in major trauma patients. However, few studies have examined the contribution of  these scores and Prognostic scores in intensive care ICU severity scales as prognostic indicators in severe TBI.

Methods:

Retrospective study of patients 18 years and older, presenting in the emergency department with isolated severe TBI and requiring mechanical ventilation between January 2015 and January 2017. Collected variables included comorbidity data, Glasgow Coma Scale (GCS), vital parameters, imaging data, popular traumatology scores (GAP, MGAP, ISS and TRISS) and common ICU scores ( APACHE II and IGS II) at admission. Fischer exact test and T-test were used when appropriate to compare mortality groups.

Results:

Twenty-nine patients were eligible for the study. Males were represented more than femals (sex ratio = 6 ), the mean age was 42 +/- 18. The overall in-hospital mortality rate was 58%. Early mortality (<24 hours) was observed in 13.8% of cases. GCS (p=0.046; 5 Vs 7.5), APACHE II score (p=0.018; 16.56 Vs 11.52) and IGS II score (p= 0.006; 44.3 Vs 31.5) were significantly associated with overall mortality whereas TRISS, GAP and MGAP as well as age, Shock Index and the presence of brain edema at admission did not prove to be significant prognostic indicators. Elderly age (p=0.04, 60 vs 40), high glycemic level at admission ( p=0.025; 2.1 vs 1.5 g/L) , APACHE II score (p=0.018; 16.56 Vs 11.52) and IGS II score (p= 0.006; 44.3 Vs 31.5) were significantly associated with mortality occurring within the first 24 hours following admission. None of the above scores was associated with late mortality.

Conclusion:

Unlike the commonly used traumatology scores like GAP, MGAP and TRISS which did not prove to be significant prognostic factors in TBI, APACHE II and IGS II are significantly associated with early and overall in-hospital mortality. Their use in traumatology for prognostication should be investigated more thoroughly in future studies.

Background:

Traumatic brain injury (TBI) is one of the leading causes of death in traumatology. It is a very common pathology with a high mortality rate that usually affects young healthy individuals. Identifying patients who may progress to a poor clinical short-term outcome will encourage earlier therapeutic interventions in the emergency department.

Methods:

Retrospective study over 2-year period that included all patients aged 18 or more, presenting with isolated severe TBI and requiring mechanical ventilation. Demographics and comorbidity data, Glasgow Coma Scale, vital parameters, glycemia at admission and imaging data were collected. , popular traumatology scores (GAP, MGAP, ISS and TRISS) and common ICU scores ( APACHE II and IGS II) at admission were calculated. Fischer exact test and T-test were used when appropriate to compare short-term mortality group.

Results:

Twenty-nine patients were eligible for the study.  Mean age was 42 +/- 18 [16 – 82] and the sex ratio was 6. Two patients (6%) had diebetes history. %. Short-term mortality (<24 hours) was observed in 13.8% of cases. Advanced age (p=0.04, 60 vs 40), high glycemic level at admission ( p=0.025; 2.1 vs 1.5 g/L) , APACHE II score (p=0.018; 16.56 Vs 11.52) and IGS II score (p= 0.006; 44.3 Vs 31.5) were significantly associated with mortality occurring within the first 24 hours following admission. GCS of 3 at presentation, presence of bilateral fixed or dilated pupils, stress-induced hyperglycemia (non diabetic hyperglycemia) and presence of mass effect or early brain edema on initial computed tomography, traditionally associated with worse TBI outcomes were not significantly associated with short-term mortality in our study. Popular traumatology scores such as TRISS, GAP and MGAP as well as Shock Index did not prove to be significant prognostic indicators in severe TBI .

Conclusion:

Hyperglycemia, advanced age and high levels of APACHE II and IGS II scores are indicator of poor early outcome in severe and isolated TBI in the emergency department. 

BACKGROUND:Severe pneumonia remains a major cause of death. Acute respiratory distress syndrome (ARDS) and pneumonia are closely correlated in the critically ill patient and ARDS was described as an independent predictor factor of mortality in case of pneumonia. Recent research suggests that host factors have a major bearing on the development of ARDS. Other studies suggest sepsis as the principal link between pneumonia and ARDS. The aim of the study was to identify factors that predict the occurence of ARDS during severe pneumonia. 

METHODS:

Retrospective study over 2-year period that included patients 18 years and older, presenting in the emergency department with severe pneumonia diagnosis. ARDS was defined with the Berlin criteria. Fischer exact test and T-test were used when appropriate to compare ARDS group.

RESULTS: N=24.The mean age was 69 + 14 years with a sex ratio of 2. Medical history: hypertension (29,8%), diabetes (37,7%) and tobacco (60,9%). chronic respiratory failure (33,3%), chronic heart failure (12,5%), immunosuppression (32%), patients had cumulated more than three comorbidities in 46 % of cases. The mean PSI score was about 124 +39, class V: 43,5%, the CURB 65 score was greater than or equal to two in 74% of cases, the mean value of APACHE II score was 32,  IGS II score was 69  and SOFA score was 11. The only Predictive factor of ARDS was the presence of immunosuppression (p=0,01) and the APACHE II score was correlated with the risk of development of ARDS  (p=0,000; 24 vs 14). The sepsis was not a predictive factor for the occurence of ARDS during severe pneumonia in this study.   CONCLUSION: The pulmonary infection is the most frequent cause of ARDS. Immunosuppression seems be the principal predictive factor in the occurrence of ARDS in severe pneumonia patients. The APACHE II score was correlated with the risk of development of ARDS and his use in pneumonia patients for severity and prognosis assessment should be investigated more thoroughly in future studies.

Background:

Diabetic ketoacidosis (DKA) is a frequent acute metabolic complication of diabetes mellitus. Cerebral edema (CE) is a rare therapeutic complication but it is known as the major cause of mortality and long-term morbidity in DKA patients, especially in children and young adults. Until yet, the mechanism of this severe complication remains poorly understood and guidelines for management of DKA can never be considered entirely safe.

Purpose:

To describe the incidence of CE after standardization of DKA therapy according to the recommendations of American Diabetes Association (ADA) published in 2009.

Methods:

Prospective descriptive study over 2-year period including patients aged > 16 years admitted to the emergency department for moderate to severe DKA. Standardization of DKA management occurring to ADA recommendations: fluid replacement, insulin therapy and replacement of electrolytes.

Cerebral edema was defined as deterioration in conscious level with imaging, histopathological or therapeutic confirmation (improvement after osmotherapy or assisted ventilation)

Results: 

We enrolled 106 consecutive DKA patients. The mean age was 36+/-16.5 years with a sex ratio of 0.63. Medical history, N (%): type 1 diabetes, 61 (57.5); type 2 diabetes, 31 (29.3); inaugural, 14 (13.2). Usual treatment, N (%): insulin, 90 (81.1); biguanides, 8 (7.5); sulfonylureas, 8 (7.5). Time to glucose control was 6.5 +/- 4 hours, time to resolution of acidosis was 13 +/- 7 hours, insulin dose to recovery was 66 Units (0.95 U/Kg). The length of stay in intensive care unit was 29 hours and mortality rate was 0.9%.Therapeutic complications were (N;%): hypoglycemia (58; 54.7), hypokalemia (21; 19.8) and Hyperchloremic acidosis (27 ; 25.7). No case of cerebral edema was documented during this study.

Conclusions:

Using the DKA standardized protocol improved several clinical outcomes with reducing time to resolution of acidosis and length of stay in intensive care unit and understating the incidence of fatal complications especially cerebral edema.

Intoduction:

Chronic obstructive pulmonary disease (COPD) is the fifth cause of morbidity and mortality worldwide. Exacerbation of COPD is a sustained worsening of the patient's condition.The Global initiative for chronic Obstructive Lung Disease (GOLD) 2016 is the main recommendations document for diagnosis and management of COPD exacerbations.

The aim of our study was to evaluate the management of patients admitted to the emergency department (ED) for COPD exacerbations using international guidelines.

Methods:

Prospective observational study over four months period. Inclusion of adult patients admitted to the ED for COPD exacerbations. Collection of epidemiological, clinical and para-clinical characteristics. Treatment management was standardized using GOLD2016 guidelines. All the medical staff was asked to carry out the same protocol.

Results:

Inclusion of 198 patients. Mean age: 67±11 years. Sex ratio = 3.95. Comorbidities n(%): hypertension 39(20), diabetes 33(17), tobacco 137(69), atrial fibrillation 15(8), dyslipidemia 13(7), chronic heart failure 11(5). ABCD classification of COPD n(%): C group 19(10) and D group 112(64). COPD Assessment Test more than 10 n(%):  145(81). Symptoms n(%): cough 148(76), dyspnea 140(71), sputum production 138(72), asterixis6(3) and cyanosis10(5). Physical examination n(%): wheezing 150(75), crepitates27(13,5%) and CPC 6(3)

Short-acting inhaled beta2-agonists (SABA) were prescribed in 158 patients (80%). Nineteen patients (10%) had short-acting anticholinergics bronchodilators in addition to the SABA. All patients received systemic corticosteroids (mode of administration n(%): oral route 131(66) and intravenous 67(34)).

Non-invasive ventilation was required in 37 patients (19%). Six percents (n=12) of patients were admitted to the intensive care unit for mechanical ventilation.

Main causes of exacerbations n(%): infection 74(38), treatment cessation 46(23), acute heart failure 17(9) and pulmonary embolism 12(6).

CONCLUSION:

The goal of treatment in COPD exacerbations is to minimize the impact of the current exacerbation and to prevent the development of subsequent exacerbations. A protocolized protocol at the ED helps to improve management and thus to decrease complications.

Background: Noninvasive ventilation (CPAP/NIPPV) is widely used to treat acute respiratory failure (ARF) in the Emergency Department (ED). Its use seems challenging also for patients who are not eligible for endotracheal intubation (ETI) both to treat ARF due to reversible causes and to relieve symptoms in end stage ARF. 

Methods: INVENT (Italian Noninvasive Ventilation in Emergency National Trial) is an observational prospective multicentric study whose aim is to outline the use of CPAP/NIPPV in Italian Emergency Departments. It involves 19 EDs and it is promoted by the SIMEU (Italian Society of Emergency Medicine) Study Center. Enrollment started in May 2015 and went on until February 2017. Data about patients treated with CPAP/NIPPV during four weeks/year, one for season, were collected.

We focused on the subgroup of patients for whom ETI was considered not indicated (Do Not Intubate: DNI) to outline the main features of DNI patients and to analyse the impact of DNI status on hospital mortality. 

Results: among 245 patients, 72 were considered DNI (29,3%). Patients with a DNI status were older (78,5±12,6 vs 73,2±13,7 years, p:0,004) and were more likely to have dementia (25,0%vs 8,2%, p<0,001) and solid tumours (31,9% vs 8,8%, p<0,001). They were less likely to have COPD (36,1% vs 56,7%, p:0,003), diabetes (18,7% vs 35,7%, p:0,012) and obesity (10,0% vs 22,9%, p:0,021). DNI patients were more likely to have ARF due to pneumonia than other causes (33,3% vs 13,5%, p<0,001).

Hospital mortality was higher in the DNI group (34,7% vs 14,6%, p<0,001). 

Among patients with a DNI status, the dead  had higher lactate levels (7,2±11,1vs 2,8±3,7, p: 0,022), lower diastolic blood pressure (DBP) levels (69,4±14,7 vs 78,8±19,2, p:0,025) and were less likely to have history of COPD than the dead. No ARF cause significantly affected hospital mortality. In the first hours of treatment, survivors showed an improvement of: DBP (77,9±19,6 to 71,1±13,0 mmHg, p:0,011), respiratory rate (RR) (29,9±6,4 to 24,7±6,7 bpm, p<0,001), pH (7,31±0,11 to 7,36±0,09, p:0,001), paCO2 (62,6±23,7 to 55,2±20,9 mmHg, p:0,001), paO2 (64,9±32,8 to 100,6±61,9 mmHg, p:0,001). 

Conclusion: DNI patients represented almost one third of those treated with CPAP/NIPPV for ARF in the ED, according to our data. They have higher hospital mortality and they are more likely to have ARF due to pneumonia. Dementia, solid tumours and an older age correlate with DNI status, while COPD patients are more likely to be not-DNI. Among DNI patients, higher lactate levels  and lower DBP levels correlate with survival rate. 

Although hospital mortality is higher in DNI patients, CPAP/NIPPV seems to be appropriate to treat ARF and to relieve symptoms of dyspnoea

Background: Noninvasive ventilation (NIV) is widely used to treat acute respiratory failure (ARF) in the Emergency Department (ED), in particular in acute cardiogenic pulmonary edema (ACPE) and  acute exacerbation of chronic obstructive pulmonary disease (AECOPD); its use has been described for other pathologies, such as pneumonia, pulmonary contusion or neuromuscular disorders, though evidence about these indications is still controversial.

Methods: INVENT (Italian Noninvasive Ventilation in Emergency National Trial) is an observational prospective multicentric study promoted by the Italian Society of Emergency Medicine (SIMEU) Study Center and involving 19 Italian EDs. it’s aim is to describe the reality of NIV use in Italian Eds, considering both Continuous Positive Airway Pressure (CPAP) and Non-invasive Positive Pressure Ventilation (NPPV). Patients treated with NIV were enrolled during 7 periods lasting one week from may 2015 to February 2017, 1 period for every season.

Results: We collected data from 245 patients, 138 males (56,3%), average age 74,8±0,87 years.

The indication for NIV was ACPE in 67 patients (27,3%),AECOPD in 56 (22,9%), pneumonia in 47 (19,2%), neuromuscular disorders in 6 (2,4%). 45 patients (18,3%) were treated because of a mixed indication: 13 (5,3%) had ACPE and AECOPD, 14 (5,7%) had ACPE and pneumonia and 18 (7,3%) had AECOPD and pneumonia. 47 patients (19,2%) were treated with NIV because of a mix of other pathologies. 

The initial modality of ventilation chosen was CPAP in 65% of patients with ACPE, 17,6% of patients with AECOPD, 51,9% of patients with pneumonia, and 1,67% of patients with neuromuscular disorders. The other patients were started firstly on NPPV.

The preferred interface using CPAP was the oronasal mask (66,4%), followed by the Helmet (33,9%), the full face (4,4%) and the nasal (0,9%) masks. For NIPPV the oronasal was still the most used interface (75,7%), followed by the full face mask (24,3%). In a few patients more than one device was used due to intolerance. CPAP was stopped because of intolerance in 10 patients (10,2%), while NIV in 11 patients(7,5%). Sedation was needed in 28 patients (11,4%).

19 patients (7,8%) underwent endotracheal intubation.  72 patients (29,4%) were considered not eligible for endotracheal intubation (DNI) by the treating physician.

Overall in-hospital mortality was 20,4% (50 pts), while it was 16,3% in ACPE patients (15/92), 10,6% in AECOPD patients (9/85), 31,2% in pneumonia patients (24/77) and 33,3% in neuromuscular disorder’s patient.

Conclusion: NIV is used in Italian EDs for many pathologies. CPAP is preferred in patient with ACPE, while NPPV is the ventilatory support of choice in AECOPD. The preferred interface in our study was the oronasal one. The mortality rates are consistent with the value found in literature.  These are preliminary data of an ongoing study, further investigations are needed to investigate this topic.

Intravenous Lipid Emulsion Treatment: Review of the effect on Lipophilicity

Background: Although the action mechanism of intravenous lipid emulsion has not been fully elucidated yet, its use in liposoluble drugs intoxications. Mechanism of effect is suggested that lipid sink theory, cardiotonic effect and positive inotropic effect by increasing the calcium level via the calcium channels. The aim of this systematic review is to investigate the relationship with the lipophilic feature (log p values) of drugs and the success rate of ILE therapy in poisoned patients.

Methods: We reviewed 765 cases published in PubMed between 1966 and June, 2015. After applying exclusion criteria, totally 141 cases ingested single substance and received ILE therapy with 20% ILE solution were included in present study. Amount of lipid solutions given and the results were recorded. Success rate was statistically assessed according to log p values of the substances taken and the amount of lipid emulsion used.

Results: 141 patients were involved in this study; log p values were calculated for all drugs regardless of the success of ILE therapy. Amount of ILE therapy given was ≤500 mL in 87 (61.7%) (≤100 mL in 14 (9.9%)) and >500 mL in 54 (38.3%) of the cases. The success rate was 85.1% in patients received ILE therapy≤500 mL, whereas the same rate was 92.6% in patients that received ILE therapy>500 mL. There was no significant difference between groups received ILE therapy≤500 mL or >500 mL (p=0.142). When amount of lipid emulsion given was below 500 mL (1-500 mL), the log p value, especially the ALOGPS and ChemAxon data, becomes more important. In cases that received ILE therapy≤500 mL, the ALOGPS and ChemAxon log p values were higher in the group with successful outcome than those observed in cases, in which ILE therapy was failed (p values are 0.043 and 0.008). In addition, Experimental log p value was higher, indicating a trend towards statistical significance (p=0.071). Thus, we can argue that log p value has significant effect on treatment success when amount of lipid emulsion is equal or below 500 mL. But, there is no significant effect of treatment outcome when amount of lipid emulsion is higher than 500 mL

ILE therapy under the amount of 100 mL failed to achieve successful outcome. ALOGPS and ChemAxon log P values were higher in cases, which received ILE therapy ≤500 mL and showed successful results. It was found that log p value had no contribution to the treatment success in the group received ILE therapy >500 mL.

Conclusions: It was found that ILE therapy500 mL, and that liposolubility had no significant contribution to treatment success. It could be thought that additional action mechanisms other than lipid sink phenomenon are more active in ILE therapy.

Background: Recently, the number of ambulance dispatches has been increasing in Japan and it is, therefore, difficult to accept emergency patients to hospitals smoothly and appropriately because of exceeding the hospital capacity. To facilitate the request for patient transport by ambulance and hospital acceptance, the emergency information systems using information technology (IT) has been built up and introduced in various communities. However, its effectiveness has not been insufficiently revealed in Japan. Herein, we developed a smartphone application system that enable the emergency medical service (EMS) to share information about ambulance and hospital situation in 2013. The aim of this study was to assess the implementation effect of this application for EMS system in Osaka City, Japan.

Methods: This study was a retrospective study with population-based ambulance records of Osaka Municipal Fire Department. This study period was six years from January 1, 2010 to December 31, 2015. In this study, we enrolled emergency patients that on-scene EMS personnel conducted the hospital selection for them. The main endpoint was difficulty in hospital acceptance at the scene. The definition of difficulty in hospital acceptance at the scene was to make >=5 phone calls by EMS personnel at the scene to each hospital until a decision to transport was determined. The definition of using smartphone application is the period of 2013-2015 after the introduction of this application since in 2013, and we assessed the effect of using smartphone application with multivariable logistic regression model.

Results: A total of 600,526 emergency patients who EMS personnel selected hospitals were eligible for our analysis in this study. There were 300,131 cases (50.0%) without using the smartphone application in 2010-2012 and 300,395 cases (50.0%) with using the smartphone application in 2013-2015. The proportion of the difficulty in hospital acceptance without using smartphone application was 14.2% (42,585/300,131) and that with using smartphone application was 10.9% (32,819/300,395), and the difficulty in hospital acceptance significantly decreased by the introduction of the smartphone application (adjusted odds ratio; 0.730, 95% confidence interval; 0.718-0.741, P<0.001).

Conclusion; Sharing information between ambulance and hospital by using IT was associated with decreasing the difficulty in hospital acceptance. Our findings may be considerable useful for developing emergency medical information system with IT in other areas of the world.

Motivation of employees in pre-hospital and in-hospital emergency care in Bulgaria.

Desislava Katelieva MD, phD; Lora Georgieva MD, phD, ass.prof.

Key words: emergency care, Bulgaria, motivation

Background: The shortage of personnel in emergency care in Bulgaria is a serious problem. Regardless of subsequent wage increases in recent years, the system has a fluctuation and insufficient number of specialists.

Methods: A research was conducted by semi-structured questionnaire in 2016 to identify attitudes, reasons for leaving or staying in the system. The data was processed by descriptive statistics, nonparametric chi-square test, correlation analysis (Spearman's coefficient) and regression analysis (linear regression). The study involved 291 participants: 149 (51,2%)  of outpatient care centers and 142 (48,8%) from emergency departments. The average age of respondents was 47,7 +/-9,2 years. According to their qualification the participants were: 97 physicians (33,3 %); 76 feldshers (26,1%); 93 nurses (32,0%) and 25 drivers (8.6%).

Results: 210 of the respondents (72,2%) do not intend to leave – 66,7% of whom like their job, and 5,5% cannot find professional realization elsewhere. Respondents who intend to leave state as reasons: their intention to work outside of medicine (6,6%); to work abroad (9,6%); to work in another medical facility (8,95%). The leading motive for staying in systems is the satisfaction of saving a human life for 190 (65,3%) of those surveyed, followed by free time between shifts-178 (61,2%) and reduced working time - 114 (39,2%). According to 232 (79,7%) salary is not a motivating factor to work in the system of emergency aid. According to 244 (83,3%) of respondents career development opportunities are not satisfactory. A statistically significant difference between satisfaction with career development and qualification of the respondents (chi² = 2,410, p = 0,566) is not established. As possible incentives to remain in the system of emergency aid respondents indicate: measures to restrict aggression (67,4%); the introduction of clear rules (60,1%); more opportunities for further training (59,1%); the introduction of triage (51,5%).

In recent years, emergency teams are increasingly subjected to physical and verbal aggression. Among the respondents, 81,1% were subject to physical aggression, while 93,5% - to verbal aggression. Mostly physicians are victims of physical aggression (r = 0,153, p = 0,009). A causal link between the frequency of unfounded calls and surveys and frequency of physical aggression (B =-0,349, p = 0,001) is found through linear regression.

Discussion: In order to solve the problem with staff fluctuation and shortage of specialists in emergency assistance, it is essential to seek the reasons behind their departure. The motivation factors include: decent pay, good working conditions, measures against the physical and verbal aggression, and opportunities for career development.

Application of telemedicine in prehospital emergency care in Bulgaria

Desislava Katelieva MD, phD; Atanas Mitkov MD; Dimitar Shandurkov MD

Keywords: telemedicine, telemedicine consultation, Center for outpatient emergency care

Background: The lack of nearby hospitals and doctors in Bulgaria, requires the introduction of telemedicine in emergency care. In January 2014 a pilot project was launched to introduce a multifunctional system monitoring, defibrillation and telemedicine in remote, hard-to-reach regions, operated by emergency crews without a doctor. This device has an integrated defibrillator and monitor of the vital indicators (the blood pressure, pulse, O₂, CO₂, body temperature), transmitted in real time over the Internet to the Center for telemedicine consultation. The pilot project starts with a peripheral device, used to train teams in Krumovgrad. The consultations are carried out by physicians in the coordination headquarters of outpatient emergency aid. The Ministry of health has purchased the first two peripheral devices for out-patient centers of emergency in Krumovgrad and Ardino in February 2015

Metods: Analysis of telemedicine consultations was carried out in Krumovgrad according to age, gender, the need to set hospitalization and diagnoses of patients for the period 22.02.2015. - 22.02.2017. The center for outpatient emergency aid in Krumovgrad covers 19907 people on a territory of 843 km². and is situated 47 km. from the regional hospital.

Results: A total of 135 telemedicine consultations for patients (65% are male and 45% female) were conducted for the research period. According to their age patients are: children-1 (0,2%); young people up to 30 years - 3 (2,2%); people with an average age of 30-60 years- 43 (32%) and over 60 years- 88 (66%). The diagnoses set after consultations, are mainly cardiac – ACS 27 (17%); pulmonary tromboembolism 7 (5%); rhythm-conduction disorders 26 (19%); arterial hypertension 34 (25%); respiratory failure 19 (14%) and clinically healthy 22 (16%). After consultation with physicians the emergency teams hospitalized 34 patients (25%). Telemedicine consultations during the first year were only 36, and in the second year they have increased 2,7 times. The relative amount of hospitalizations during the first year was 28%, in the second year decreasing to 24% due to increasing telemedicine consultations.

Discussion: After positive experiences from Krumovgrad, in September 2015 the State equipped more than 18 outpatient center with 22 new peripheral devices for telemedicine. Unfortunately a single center for telemedicine is still missing. The increase in emergency teams without doctor requires the application of medical control over their activities. A good and secure communication between emergency teams and doctors in hospitals is needed. Telemedicine guarantees patients, served by a team without a doctor, with competent and timely physician advice and reduces hospitalizations.