Objectives

On November 8, 2013, the central Philippines islands were struck by typhoon Haiyan (Yolanda), damaging many local hospitals and disrupting acute and regular healthcare. The Belgian First Aid and Support Team erected a type 1 field hospital and water purification unit in Palo (south of Tacloban) to temporarily replace the damaged local healthcare. This study aims to describe the diagnoses encountered, and treatment provided by the Belgian team. Hypothesis is that besides disaster-related trauma, medical problems emerge soon, emphasising the importance of an appropriate composition of Emergency Medical Teams and their supplies.

Methods

Using a descriptive observational study design, all patients presenting to the Belgian field hospital were retrospectively reviewed. Each patient had an individual paper medical record that included gender, age, triage chief complaint, all secondary complaints, diagnosis, management and possible referral information. These were compared with a control group of patients from the same area and season, but from another year.

Results

All 1267 patients triaged, examined and treated in the field hospital, were included and analysed. Almost 28% suffered from injury, but the most important part of patients rather presented with medical diseases (64%), particularly respiratory (31%), dermatological (11%) and digestive (8%). The remaining 8% presented for follow-up, mental problems or pregnancy related issues. Most (53%) of the patients did not present with direct disaster-related acute pathology. More than 59% showed signs of infection within two weeks after the event. Most frequently used treatments were wound care (47%), pain relief (33%), vitamins and minerals (31%) and antibiotics (29% of all patients). Procedures were needed for 9%, fluid therapy for 8%, and psychological support for 5%. Logistic regression analysis indicates that children younger than 5 are more at risk for infectious diseases (OR 18.8 CI 10.6-33.3), and for injury (OR 10.3 CI 6.3-16.8), and males are twice more prone to be injured than females (OR 2.1 CI 1.6-2.6).

Conclusions

These results reveal that one week after the acute phase of a typhoon, respiratory, dermatological, and digestive problems emerge to the prejudice of trauma. Most patients did not present with direct disaster-related but with less acute diseases. Young children are more at risk for injury and infectious diseases. These facts should be anticipated when composing Emergency Medical Teams and supplies to be sent to the disaster site. 

Purpose: To examine what roles bystanders and volunteers can play during a disaster and to propose an action card for the (medical) incident commander to manage this often unutilised resource of manpower and knowledge.

Relevance: During the terrorist attacks in Brussels on March 22^nd 2016 the advantages as well as the problems with bystanders and volunteers during disasters were encountered. Many lives were saved by bystanders by using simple bleeding control techniques and the application of tourniquets. Among the bystanders there were soldiers patrolling the national airport. Their knowledge of lifesaving first aid (e.g. the use of tourniquets), extrication and triage proved pivotal in the first aid rendered to the victims.

However there were also unsolicited medical volunteers arriving with unauthorised private ambulances who became more a liability than a fruitful resource. Drawn to the scene out of curiosity and desire to help, not only were they unfamiliar with the Incident Command System (ICS), but because of the fact they were not registered in the regular EMS system they didn’t have the appropriate means of communication and started freelancing in deciding what to do on site and where to take victims in unregistered ambulances.  

An updated version of a national medical emergency plan was recently published. Being updated with the terrorist attacks in mind, it still fails to recognize bystanders as first aid providers.

Methods: Review of existing literature and unstructured interviews with medical personnel who volunteered during the aftermath of the Brussels Airport attack and the national EMS director.

Results: It is a certainty that (untrained) bystanders are the first providers of help during disasters. During the Brussels attacks we have seen the benefits of bystanders performing lifesaving bleeding control techniques, extrication of entrapped victims, transportation of casualties away from the blast sites and comforting victims.

All too often bystanders and volunteers at a disaster site remain unused and kept outside a perimeter upon arrival of EMS services and police and a clear guideline on how to integrate bystanders and volunteers was and still is lacking in any existing medical emergency plan. However, coordination of highly motivated bystanders and volunteers by professional EMS personnel had a positive effect on reducing morbidity and mortality in the Brussels attacks.  

Conclusion:  Because regular EMS is initially disrupted, bystanders and volunteers can aid in immediate search and rescue and first aid to victims. Instead of discouraging, their desire to help should be encouraged and planned for in emergency plans. To reduce the risk of untrained bystanders and volunteers disrupting the official organised response an action card to aid onsite incident managers is proposed.

Introduction

When working with infectious diseases of high consequences the simple act of donning/doffing Personal Protective Equipment (PPE) becomes a lifesaving procedure not only for the medical staff but for the thousands of people who depend on them. Previous studies have shown that donning and doffing skills may be insufficient even after training. That raises a question on how to properly train staff in PPE donning and doffing to maintain the long term competence of PPE donning and doffing?

This study assessed if there is a performance difference one month after training between a control group that received instructor training and a study group that had access to a video over the month to compare the traditional tutorial based teaching method in teaching PPE donning and doffing.

Methods

This was a randomized controlled trial pilot study of video versus instructor training. 21 medical students and junior doctors where divided into 2 groups by simple randomization. The control group received training with an instructor. This training involved a demonstration of donning and doffing of PPE. Students were then observed donning and doffing of PPE until satisfactory performance had been achieved. There was no other intervention until the day of the assessment. The video group watched a training video demonstrating proper donning and doffing. The video group was given the video to watch at home as many times as they wanted. The training video was made by the same nurse who conducted the instructor training, using the same equipment. After a 1month period, a doctor performed a blind evaluation of all control and study groups using an adjusted Donning and Doffing PPE Competency Validation Checklist 2014.

Results

19 participants attended assessment session after a month with 9 in a control group and 10 in the study group. The mean donning score was 86,5/100.  Mean score was 84,8 for the instructor group, and 88.0 for the video group.There was no statistically significant difference in the donning score between the video and instructor group (95% confidence interval for the effect: -7.7 to 9.5; p-value: 0.54). The mean doffing score was 76,4/100. The mean score for instructor group was 79.1 and 73,9 for the video group. There was no significant difference in the doffing score between the video and instructor group (95% confidence interval for effect: -7,6 to 18,0; p-value: 0.54).

Conclusion

The study results suggests that donning and doffing competencies are similar for those who were trained with an instructor to those who were trained with the video method.

Objective: To find out if a table-top team training program would positively affect perception towards teamwork, and their ability to recognize the presence and quality of team skills in disaster events.

Background: Disaster training involves coordination and communication between various units, which necessitates involvement of the whole chain of response simultaneously. Due to the strict hierarchy culture in Korea, it is not easy to train healthcare providers in teamwork. Hospitals in Korea performs large-scale disaster exercise which takes a lot of preparation and resources. It is also difficult to assess teamwork and communication during a large-scale disaster exercise. Table-top simulation enables you to look at the whole process and the advantage of reflective, repetitive, and safe learning environment, where effective feedback can be provided. Since table-top simulation allows people to go through the thinking process, this could be a good module to train people improving on teamwork competency.

Methods: The educational intervention consisted of a half-day workshop for selected 24 emergency residents and 24 emergency nurses. Participants were given lectures on incident command system and surge capacity. They were randomly mixed into 6 groups (8 participants per group, 4 residents and 4 nurses). Participants were assessed as a group before and after the intervention, which consisted of debriefing session, focusing on the 5 components of teamwork (Team Structure, Communication, Leadership, Situation Monitoring, and Mutual Support). Discussions were focused on breaking the barrier of hierarchy in a crisis situation. The correct number of triage, treatment, and teamwork aspects were assessed. Assessment of teamwork was done in two parts. One was self-assessment of perception of teamwork, the Teamwork Perceptions Questionnaire (TPQ), and the other was assessment of the team performances, the Team Performance Observation Tool (TPOT). Both tools were derived from the TeamSTEPPS^® Project (5-point Likert scale). They were modified to fit our culture and translated to Korean. Content validity index was performed (0.94). All pre-to-post differences within subjects were analyzed with paired t tests. The statistical level of significance was set at 0.05.

Results: Correct triaging and treatment improved after training with table-top simulation. Under triaging improved as well, but over triaging seemed to increase. Pre- and post-intervention differences for the 5 sections of the TPQ and TPOT improved. All results were statistically significant (p<0.05).

Conclusion: Teamwork and communication has cultural different aspects. Therefore, carefully planned curriculum tailored to the trainees, and debriefing session including discussion on cultural aspect is important when training for teamwork. Table-top exercise can positively affect perception toward teamwork, and their ability to recognize the presence and quality of team skills in disaster events.

INTRODUCTION

Well-prepared humanitarian workers are now more necessary than ever; simulation-based training and evaluation are essential for the preparation process. This study aimed to assess the efficacy of a training program developed by the Research Center in Emergency and Disaster Medicine (CRIMEDIM) in collaboration with the international organization Médecins Sans Frontières (MSF) to professionalize senior residents in humanitarian assitance.

METHODS

The first three levels of the Kirkpatrick’s evaluation model (Reaction-Learning-Behaviour) were assessed.The 8 participants of the third course edition (4 residents in emergency medicine, 3 in anaesthesia and 1 in pediatrics) were enrolled in the study; the median age was 31. Residents participated in an introductory phase, completed a 3 month e-learning course, attended a residential week and were deployed with MSF in Pakistan (1), Afghanistan (2), Democratic Republic of Congo (1), South Sudan (1), Central African Republic (2) and Yemen (1). Reaction was assessed through a Likert scale questionnaire. The three dimensions of Learning were evaluated separately through a pre and post test as follows: a multiple-choice test was used to assess knowledge, a Likert scale questionnaire was used to evaluate attitudes, and simulation-based performance tests (using the Ottawa Global Rating Scale-GRS) were used to assess skills. Total multiple-choice scores and GRS overall performance scores were considered as primary and secondary outcomes, respectively. Differences were assessed using paired t-­tests. P ­values of less than 0.05 were considered significant. Behaviour was assessed qualitatively at the end of students’ missions by their field supervisors through the MSF standard evaluation module. Supervisors were blind to the students’ participation in the training program.

RESULTS

Reaction: the delivery modality and residential course were highly appreciated. The average median score for the overall course was 5 (excellent). Knowledge: there was a significant improvement in the post-test multiple choice scores when compared to the pre-test scores (p = 0.0011). Skills: there was a significant improvement in the overall performance score (P = 0.000001). No differences were detected in attitudes scores. Behaviour: for most participants the following strengths were highlighted: compliance with MSF standards and principles, flexibility, good team working skills and cross-cultural sensitivity.Their professional competence was never questioned. All residents were recommended for future MSF missions.

CONCLUSIONS

Residents were highly satisfied with this training program and their knowledge and skills in low-resource simulated humanitarian environments improved after participation in the course. The implementation of this project represents a model of how academia can successfully partner with humanitarian aid organizations to increase professionalization within the humanitarian health sector.

Study/Objective:

To quantify the frequency and intention with which “stampede” is used to describe types of mass gathering disasters

Background:

Hazard vulnerability analysis would identify “human stampedes” as high probability events at mass gatherings. Over 200 “stampedes” have occurred in the past 30 years. At the 2015 Hajj, at least 2000 pilgrims died in one of the deadliest mass gathering disasters in recent history. News and literature referenced the event as the “Hajj Stampede”, implying abruptly increased speed and mass panic.  At the crux of many of these events, however, is a dense, immobile crowd – not the uncontrolled mindless mass implied.

Methods:

The authors performed a systematic search of peer reviewed literature indexed in PubMed, EMBASE, and Web of Science. Studies were limited to human studies using the keyword stampede. Gray literature using “stampede” in the title or abstract in reference to mass gathering disasters were also reviewed.

Results:

Search strategy using the term “stampede” yielded 649 articles. After excluding those using the term 1) apropos computing, 2) as an acronym, or 3) colloquially, 61 remained which used the term in reference to mass gathering disasters. 29 of 61 articles describe a slow-moving, highly dense crowd. 12 articles cite sudden mass movement as the main trigger for the referenced disaster. The remaining 18 described both slow-moving crowds and sudden mass movement. Only three articles distinguished between crowd disasters caused by sudden movement and high density. Overall, “Stampede” was used in the same context as “crowd disaster”, “turbulence”, “quake”, “mass panic”, “crush”, and “trampling”.

Discussion:

It is important to distinguish between stampede and non-stampede events for the benefit of survivors and for mitigation strategies. Few articles describing stampedes actually involve speed anywhere in the description. The generic “stampede”, through suggesting a fast moving, irrational and culpable crowd, focuses on herding the masses rather than improving safe access or egress routes to the gathering site. We must stem the notion that these disasters are a whim of the crowd and work towards evidence-based engineered solutions. 

Introduction: Nurses can be confronted with disasters and the care for the patients resulting from these incidents, be it in - or prehospital or in their own environment. Are they educated to do so? Following worrisome results in a survey on this subject amongst medical students our study hypothesis is that nursing students aren’t educated at all.

Material and methods: To evaluate disaster education in Flemish nursing students an online survey on Disaster Medicine, training and knowledge and willingness to report was sent to students in the last year of basic nursing training. This reported knowledge was tested by a mixed set of 10 theoretical/practical questions. A similar survey was sent to students in the Bachelor-after-Bachelor (BAB) specialisation year of Emergency Medicine and Intensive Care.

Results: Preliminary results from the first responding educational basic training centers reveal a M/F ratio of 13/87 with 29% that state that they have had any disaster training what so ever. 25% state to have some knowledge on CBRN incidents. 42% are convinced that a basic training on disaster management should absolutely be included in the basic nursing curriculum. None of the respondents found it useless. Estimated knowledge on several disaster scenarios varied from 1.92/10 (dirty bomb) over 2.24/10 (nuclear) and 3.49/10 (Ebola) to 4.05/10 in highly contagious influenza pandemic. Self-estimated capability to deal with these incidents varied from 2.22/10 (dirty bomb) over 2.59/10 (nuclear) and 3.54/10 (Ebola) to 4.14/10 in mass shooting incidents. Willingness to report to work in these incidents was much higher and varied from 7.19/10 (dirty bomb) over 7.41/10 (Ebola) and 7.56/10 (nuclear) to 7.94/10 in mass shooting incidents. Some topics of the theoretical / practical case mix raise some concern. 64% directs potentially contaminated patients direct into the emergency department. 75% believes that iodine tablets protect against external radiation and 37% would use them as the first step in nuclear decontamination. 37% believes that chemical decontamination consists of a total body antidote spray in a civil defence cabin and only 20% would use a shower with water and soap. Up to 47% would rush unprotected into a traffic accident scene with active leakage from a tanker truck. Self-reported knowledge and capability in the BAB group did not differ from the basic students and also the willingness to report was similar. They had however a better score on the theoretical / practical case mix.

Conclusion: Our data support the hypothesis that Flemish nursing students are ill-educated in disaster management. Despite low estimated knowledge and capability there is a high willingness to report.

In the context of the current European refugee crisis, at the Geneva University Hospitals (HUG) the languages which caused most problems were in 2016 Tigrinya, Arabic and Farsi. Several researchers pointed out serious problems of quality, security and equitability when no communication is possible between the doctor and his patient. BabelDr (http://babeldr.unige.ch/) is a common project of Geneva University's Faculty of Translation and Interpreting (FTI) and HUG which aims at facing this problem. The BabelDr application is a flexible speech-enabled phrase-book. The linguistic coverage is organised into domains, centered around body parts (abdomen, chest, head, kidney). Each domains has a limited semantic coverage consisting of 2000-2500 canonical sentences, but users can use a wide variety of surface forms when speaking to the system. The translation is not automatic; the canonical forms are translated into the target languages by translation experts from the FTI, which guarantees the quality of translation. At runtime, the system matches the spoken doctor’s utterance to a canonical sentence and echoes it back to the source-language user, only producing a translation if the source-language user approves. 

We compared BabelDr with the statistical MT system Google Translate (GT) for the anamnesis in emergency settings. French speaking doctors were asked to use both systems to diagnose Arabic speaking patients with abdominal pain, based on two scenarios. For each scenario (appendicitis and cholecystitis), a patient was standardized by the HUG.  Participants were four medical students and five doctors from HUG, who each performed two diagnoses, one with BabelDr and one with GT. 

The translation quality was evaluated in terms of adequacy and comprehensibility by three Arabic advanced translation students. Adequacy was judged on a four point scale (nonsense/mistranslation/ambiguous/correct) and comprehensibility on a four point scale (incomprehensible/syntax errors/non idiomatic/fluent). For the BabelDr translations, 93% of doctor's interactions sent to translation were correct and 94% fluent at the majority judgements. For GT, we respectively obtained 38% and 38%. Inter-annotator agreement for both evaluations was moderate (Light's Kappa for adequacy: 0.483; for comprehensibility: 0.44). With Google Translate 5/9 doctors found the correct diagnosis, against 8/9 with BabelDr. The satisfaction of doctors was also higher with BabelDr than with Google Translate: doctors were more confident in the translation to the target language with BabelDr than Google Translate (1/9 negative opinion with BabelDr vs 8/9 in GT). They also think they could integrate BabelDr in their everyday practice in the emergency room, contrary to GT (1/9 negative opinion with BabelDr vs 5/9 with GT).These results tend to show that BabelDr is a promising tool for the task and that GT translations are insufficiently adequate, accurate and comprehensible for emergency settings. 

Background

Emergency department (ED) crowding and increasing ED utilization are well-recognized problems for patient care in the United States.  To what degree predictive analytic techniques can improve wait times and patient outcomes when employed early in the ED stay--specifically during the triage process--is not well described.  We created predictive models to compare logistic regression (LR) and multilayer neural network (MLNN) techniques to predict hospital admission/transfer or discharge following initial presentation to ED triage with and without the addition of natural language processing (NLP) to analyze patient-reported free-text information.

Methods

Using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a cross-sectional probability sample of United States EDs from 2012 and 2013 survey years, we developed several models to predict patients’ disposition: hospital admission or transfer vs. discharge. We included patient characteristics which are immediately available after the patient presents to the ED following ED triage. We used this information to construct logistic regression and multilayer neural network models which included NLP and principal component analysis to incorporate the patient-reported reason for visit.  Ten-fold cross validation was used to test the predictive capacity of each model and c-statistics / receiver operating curves (AUC) were calculated to compare these predictive models.

Results

Of the 47,200 ED visits from 642 hospitals, 6,335 (13.4%) resulted in hospital admission (or transfer). A total of 48 principal components were extracted by NLP from patient’s reason for visit, which explained 75% of the overall variance for hospitalization. In the model excluding patient’s free-text reason for visit, the AUC was 0.824 (95% CI 0.818-0.830) for LR and 0.823 (95% CI 0.817-0.829) for MLNN. When patients’ free text reasons for visit were included, the AUC increased to 0.846 (95% CI 0.839-0.853) for LR and 0.844 (95% CI 0.836-0.852) for MLNN.

Conclusions

The predictive accuracy of hospital admission/transfer or discharge for patients who presented to ED triage improved with the inclusion of free text data from patients’ reason for visit regardless of modeling approach.  The predictive ability of these models was generally quite good at predicting disposition with the limited information immediately available during the triage process. Natural language processing and multilayer neural networks provide ways to incorporate patient-reported free-text information when predicting various outcomes that are important in providers’ clinical decision-making. 

Background:

Coronary Artery Disease (CAD) is one of the major causes of death. Evidence suggests that some preventive measures by patients in emergency phase can reduce the rate and risk of mortality. Thus, understanding the signs and risk factors of CAD from the patients’ perspective and their ways of dealing with this disease is of vital importance.

Objectives: This qualitative study aimed to explore the Iranian patients’ experiences about CAD and how they manage it in their first encounter.

Patients and Methods: This study was a grounded theory study conducted on 18 patients with CAD. The data were collected through semi-structured interviews. Initially, purposeful sampling was performed followed by maximum variety. Sampling continued until data saturation. Then, all the interviews were recorded and transcribed verbatim. After all, the data were analyzed by constant comparative analysis using MAXQUDA2010 software.

Results:

The themes manifested in this phase of disease included 1- "Invasion of Disease"  with subthemes of "warning signs" and "risk factors", 2- "Patients’ Primary Challenges" with subthemes of "doubting primary diagnosis and treatment", and feeling of being different from others", 3- "Psychological Issues" with subthemes of "mental preoccupation", "fear of death and surgical intervention", "stress due to recurrence",  and "anxiety and depression", 4- "Management Strategies" with subthemes of "seeking for information", "follow-up' , and "control measures".

Conclusions: Based on the results, physicians and nurses should focus on empowerment of patients by facilitating this process as well as by educating them with regards to dealing with CAD. Further, it is also essential for the mass media to educate the public on how to treat patients with CAD.

Key words: Management, Coronary Artery Disease, Emergency Phase, Grounded theory, Iran 

Background: Our Emergency department at New Queen Elizabeth Hospital in Birmingham is one of the busiest Major Trauma Centres in UK with around 250 staff with annual attendances of more than 100,000 patients. The issues of work load, space, staffing level and performance makes it a challenging environment. A multidisciplinary teams are more likely to perform better if they are made to feel appreciated and their good practices are acknowledged. 

Learning from excellence is a new concept. The positive feedbacks are widely used in education for children and by corporate non- medical institutions. We wanted to explore its role in adult education and behaviour in the medical background. It’s very rare we recognise, celebrate and learn from good practice in the current working climate. The feedback had to timely, genuine, reflective, meaningful, specific and consistent. A template of a positive feedback along with specific local human factors framework (modification of NOTECHS II system) was developed based on the previous work on Favourable Event Reporting Form (FERF). The Human factors were analysed under the following topics- Leadership & management, Team building & cooperation, Problem solving and decision making, Situational awareness and environment. 

The new initiative of positive feedback forms were introduced to the entire medical, Nursing and managerial staff in the emergency department. We organised few educational sessions for all the staff. The project went live three months ago in January 2017. We chose the option of hard copies rather than the online version to capture more data.

Analysis and results: We had sixty positive feedback forms form last three months. The returned forms were reviewed and analysed by Non-Emergency department staff to minimise the bias. The common theme was that the staff felt more appreciated and acknowledged. The newly appointed staff felt more welcome and seemed to understand the expectation of their new working environment. Interestingly we also found that the staff would highlight the issues such as staff shortages and process on a feedback form. This has enabled the senior management to respond immediately to appoint more staff and emphasise/encourage on process to improve performance. It also shared the exemplary practice of certain staff highlighting their leadership skills, situational awareness and decision making process in a high pressure environment. The forms also were beneficial for all the staff as a part of their yearly appraisal. The staff felt supported during difficult times regardless of role or grade.A short staff survey is also planned following the implementation. The feedbacks are now a regular part of clinical governance structure .

In summary, the positive feedback forms are a valuable tool in adult education, behaviour and performance of a multidisciplinary team. The positive feedback reinforces good practice and encourages positive self- esteem among the various members of the team. 

Introduction: The increase in attendance of Emergency Department is responsible of a real problem of flow management. The implementation of a Fast Track (FT) is one of the organizational measures to improve this flow and thus to reduce the length of stay of daily patients. The aim of this study was to evaluate the effectiveness of implementation of a non-traumatologic FT (a trauma FT already existing) in our ED, and also to evaluate the staff’s satisfaction with the establishment of this procedure and the number of orientation errors.

Methods: We present here a prospective and observationnal study over a period of three months (winter 2015-2016) in an academic French ED. A total of 258 patients who received in FT were included in the study. This cohort was compared with a control group that consulted a year previously during the same period and who could have been eligible for care in the FT.

Results: Our study showed a significant reduction of ED length of stay of patients referred to FT (95.5 min for the FT group versus 141 min for the control group, p<0.0001) and a significant decrease in patients left without care by 6,1% (1.1% for FT group versus 2.8% for the control group, p=0.01). The rate of errors of orientation in patients initially referred to FT who had to be reoriented to the standard care system was 3,3% (95%CI: [3.2-3.4]). The implantation of this Fast Track was a measure deemed satisfactory by the paramedical ED teams with a score of 3.65 ±0.57 out of a total of 4 and in a more nuanced way by the medical teams with a satisfaction noted at 2.58 ±1.24 out of 4. In spite of the relative satisfaction of both paramedical and medical teams, our study also highlights the problem of ED utilization by patients with minor complaints.

Conclusion: Establishing a Fast Track in the ED could be one of the answer to reduce the length of stay of patients present with minor complaints. Organizational measures such as adequacy between the working hours of the FT and those of the physician responsible for it or the improvement of the computer tool (DxCare®) would make it possible to improve its functioning. The establishment of a FT was a satisfactory measure by paramedical and medical ED teams and significantly reduced the time taken to manage patients with non-urgent complaints.

Background Emergency department crowding and poor flow has been shown to lead to both poor clinical outcomes and poor patient experience.  As such, improving ED care is usually important to policymakers, but which visits should be highest priority to address is often controversial.  Many interventions to improve ED flow are focused on low-acuity, “fast-track” or primary care type patients, but it is not clear that these patients are the biggest drivers of ED crowding. Using a previously-developed Patient Encounter Costing (PEC) system, we show that simple triage level (RETTS in Sweden) can identify which patients drive ED utilization, and should be the key targets of improvement efforts.

Methods We used data from Region Halland, Sweden, a county of 300,000 people over 5,500 km². We analyzed all 88,132 ED visits across 2 hospital-based ED sites in 2015.  These visits incurred total costs of 255 million Swedish Crowns (SEK), or approximately 26 million EUR. Time spent per visit was determined from prospectively recorded ED records, and resource adjusted by published weighting factors for nursing care by triage acuity level. We used PEC methods to determine unit-time costs for ED care, which were then used to determine total ED patient-care costs for each visit. These data were aggregated at the triage (RETTS) level, showing the variation by triage score.

Results In 2015, Region Halland spent 255 million SEK on its emergency departments, incurring unit costs of 1,645 SEK per nursing hour. This represents approximately 4% of total healthcare expenses in the region.  Patients were receiving care in a designated care space for a total of 262,705 hours.  The average ED visit service cost 2,886 SEK (95%CI 2,264-2,299). Average costs by RETTS level were: 650 SEK for triage level 5, 1 696 SEK for level 4, 2 824 SEK for level 3, 4 551 SEK for level 2, and 4 534 SEK for level 1.  In terms of total costs, 4% of total ED costs were spend on level 5 or uncoded visits, 9% on level 4, 47% on level 3, 34% on level 2, and 6% on level 1 patients.  ED treatment space utilization followed a similar pattern.

Conclusion 81% of ED costs, and 80% of total treatment-space utilization time, is spent on RETTS level 2 and 3 patients.  Interventions to improve ED throughput and resource utilization will be most effective if they focus on moderate to high-acuity and complexity patients, who often have multiple comorbidities and are at a higher risk of being admitted.  Low acuity and primary care oriented interventions are likely to have a more limited effect potential.

Objectives - To evaluate the impacts of two triage interventions compared to protocol-based comprehensive nurse-led triage on emergency department (ED) waiting times: senior physician-led triage and triage replaced by inter-professional teamwork in modules.

Design - A single center before-and-after study.

Setting – Conducted 2012.05.09 to 2015.11.11 at the adult ED of an urban county teaching hospital in Sweden, with 110 000 annual visits.

Participants – Registry data of patients arriving on weekdays 8 am to 9 pm during one year prior to the first intervention and one year immediately following each intervention.

Interventions - Senior physicians were reassigned to replace the triage nurses 8 am to 9 pm in the first intervention. In the second intervention, the triage section was abolished and replaced by inter-professional teamwork in modules.

Main outcome measures – Primary outcomes were the median total length-of-stay (LOS) and time to physician (TTP). Secondary outcome was the proportion of patients who left before treatment completed (LBTC).

Results – When senior physicians replaced the triage nurses, the median TTP plunged from 119 (95% CI; 117 to 120) to 57 min (95 % CI; 56 to 58). However, the median LOS increased from 236 (95% CI; 235 to 238) to 258 min (95 % CI; 256 to 260). When triage was abolished during teamwork in modules, the median LOS decreased to 229 min (95 % CI; 227 to 231). The median TTP was increased to 74 min (95 % CI; 73 to 76), yet 45 min shorter than during nurse-led triage. The LBTC rate increased over time: 2.5 % for nurse-led, 2.7 % for physician-led and 4.0 % for no triage during teamwork in modules. All differences in outcome measures were statistically significant with p-values < 0.001, except the non-significant difference in LBTC rate between nurse-led and physician-led triage.

Conclusions - Inter-professional teamwork in modules replacing triage performed the shortest LOS and may be an approach to cut waiting times in large busy EDs.

Background

Teams in the shock room (SR) usually are so-called „ad hoc teams”: They randomly convene to fulfill an ambitious task under time pressure with limited information and usually leave the scene as soon as this task is completed. What are the essential requirements to lead such a team? What can help to reach excellence as team leader in the SR?

Methods

We searched in the medical literature for the expressions team leading / team leader / team coordinator and emergency medicine. Moreover we conducted a survey with experienced consultants in our Emergency Department, who regularly work as team leaders, asking them to tell us their challenges, but also tips and tricks for reaching high performance in the SR.

Results

Structure is often mentioned as important factor for high performance in the SR in the literature. This includes a briefing before the patient arrives, hands-off during handover, standards like the ABCDE and CRM (crisis research management) criteria or non-technical skills, and team debriefing after completion of the task. Additionally team resilience or high-performance teams can be found  in the literature as important factors for high-quality teamwork. These terms primarily stem from other highly dynamic industries outside of healthcare like nuclear power plants or aviation.

In interviews with experienced emergency physicians who regularly work as team leaders in the shock rooms, they stressed the importance of pre-existing structures and standards, which should be implemented by an experienced emergency physician as team leader. As examples the “ABCDE” and CRM principles are mentioned. Many of the emergency physicians expressed being challenged by their colleagues from anaesthesiology or surgery. “Risk factors” for losing the lead in the SR are being inexperienced, junior, short or female, having a low voice or the wrong position in the room. In order to clarify their role and responsibility, ED consultants mention good visibility by wearing a coloured jacket defining them as team leader, using a footstool, developing a strong voice or knowing the names and functions of all involved team members. They emphasize the importance of Interdisciplinary and interprofessional in-situ simulation training for developing standards of collaboration and shared mental models.

Discussion

Team leading in the shock room is extremely challenging: an ad-hoc team must collaborate in a highly dynamic situation with many uncertainties. Excellence as team leader not only depends on the team leader who must be highly competent in content, coordination and communication, but also on clear structures and standards. In order toe be prepared for often “unpreparable” situations, simulation training with all team members helps to reach excellence of care for patients whose survival often depends on high team performance.

INTRODUCTION

Over 10,000 refugees lost their lives in the Mediterranean since 2016 in their endeavor to reach the European Union (EU), first half of 2016 there were 2809 deaths

Immigration, most important problem in the world today & a purely human challenge for all stakeholders, especially the EMS in GREECE, as national first responder.

The large flow of refugees into our country, through the Aegean islands, has created great challenges, in the field of health.

SCOPE-METHOD

In 2015, Greece, the main point of entry into the EU for refugees and immigrants from Turkey. It is estimated that 850,000 people attempted the dangerous passage of the Aegean Sea.

47,000 refs remained in Greece. Most of them (90%), originate from Syria, Iraq, Afghanistan. Among them people with severe health problems, pregnant women, infants.

The management of the severely ill amongst refugees based on a survival chain starting at the pre-hospital level, often at the site of arrival, and ends at the definitive care.

The role of EKAB, especially in the specific geographical relief of Greece, is particularly critical for the survival of people in distress.

Refugee-related diseases are unexpectedly severe, complex due to the difficulties of their situation: the extreme events of war; long-distance travel; lack of available medication for chronic pathologies; malnutrition; or the existence of past injuries. This vulnerable population, often consisting of infants and elderly, have reduced reserves in injury & sickness

CHARACTERISTICS

Children, 48% of the refugee population; men 30% & 22% women. 10% of refugees in Greece are 2 to 4 years old, 14% are aged between 5 and 9 years, 11% are aged 10 to 14 years old

MD in  small islands deal with an emergency patient among POPULATIONS ON THE MOVE in remote areas, in the absence of proper medical equipment in a small regional clinic on a border island and is able only to offer Initial stabilization and nothing  more. Afterwards the EKAB system ensures the transfer of the patient to a definitive care Centre.

 DATA

 Aeromedical Department of EKAB archives:

2016: Emergency Transfers by the Aeromedical Department numbered 46, involving newly arrived seriously-ill refugees. Of these 46 patients, 17 were infants with res/ry distress; another 7 were children (1.5 to 12 ys ) suffering from various infections, burns, choking, swallowing of foreign bodies. 72% male & 28% female. Syrians comprised 64% of the pts; Afghans 20%; Iraqis 12%; and Kurds, Iranians etc. Athens was the destination for 34 patients; 5 were sent to Crete; 7 to peripheral hospitals. AIRBORNE TRANSPORT was carried out in cooperation with the Greek Air Force C27 and C130 planes H/Ps: Chinook, Super Puma. The choice was based on geographic distances, availability of appropriate landing facilities, and local meteorological conditions.

The experience of air transport provides the opportunity for prompt intervention and better management of vulnerable patients involved in a mass migration event.

Background

Acute abdominal pain is among the most common reasons for emergency department (ED) admissions. As abdominal symptoms are often vague, intermittent and non-specific, it may be difficult to distinguish non-specific conditions from specific and possibly severe conditions. Consequently, second admission to ED may be required to reach a diagnosis. As delay in diagnostics may lead to poor outcomes (including higher morbidity, mortality, prolonged hospitalization and higher costs of care), readmission rate has been one of the parameters used to evaluate the quality of care. While it has been well recorded and studied in elective surgery, the studies are few in the field of emergency medicine.

During the recent years in Finland, the emergency services have been reorganized and a new specialty of emergency medicine has been established. Emergency physicians have obtained a major role in EDs. Our aim was to evaluate the care, diagnostic accuracy and rate of readmissions in patients admitted to ED due to non-specific abdominal pain (NSAP) during the era of former and new ED organization.

Materials and Methods

All patients discharged with the diagnosis of NSAP during 2015 (former ED organization) and 2016 (new ED organization) in Tampere University Hospital were registered. Out of these, all patients readmitted to ED within 48 hours from the index admission with the diagnosis of NSAP or pelvic pain (ICD-10 codes R10.0, R10.1, R10.3 and R10.4) were included in the study. Planned readmissions were excluded. The number and reasons for readmissions, diagnostic accuracy and examinations performed were registered, and the findings between the two time periods were compared.

Results

Out of a total of 173,630 ED admissions, 10,609 patients (6%) were discharged with the diagnosis of NSAP. Median age was 32 years (range 0-98) and 60% were female. 313 of these (1.2%; median age 32 years (range 0-98), 59.8% female) were readmitted to ED within 48 hours. The readmission rate was highest (4.1%) among patients aged 18 years or less. Non-specific diagnoses were significantly less common in 2016 than in 2015 (n=7.1% vs. 5.2%, p<0.001). However, the rate of readmissions remained similar (3.0% vs. 2.9%, p=0.975). Again, the rate of computed tomography and ultrasonography remained equal. An improvement in the diagnostic accuracy was noted especially in patients with acute cholecystitis, which was the single most important reason (n=16; 9.4%) for ED readmissions during 2015.

Conclusions

Readmission rate among patients discharged from ED with the diagnosis of NSAP was surprisingly low. After the ED organizational change in our hospital the diagnostic accuracy during the index admission has improved, but no reduction in the rate of readmissions has been observed. Better availability of radiological imaging may have reduced the misdiagnoses of some conditions, such as acute cholecystitis.

BACKGROUND: Ceilings of treatment are crucial early decisions aimed at improving the quality of care for patients in whom they are deemed appropriate. Decision making concerning limitation of potentially life prolonging treatments is often challenging. Knowledge of end of life issues and decision making involved is lacking, and no research into ED ceiling of treatment decision making has been conducted in the UK. A qualitative approach is needed to expand the limited literature and validate transferability of research to current UK practice. AIMS: To determine the factors that influence the institution of ceilings of treatment for patients presenting critically ill to the Emergency Department. METHODS: This qualitative study used a phenomenological approach to explore attitudes and factors considered important in driving end-of-life decision making by ED consultants. Semi-structured interviews were conducted until data saturation was achieved (n=15). Participants were recruited via convenience sampling and represented 5 EDs in the West of Scotland. Interviews were audio recorded, transcribed verbatim, and thematic analysis was carried out using NVivo. A reflexive diary was kept throughout the data collection and analysis process, and emergent themes were returned to participants to validate findings. RESULTS: We present a model of factors that influence ceiling of treatment decisions making. It was found that acute clinical factors and patient specific factors lay the foundations of ceiling of treatment decisions. Such case-specific information is heavily contextualised by patient and family wishes, collateral information, anticipated outcome and whether the patient is accepted for higher care. This process flows through a ‘filter’ of cultural and environmental factors. The overarching nature of patient benefit was found to be of key importance, framing all aspects of ceiling of treatment institution. Ultimately, all decisions determining an appropriate ceiling of treatment for a given patient resulted in one of three common patient pathways: full escalation, ward-based care or palliative care initiation. CONCLUSIONS: To our knowledge, this is the first investigation of factors that affect ED ceiling-of-treatment decision making in the UK. Key factors identified included acute clinical factors, patient specific factors, patient and family wishes, anticipated outcome and eligibility for higher care. Together with cultural factors, environmental factors and collateral information factors, these key themes are framed by patient benefit to establish an appropriate level of treatment. This may have importance as an educational tool and can act as a guide for physicians making end-of-life decisions in the E.D. How different factors are combined, their weighting and influence on the decision to institute ceilings of treatment is variable. Clinicians should be cognizant of these factors and their associated biases when making these challenging decisions.

Acute kidney injury and mortality among patients with rhabdomyolysis

 Nielsen FE^1,2, Cordtz J^1,3, Rasmussen TB⁴, Christiansen CF⁴.

¹Department of Emergency Medicine, Slagelse Hospital, Denmark. ²Institute of Regional Health Services Research, University of Southern Denmark. ³Department of Emergency Medicine, University Hospital of Zealand, Denmark. ⁴Department of Clinical Epidemiology, Aarhus University Hospital, Denmark.

Background

Acute kidney injury (AKI) is a life-threatening complication of rhabdomyolysis (RM). There is controversy if the degree of the initial creatine phosphokinase (CK) elevation is associated with the risk of AKI and death.

Purpose

To examine the risk of AKI, renal replacement therapy (RRT) and mortality among patients with RM and to evaluate the association between CK level and the risk of AKI, RRT and death.

Methods

Register-based study of adult patients admitted to hospitals in the region Zealand during November 1, 2011 to March 1, 2014 with CK levels higher than 1,000 U/L within 72 hours of admission. Information about CK and other laboratory data was obtained from a regional laboratory database. Data on medical history, medical treatment and survival were obtained from the Danish National Registry of Patients, the National Health Service Prescription Database and the Danish Civil Registration System. Patients with preexisting end-stage renal disease or acute myocardial infarction were excluded. AKI was defined according to Kidney Disease Improving Global Outcome. Logistic regression was used to compute odds-ratios (OR) with 95% confidence intervals (CI) comparing the risk of AKI, RRT and all-cause mortality according to CK-level adjusting for confounding.

Results

The study included 1,024 patients with a median age of 72.9 years. Median CK was 2,226 U/L, 831 (81.2%) patients with CK 1,000-5,000 U/L, 154 (15.0%) with CK 5,001-15,000 U/L and 39 (3.8%) with CK 15,001+ U/L. A total of 442 (43.2%) patients developed AKI within 30 days, and 42 (4.1%) required RRT during the first year. A total of 170 (16.7%) patients had died within 30 days and 277 (27.1%) had died within 365 days.  Twenty-seven (69.2%) patients with CK > 15,000 U/L developed AKI within 30 days compared to 62 patients (40.3%) patients with CK 5,000-15,000 U/L and 353 (42.5%) patients with CK < 5,000 U/L. Five (12.8%) patients with CK > 15,000 U/L required RRT within a year compared to 7 (4.6%) patients with CK 5,000-15,000 U/L and 30 (3.6%) patients with CK < 5,000 U/L. In multivariate analyses it was found that OR of AKI within 30 days was 2.6 (95% CI 0.9-7.3) and the OR of RRT within one year was 3.0 (95% CI 0.8-10.9) among patients with CK +15,000 U/L (CK < 5,000 U/L as reference). The CK level was not associated with the risk of death.

Conclusion

Our initial analyses showed that elevated initial CK values was not associated with death. However, elevated CK values was associated with increased risk of AKI and RRT, although estimates were statistically imprecise.

Introduction: Patients with End Stage Renal Disease (ESRD) use the emergency department (ED) at a 6-fold higher rate than U.S. adults.  No national studies have described ED utilization rates among kidney transplant (KTx) recipients, and the factors associated with higher ED utilization. A more definitive understanding of the trends, causes, and outcomes of ED utilization among KTx patients is necessary to identify the potentially modifiable factors and to identify opportunities for better care coordination, lower resource utilization, and improved quality of care. 

Methods: We examined a cohort of 132,725 incident adult KTx recipients in the United States Renal Data System, a comprehensive national database of ESRD patients in the US, from 2005-2013.  ED use, hospital admission, and diagnoses were obtained from the Medicare Physician/Supplier and Inpatient databases.  Multivariable Poisson regression was conducted to assess the association of relevant patient variables with each of the primary and secondary endpoints where appropriate. 

Results: Nearly half (46.1%) of KTx patients had at least one ED visit within the first post-transplant year (1.61 ED visits/patient year); 39.7% of ED utilizers were hospitalized in the first year post-transplant. ED visit rate was high in the first 30 days (5.26 visits/person year), but declined substantially thereafter (1.81 visits/person year (PY) in months 1-3; 1.13 visits/PY in months 3-12 post-transplant) (Figure 1). In multivariable analysis, factors associated with a lower ED utilization rate included preemptive transplantation (RR: 0.770, 95% CI: 0.751-0.790), peritoneal dialysis (RR: 0.859, 95% CI:  0.843-0.875), private insurance coverage, and transplant at high-volume centers (>200 transplants/year). Predictors of higher ED utilization rate included older age (RR: 1.010, 95% CI: 1.005-1.015 per 10 years), female sex (RR: 1.173, 95% CI: 1.159-1.187), comorbid medical conditions, Medicaid or Medicare insurance coverage, higher proportion of neighborhood poverty (RR: 1.002, 95% CI 1.001-1.002), longer dialysis vintage (RR: 1.302, 95% CI: 1.271-1.333 per 10 years), older donor age (RR: 1.002, 95% CI: 1.002-1.003, greater degree of HLA mismatch, longer index hospitalization (RR: 1.004, (%% CI: 1.004-1.004), delayed graft function (RR: 1.268, 95% CI: 1.251-1.285).  

Conclusions: ED utilization for KTx patients is three-fold higher than the general population, but less than half the rate for ESRD patients on dialysis. Policies and strategies addressing preventable ED visits have high potential for improvement and savings

Introduction and objective:

Particulate matter (PM) with particle sizes less than 10 microns, which are known as breathable suspended particulates, can get deep into the lungs and cause a broad range of health effects, respiratory and cardiovascular particularly. Studies confirmed a strong association between air concentrations of PM and cardiovascular disease. On the other hand, it is still unclear if exposure to breathable (size 10 microns or less) PM leads to stroke events and whether the timing of exposure is associated with stroke risk. In this study we examined the association between occurrence of stroke and respirable PM air concentration.

Methods:

We retrospectively studied Emergency Department (ED) admission of acute stroke patients from Jan 2011 to Dec 2016. We registered occurrence of stroke compared to breathable PM (PM ₁₀ and PM_2.5) concentrations. Incidence of events was associated with PM levels on the day of onset and on the 3 days following PM elevation. PM concentrations were provided from local monitoring data from the Veneto Regional Agency for Prevention and Environmental Protection (ARPAV), classified accordingly with EU health based standards for pollutants in air (25 µg/m3 for PM_2.5 and 50µg/m3 for PM₁₀).

Results:

During the study period 2,590 stroke patients referred to our ED: 1,721 (66.4%) were ischemic and 869 (33.5%) were hemorrhagic. Gender (ischemic stroke: M: 49.3%; F: 51.7%; hemorrhagic stroke: M 51.6%; F: 48.4%) and age (ischemic stroke: 74 years, range: 18-102; hemorrhagic stroke: 68 years, range: 18-99) distribution were similar in the two groups. We did not observe any difference in stroke incidence with PM₁₀ levels within or over the EU standards. PM_2.5 air concentration over the EU standards revealed to be associated, acutely and on 3 following 3 days, with a higher incidence of ischemic stroke (+38.4%) and hemorrhagic stroke (+12.5%), compared to stroke events occurred on the within the EU standards PM_2.5 levels days. Also in this case no age and gender differences were observed between the two study groups.

Conclusions:

Medical researches show that the risk for various health impacts increases with air particulate matter exposure but there is little evidence to suggest a threshold below which no adverse health effects would be anticipated. It has also been shown that the health risks would be higher for those particles with particle sizes of 2.5 microns or less, which are commonly referred to as fine suspended particles or PM_2.5. Our study suggests that short-term exposure to elevated PM _2.5 is associate with a higher incidence of ischemic stroke whereas the association with hemorrhagic stroke is less clear.

Introduction : Stroke has a major impact on individual lives and the nation's health and economy. It is the third  cause of death in the world, and a major cause of adult disability. The therapeutic revolution has completely changed the functional and vital prognosis of patients with stroke due to reperfusion, and particular intravenous stroke thrombolysis with rt-PA. Because «  time is brain  », thrombolysis should be performed as early as possible. Istablishing specific neurovascular units may improve  the management of acute ischemic stroke. However, initiation of thrombolysis in the emergency room is still controversed.

Objective : The objective of this study is to compare the results of intravenous stroke thrombolysis performed in the ED versus that performed in the department of neurology in terms of delays, prognosis and complications .    

Methods : we made a  transversal analytical study in our ED during 2 years  . In this study we analysed all the patients alerted for thrombolysis. We made two groups (group 1 = thrombolysis performed in the ED and group 2 = thrombolysis performed in the neurology department). All patients underwent brain CT in the ED. All delays were noted, in particular the delay "door to needle". The NIHSS score before thrombolysis, H1, H6 and H24 post thrombolysis and the occurrence of hemorrhagic transformation were noted too.

Results : 520  patients were included, only 188 patients were alerted for thrombolysis protocol. 60 patients underwent thrombolysis divided into 2 groups : group 1 in the ED and group 2 in the neurology department. The mean age was 64±12 years in group 1 vs 67±13 years in group 2. There wis no great gender predominance in the 2 groups.The time onset to needle was 2h50±30mn in group1 and 4h10±20mn in group2( p=0.007). There is a significant difference in the mean door-to-needle time between 2 groups : 80±33mn in groupe 1 vs 173±39 in group2 (p=0.0001). There is no significant difference between 2 groups in NIHSS score (at admission,at H1 and H6 post thrombolysis) and  in good early outcome. The risk of intracerebral hemorrahge is more important in group 2than group 1 (10% vs 3% respectively with a significant difference p=0.004).

Conclusion : the beneficial effect of thrombolysis on mortality and functional outcome  in patients with acute ischemic stroke may be improved  when it is performed early and within the recommended delays.

Background

Pain is the leading symptom in emergency departments (ED). Due to overcrowding, some patients are oriented to the waiting room and their medical evaluation deferred.  In order to ease analgesia in the waiting room, we have enforced a dedicated pain management protocol allowing nurses to administer analgesia when indicated. The objectives of this study were: (1) to measure treatment administration to patients with documented pain upon arrival; (2) to identify predictors of non administration of pain treatment (oligoanalgesia) ; (3) to evaluate pain protocol adherence by nurses.

Methods

Prospective observational study in the ED of a primary and tertiary urban teaching hospital with an annual census of 68‘000 patients.  All patients with a pain score documented on arrival and oriented to the waiting room were eligible.  Demographic characteristics, pain severity scores (0 to 10), time delays, triage complaint and emergency level as well as medication use were extracted from the electronic patient records.  Univariate and multivariate analyses were performed to identify predictors of oligoanalgesia.

Results

During a three months period, 2’371 patients were included. Their mean age was 49 years and the majority were male (51%). The leading triage complaint was abdominal pain (30.3%). Pain treatment was given to 734 patients (31%). Treatment was more frequently administered (43%) for pain severity scores > 5 than for lower acuity scores (16%, p <.0001). Time to treatment was 60 minutes (IQR 20-121) and 16 minutes (IQR 7-40) for pain scores < 5 and > 5 respectively (p =.01). Patients with an initial pain score < 5 were treated in accordance to the nurses’ protocol in 73.1% of the cases. This rate dropped to 32% in patients with initial pain scores ≥ 5.

In multivariate analyses, risk predictors for non treatment of pain in the waiting room were:

age > 80 y (OR 2.32 ; 95% CI 1.49-3.60), admission by ambulance (OR 1.50 ; 95% CI 1.12-2.01), higher triage severity level (OR 1.67 ; 95% CI 1.32-2.11), initial pain score < 5 (OR 3.78 ; 95% CI 2.99-4.76), waiting room LOS < 30 minutes (OR 2.79 ; 95% CI 2.06-3.78). When compared to pain suggestive of renal colic, pain associated with a neurological complaint (OR 6.54; 95% CI 2.88-14.84) was the most important predictor for oligoanalgesia. In the multivariate model neither waiting room occupancy nor ED’s patients’ load were significantly associated with non treatment.

Conclusion

In the waiting room of our ED, the proportion of patients receiving pain medication is low.  Adherence to our pain protocol is insufficient. Older patients, patients with low intensity pain scores and presenting complaints other than renal colic are at higher risk of treatment abstention independently of emergency room workload. These patients should be targeted by specific interventions.

Introduction: The effective and safe sedation for painful procedures in the emergency department is one of the principal concerns of emergency physicians. The sedative agent must be one with rapid onset, steady effects, quick recovery, and acceptable side-effects. Ketamine is an ideal sedative agent but emergency physicians are reluctant to use it due to fear of recovery agitation. It has been proposed to use other drugs specifically benzodiazepines as premedication to reduce the agitation.The goal of our study was to evaluate the effect of midazolam and haloperidol premedication on ketamine induced agitation, and also the emergency physician satisfaction with the procedure.

Method: This was a randomized double-blind placebo-controlled trial to assess the efficacy of ketamine premedication by midazolam or haloperidol, in reducing agitation incidence and severity. The study was approved by the university ethics committee. The samples were chosen from patients older than 18 of either sex who needed sedation in emergency department at Sina Hospital. Patients who had any contraindication to ketamine, midazolam or haloperidol were excluded.

Patients randomly allocated in 3 groups, Arm 1: patients received 2 intravenous injections of distilled water (1cc and 0.05 cc/kg) 5 minutes prior to receiving a sedative dose of 1 mg/kg IV ketamine.  Arm 2: patients received 2 intravenous injections, 1cc of distilled water and 0.05 mg/kg midazolam, 5 minutes prior to ketamine. Arm 3: patients received 2 intravenous injections, 0.05 cc/kg of distilled water and 5mg of haloperidol, 5 minutes prior to ketamine.

Level of sedation and agitation were assessed using RASS score (after 5, 15 and 30 minutes of ketamine injection) and Pittsburgh Agitation Scale. Also, physician satisfaction with the sedation procedure was evaluated using Clinician Sedation Satisfaction Index(CSSI).

 Results: 180 sample enrolled from July 2016 to March 2017.The incidence of Recovery Agitation, was 66% in the group that received no premedication and 20% in both groups that received premedication, whether midazolam or haloperidol (p<0.001). Also, agitation severity (mean PAS score of 3.37) in the group which only received ketamine was much higher in comparison to the other two groups (mean PAS score of 0.65 and .063) (p<0.001). The comparison between the two intervention groups (midazolam versus haloperidol) showed no significant difference in agitation severity (mean PAS score of 0.65 versus .063).The score of physician satisfaction was significantly higher in the field of reduced agitation in premedicated group (p<0.001).

Discussion: We found a significant reduction in recovery agitation of ketamine by using midazolam or haloperidol as premedication. Our results were similar to most previous studies about the effect of BZDs. However, few studies have been done about the effect of haloperidol on reducing ketamine induced agitation.

Trial registration: ClinicalTrials.gov NCT02909465

Background

Procedural sedation and analgesia (PSA) is routinely used in pediatric patients for painful procedures. The use of IV ketamine and propofol (‘ketofol’) for PSA is established in adult patients and has been shown to be safe and effective. The purpose of this study was to analyze the safety of ketofol in pediatric patients. 

Methods

This was a single-center retrospective study at a Canadian pediatric tertiary care centre. Patients were included if they were less than 18 years old at time of PSA, and received ketofol within the period January 1, 2011 to December 31, 2016. Adverse events, interventions and recovery times were captured.

Results

233 charts were analyzed, of which 163 met the inclusion criteria. 65% of the patients were male. 9% had an underlying medical condition, with 6% of all patients having asthma. The average age was 9.5 years (range 2 months to 18 years).

The indications for PSA using ketofol were usually fracture or joint reduction (63%) and laceration repair (18%). Other indications included plastics procedures (6%), lumbar puncture (4%), abscess incision and drainage (4%), burn/wound debridement (3%), and CT sedation (1%). The median procedure time was 13 minutes (interquartile range 8-22 minutes) and median time to recovery was 30 minutes (IQR 21-46 minutes).

The major adverse reaction experienced was hypoxia (10%) with resolution by conservative measures (stimulation, airway positioning and supplemental oxygen). Two cases with hypoxia required bag mask ventilation and none required intubation. Only one case had a severe adverse reaction (laryngospasm and hypotension), which resolved with supplemental oxygen, bag mask ventilation, and fluid bolus. 3% of cases had nausea or vomiting. No cases had hypersalivation, bradycardia, emergence reaction, or seizure. There was no relation to the dose of either ketamine or propofol to the observed adverse reactions. Three cases required re-sedation due to failure of previous sedation. Two of these cases failed intranasal sedation or local block and then received ketofol. Only one sedation failure was due to inadequate sedation from ketofol with repeat sedation requiring additional adjunct of midazolam.

Subgroup analysis on patients less than 24 months yielded no additional risk for adverse events or failed sedation.

Discussion

This is the largest study to date analyzing the safety profile of ketofol in the pediatric population. Overall, ketofol is a safe and effective combination for pediatric PSA. Major adverse effects were lower than previous smaller studies. Additionally, mean recovery time was similar to published literature.

Background:

Acute pain is the most frequent complaint in emergency department (ED), but its management is often  complex, placing patients at risk of oligoanalgesia. Emergency physicians are considering alternative, complimentary medications, such as ketamine, combined with traditional drugs such as opioids to achieve multimodal analgesia in the acute setting.

The aim of this study was to determine the effectiveness of low-dose ketamine as an adjunct to morphine versus standard care with morphine alone for the treatment of acute moderate to severe pain among ED patients.

Methods:

We conducted a double-blind, randomized, placebo-controlled trial at the ED, over a six-month period. Eligibility criteria were: age between 18 and 65, acute moderate or severe pain (the numerical pain rating scale (NRS)>5) who require morphine. Patients were randomized on three study groups: standard group receiving morphine and normal saline placebo; group1 receiving morphine and 0.15 mg/kg ketamine and group2 receiving morphine and 0.3 mg/kg ketamine. Pain was assessed at 30, 60 and 120 minutes after drug administration; rescue analgesia consisting on 0.5mg/kg morphine was prescribed if the reduction of pain was lower than 50%. The occurrence of adverse events was also measured.

Results:

One hundred twenty patients were enrolled: 41 patients in standard group, 42 patients in both groups 1 and 2. There were no difference between the three groups in baseline NRS, as well as in the demographic and clinical characteristics. The most common cause of pain was nephritic colic in 50.4% of patients. NRS improvement was more important and rapid in group 2 compared to the other groups with a statistically significant difference at 120 minutes. The SPID was higher in ketamine’s groups compared to standard group. Among patients receiving rescue analgesia, 28 were in standard group, 24 in group1 and 5 in group2 (p<0.001). The total  dose of morphine was significantly greater in morphine group comparing to the ketamine groups. There was no difference in side effects between the three groups. More participants in the ketamine groups reported minor neuropsychiatric adverse effects  such as dysphoria and dizziness. Patients from placebo group developed more digestive events such as nausea and vomiting.

Conclusion:

Low doses of ketamine are well tolerated and present efficient analgesic effect in adjunction to morphine compared to morphine alone for pain management in ED. The dose of 0.3mg/kg seems more effective than 0.15 mg/kg but might cause more adverse neuropsychiatric events.

Background:

Acute pain is the most frequent complaint in emergency department (ED), but its management is often  complex, placing patients at risk of oligoanalgesia. Emergency physicians are considering alternative, complimentary medications, such as ketamine, combined with traditional drugs such as opioids to achieve multimodal analgesia in the acute setting.

The aim of this study was to determine the effectiveness of low-dose ketamine as an adjunct to morphine versus standard care with morphine alone for the treatment of acute moderate to severe pain among ED patients.

Methods:

We conducted a double-blind, randomized, placebo-controlled trial at the ED, over a six-month period. Eligibility criteria were: age between 18 and 65, acute moderate or severe pain (the numerical pain rating scale (NRS)>5) who require morphine. Patients were randomized on three study groups: standard group receiving morphine and normal saline placebo; group1 receiving morphine and 0.15 mg/kg ketamine and group2 receiving morphine and 0.3 mg/kg ketamine. Pain was assessed at 30, 60 and 120 minutes after drug administration; rescue analgesia consisting on 0.5mg/kg morphine was prescribed if the reduction of pain was lower than 50%. The occurrence of adverse events was also measured.

Results:

One hundred twenty five patients were enrolled: 41 patients in standard group, 42 patients in both groups 1 and 2. There were no difference between the three groups in baseline NRS, as well as in the demographic and clinical characteristics. The most common cause of pain was nephritic colic in 50.4% of patients. NRS improvement was more important and rapid in group 2 compared to the other groups with a statistically significant difference at 120 minutes. The SPID was higher in ketamine’s groups compared to standard group. Among patients receiving rescue analgesia, 28 were in standard group, 24 in group1 and 5 in group2 (p<0.001). The total  dose of morphine was significantly greater in morphine group comparing to the ketamine groups. There was no difference in side effects between the three groups. More participants in the ketamine groups reported minor neuropsychiatric adverse effects  such as dysphoria and dizziness. Patients from placebo group developed more digestive events such as nausea and vomiting.

Conclusion:

Low doses of ketamine are well tolerated and present efficient analgesic effect in adjunction to morphine compared to morphine alone for pain management in ED. The dose of 0.3mg/kg seems more effective than 0.15 mg/kg but might cause more adverse neuropsychiatric events.

In February 2016 a new definition of the sepsis was introduced, redefining sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection (.Sepsis-3). A shortened sequential Sepsis-related Organ Failure Assessment score (Q- SOFA score) is used to identify sepsis according to Sepsis-3 criteria. However, these new criteria have not yet been validated in a general emergency department (ED) patient population.

Methods

This is a multi-center, non-interventional observational pilotstudy. During this pilotstudy all adult patients who visit the ED with a suspected or proven systemic infection were included. In all included patients the SIRS criteria and the qSOFA criteria were collected. In addition to routine diagnostic tests such as blood cultures, the PCT levels will be determined.

Results from the first 100 inclusions

In this pilot of 100 patients 61 were male. Median age was 65.5 years (range 18 to 94). The q-SOFA was positive in 4 patients, while SIRS was positive in 44. The mortality in the total study population was 6%. 5 critically ill patients were not identified by qSOFA, while SIRS missed 2. 2 of the SIRS positive patients and none of the qSOFA positive patients were admitted to the intensive care unit. 

Conclusion

This pilot study showed the implementation of q-SOFA as a screening tool in suspected systemic infection, did not identify all patients who needed intensive care or those with bad outcome after visiting an emergency department. More research needs to be done in a larger study to compare validity and usefulness of this scores in the ED population.

Introduction: Despite major efforts to identify and treat sepsis early, this disease remains a major cause of mortality in hospitalized patients in the emergency department (ED).

Objective: To identify factors associated with intra-hospital mortality in patients admitted to ED for sepsis.

Methods: Prospective, observational, monocentric study, over 12 months in ED. Inclusion: patients (age ≥ 18 years) with a suspected infection associated with two or more criteria of the systemic inflammatory response syndrome (temperature ≥ 38 ° or ≤ 36 °C, heart rate> 90 bpm, respiratory rate> 20 / min, or Blood pressure in CO2 <32 mmHg or White blood cells> 12,000 cel / mm3, or <4,000 / mm3). Epidemiological, clinical, therapeutic and outcome criteria were collected. APACHE 2, SOFA and quickSOFA (qSOFA) scores were calculated. Prognosis was evaluated in intra-hospital mortality. Multivariate regression analysis to identify factors associated with mortality was performed.

Results: Inclusion of 185 patients (169 in sepsis and 16 in septic shock). Mean age = 61 ± 17 years. Sex ratio = 0.46. Comorbidities n (%): diabetes 88 (48), hypertension 87 (47), dyslipidemia 23 (12), chronic obstructive pulmonary disease 14 (7). Clinical manifestations (%): fever (76), altered general state (41), respiratory signs (39), digestive signs (35), neurological signs (9). Site of Infection (%): renal (39), pulmonary (30), cutaneous (15), digestive (12). Organ failure (%): renal (20), cardiac (15), respiratory (12), hepatic (8) and haematological (7) events. Median APACHE 2 score = 9. Median SOFA score = 6. Median qSOFA score = 1.Intra-hospital mortality = 5%.  

In adjusted multiple regression models, age >75 years (adjusted OR = 2.8, 95% CI [1.72- 3,25], p<0.001), renal failure (adjusted OR = 4.6, 95% CI [1.4-14.6], p=0.009), septic shock (adjusted OR= 2.7, 95% CI [1.9 -8.32], p=0.05), and HCO3- level<18mmol/l (adjusted OR= 2.9, 95% CI [1.1-7.6], p=0.03) were independently associated with intra-hospital mortality. 

Conclusion: In this study, age of 75 years, HCO3- level <18 mmol /, renal failure and septic shock were predictive factors for in-hospital mortality for patients admitted to ED for sepsis.

Background: Many studies in the past have reported that sepsis is one of the leading causes of mortality in hospitalized patients. However, information regarding factors for early predictive mortality is limited.

Objective: The aim of this present study was to develop a 28-day mortality prediction model and assess the validity of it for the septic patient population in the emergency department by a machine-learning algorithm, Support Vector Machine and to compare with the Sequential Organ Failure Assessment (SOFA) Score.

Methods: This prospective observational study conducted in the emergency department in the Chang Gung Memorial Hospital in Linkou. Consecutive patients meeting the criteria for sepsis during the first 24 hours of ED admission were included. The 28-day mortality collected prospectively by inpatient database or telephone follow-up. We made use of the demographic and laboratory variables that used to diagnosis sepsis as the candidate variables, and applied the recursive feature elimination method to select the significant ones to build the prediction models. Data were divided into training (75%) and testing (25%) sets, and repeated 30 times to avoid selection bias. To assess the performance of the build prediction model, we calculated the area under the Receiver Operating Characteristic curve (AUC), sensitivity, specificity, and accuracy for either individual variable but also the combination of selected variables.

Results: 379 patients were prospectively recruited from the emergency department with sepsis (SIRS and infection, 42.22%), severe sepsis (or Sepsis 3.0, 56.2%), and septic shock (1.58%) with a 28-day mortality rate of 10.03%. The selected variables for prediction model were respiratory rate, albumin, C-reactive protein, D-dimer, and fibrin-degradation products. The analysis results summarized in Table illustrates that the method of Support Vector Machine had promising performance of accuracy, specificity, and AUC in training (0.842, 0.853, and 0.879, respectively) and testing (0.821, 0.890, and 0.754, respectively) sets where better than SOFA score (AUC: 0.711, accuracy: 0.835).

Conclusion: Our results revealed that using the combination of several laboratory variables is promising for early prediction of mortality in sepsis. However, further efforts still need to improve and increase the reliability of early predict mortality of sepsis such as the technique of machine learning.

Introduction: The relevance of eosinopenia, as marker of infection, has been described in internal medicine, intensive care, and more recently in Emergency Departement (ED), for all infections combined. We aimed to specify the contribution of this biomarker in different common infections in ED, alone or in association with other inflammatory markers.

Methods: We present here a retrospective mono-centric study carried out in the Emergency Department of a teaching hospital in France for a  6 months period (September 2015-February 2016). All patients with one of the following diagnosis were eligible: appendicitis, cholecystitis, sigmoiditis, acute pyelonephritis, male urinary tract infection, pneumonia. Uninfected patients were randomly selected to form a control group of equivalent size to the cohort of infected patients collected for the study.

Results: We included a total of 466 infected patients and 466 controls. The sex-ratio in the infected group was 0.94, the mean age was 57.9 years (SD: 24.7 years). The eosinophil count in the infected patients was significantly reduced compared to controls (59/mm³ versus 129/ mm³, p <0.001). Deep eosinopenia (3) had a specificity of 94.4% for the diagnosis of infection (all combined) with a positive likelihood ratio (LR +) of 6.3 and an area under the curve (AUC ) of 75.9%. Eosinopenia was more effective in pyelonephritis, male urinary tract infections and acute cholecystitis (AUC > 80%), but had lower diagnostic performance in pneumonia (AUC =75%), appendicitis or sigmoiditis (AUC < 70%). The AUC of eosinopenia was higher than those of leucoccytosis in pyelonephritis and cholecystis. The association of eosinopenia with an increase of C-reactive Protein (> 40mg/l) or simply with the presence of fever (Temperature >38.5 ° C) showed a specificity greater than 99% and an LR + of 61 and 45 respectively.

Conclusion:  Eosinopenia is an interesting biological marker to consider in the ED, alone or in combination with other clinical or biological parameters in order to diagnose an infection. It is particularly interesting in urinary or biliary infections in which it is a better marker than leukocytosis.

Background

Sepsis is the primary cause of death from infection worldwide. Recently, the 2016 Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection.” Together with the updated definition of sepsis, a new clinical concept termed ‘Quick Sepsis-Related Organ Failure Assessment’ (qSOFA) was introduced to identify high-risk patients with suspected infection outside of intensive care settings. The previous criteria- Systemic Inflammatory Response Syndrome (SIRS) - were removed from the current sepsis definition. qSOFA has not been validated in Hong Kong (HK). In the current study, we aimed to validate qSOFA in an emergency department in HK. Furthermore, we sought to compare the prognostic value of qSOFA and SIRS as well as another commonly used early warning score, the National Early Warning Score (NEWS).

Methods

This is a single-centre, prospective study conducted in the ED of Prince of Wales Hospital, HK between Jul 2016 and Feb 2017. 665 patients presenting to the ED triaged as category 2 (Emergency) and 3 (Urgent) were recruited. All variables for calculating qSOFA, SIRS and NEWS were collected. The outcome measure was 30-day mortality. Venous lactate was also measured to investigate whether lactate level provide additional value for the prediction of 30-day mortality. The prognostic value of qSOFA, SIRS and NEWS to predict 30-day mortality was studied. Receiver Operating Characteristic analysis were performed to determine the Area Under the Curve (AUC), sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio for qSOFA≥2, SIRS≥2 and NEWS>5.

Results

Of 665 patients recruited, median age was 73 years (IQR: 58-84); 313 (47%) were male. Overall 30-day mortality was 4.8%. The prognostic value for prediction of 30-day mortality, with AUC of for qSOFA≥2, SIRS≥2 and NEWS>5 were 0.54 (95%CI 0.51-0.58), 0.65 (95%CI 0.61-0.69) and 0.65 (95%CI 0.61-0.68) respectively. Using pairwise comparison of ROC curves, the difference between NEWS>5 and qSOFA≥2 in predicting 30-day mortality in ED patients was significant (p=0.0168). The AUC of lactate level ≥ 2 mmol/l of predicting 30-day mortality was 0.66 (95%CI 0.62-0.69). The combination of lactate level ≥ 2 mmol/l with qSOFA≥2, SIRS≥2 and NEWS>5, AUC were 0.53 (95%CI 0.49-0.57), 0.65 (95%CI 0.61-0.69) and 0.60 (95%CI 0.56 to 0.64) respectively. In addition, positive likelihood ratio of qSOFA≥2, SIRS≥2 and NEWS>5 to predict 30-day mortality were 19.69 (95%CI 4.14-93.73), 2.53 (95%CI 1.73-3.70) and 3.55 (95%CI 2.22-5.70).

Discussion

Among emergency and urgent patients presenting to the ED, the prognostic value for using NEWS was greater than qSOFA, while there was no difference between qSOFA and SIRS. Combinations of lactate level with qSOFA, SIRS or NEWS did not improve the prognostic value in predicting 30-day mortality for ED patients.

Introduction: The sensitivity and specificity of single lactate concentrations as markers of tissue hypoperfusion in sepsis have been debated. However, serial measurements or lactate clearance over time may be better prognosticators of organ failure and mortality.

Objective: Examine the clinical utility of the lactate clearance (or the percent decrease in lactate) as early as after 6 hours as an indicator of outcome in severe sepsis and septic shock.

Methods: Prospective observational study over one year. Inclusion of adult patients presenting to the emergency department (ED) with severe sepsis or septic shock. Inclusion criteria consisted of a suspected sepsis source and the following: a) two or more criteria of the systemic inflammatory response syndrome (SIRS) (temperature ≥38 ° C or ≤36 ° C, heart rate> 90 beats/min, respiratory rate > 20 / min or PaCO2 <32 mm Hg or WBC > 12,000 cel / mm3 or <4,000 / mm3) associated with organ failure (defining severe sepsis) or b) two of the SIRS criteria and a persistent hypotension (SBP <90 mmHg) despite fluid resuscitation or signs of hypoperfusion (lactate ≥4 mmol / l) (defining septic shock). Serial lactate levels in ED admission and 6 hours (h) later were measured. Lactate clearance, percent decrease in lactate level in 6 h ((lactate admission – lactate 6 h) x 100/lactate admission) was calculated. The main outcome measure was 7-day mortality.

Results: Inclusion of 253 patients. Mean age was 61 ± 17 years. Sex-ratio = 0.84. The overall mortality at the seven day was 10%. Baseline APACHE II score was 12 ± 78 and the median admission lactate was 1.1 mmol/L [0.6, 2.27]. Survivors compared with nonsurvivors had a median lactate clearance of 25 vs. 19, respectively (p=0.05). Based on Area Under the Curve in receiver operating characteristic analysis, lactate clearance have a significant inverse relationship with short-term mortality (0.63, 95% CI [0.45 to 0.80]), with a cut-off at 25%. The sensitivity, specificity, positive predictive value and negative predictive value of this cut-off were   56, 47, 25 and 81% respectively.

Conclusions: Lactate clearance in the most proximal presentation of severe sepsis and septic shock is associated with improved mortality rates. This is consistent with current efforts that emphasize the importance of identifying and treating tissue hypoperfusion during the first 6 hours of resuscitation. 

Background: Third-generation cephalosporins are particularly prone to promote bacterial resistance. Their use for pneumonia increased between 2002 and 2012 in our Emergency Department, and 80% of these prescriptions may have been avoided, i.e. third-generation cephalosporin may have been replaced by a penicillin. In 2013, we implemented an e-learning program that encouraged treating pneumonia with a penicillin rather than a Third-generation cephalosporin, when possible. The e-learning was completed by 65% of physicians in 2013 and by every Emergency Department resident since 2013. 

Objectives: to assess if the e-learning implementation was associated with a decreased proportion of patients treated with a Third-generation cephalosporin and with a decreased proportion of avoidable Third-generation cephalosporin prescriptions.

Methods: Retrospective study of a random sample of patients treated for community-acquired pneumonia in an emergency department between 2002 and 2015, and subsequently hospitalized in non-Intensive Care Units. Third-generation cephalosporin prescriptions were presumed unavoidable if they met both criteria: (i) age ≥ 65 year’s old or a comorbid condition; and (ii) allergy or intolerance to penicillin, or failure of penicillin first-line therapy, or treatment with penicillin in three previous months. Prescriptions were otherwise deemed avoidable. Percentages are shown with 95% confidence interval.

Results: 956 patients were included. The proportion of patients treated with a Third-generation cephalosporin increased significantly from 14% [7%–24%] in 2002 to 30% [20% – 42%] in 2012 (Chi-scare for trend, P=0,02). This proportion was stable between 2013 (26% [18%-36%]) and 2015 (29% [19%-40%]; Chi-scare for trend, P=0,78). Treatment with a Third-generation cephalosporin was avoidable in 165 out of 212 patients (78% [72% – 84%]) during the whole study period. The proportion of avoidable prescriptions tended to decrease after the e-learning implementation, but the difference was not statistically significant (before e-learning, 79% [72%– 85%]; after e-learning, 74 % [62% – 84%]; P=0,6). 

Conclusion: The implementation of an e-learning program seemed to stop the yearly increase of the proportion of patients treated with a Third-generation cephalosporin for pneumonia in the Emergency Department, but it failed to decrease the proportion of avoidable prescriptions of Third-generation cephalosporin. Other interventions are necessary to decrease the use of Third-generation cephalosporin for pneumonia in the Emergency Department.

QuickSOFA is an independent predictor of 30-day mortality among patients admitted to an emergency department with suspected or documented infection

Osama Bin Abdullah¹, Johannes Grand¹, Astha Sijapati¹, Petrine Nimskov¹ , Finn Erland Nielsen^1,2
1. Department of Emergency Medicine, Slagelse Hospital, Slagelse, DENMARK
2. Institute of Regional Health Services Research, University of Southern Denmark, DENMARK.

Background. Definitions and clinical criteria for sepsis have been revised in 2016. A simple bedside score (‘qSOFA’, for quick Sequential [Sepsis-Related] Organ Failure Assessment) has been proposed, which incorporates hypotension (systolic blood pressure ≤100mmHg), altered mental status and respiratory rate ≥ 22/min: the presence of at least two of these criteria has been associated with poor outcomes typical of sepsis.

Purpose. To evaluate qSOFA as a predictor of 30-day mortality in a model with other predictors of death among patients admitted to a single-centre emergency department (ED) with either suspected or documented infection on admission.

Methods. A historical cohort study among prospectively registered patients with suspected or documented infection. The patients were having at least two Systemic Inflammatory Response Syndrome (SIRS) criteria on admission and all the patients were treated with intravenous antibiotics in the ED. The admission period was from 1 November 2013 to 31 October 2014. Baseline clinical data and data for survival were obtained from a standard sepsis admission form, the patient records and The Danish Civil Registration System. Logistic regression analysis was used to adjust for potential confounders and to determine whether the predictive factors for death in the crude analyses were independently associated with 30-day mortality.

Results. A total of 434 patients with a median age of 70 years were included in the study, 246 (56.7%) were men. Fifty seven (13.1%; 95% confidence interval [CI] 9.9-16.3%) patients died during the first 30 days. Among several potential confounders tested in the model we found that age (odds ratio [OR] 1.29; 95% CI 1.03-1.61), Charlson Comorbidity Score ≥ 3 (OR 3.83; 95% CI 1.41-10.37), qSOFA score ≥2 (OR 4.78; 95% CI 2.09-10.91) and lactate values (lactate values < 2.0 as reference) in the interval 2.00-3.99 (OR 2.21; 95% CI 1.06-4.62) and lactate values ≥ 4.0 (OR 3.97; 95% CI 1.44-2,92) were associated with 30-day mortality.

Conclusion. This study shows that a new simple clinical bedside index, qSOFA, can be helpful to identify infectious patients in an ED with an increased risk of 30-day mortality.

Introduction :

Acute appendicitis is the most surgical emergency. Its diagnosis is not already evident. So we need a predictive score as simple and effective  to avoid  unnecessary investigations.Objective :To establish a predictive score of acute appendicitis more adapted  to our population and more practical.Methods :      A prospective study carried out in our  emergency department) over a period  of 2 years, involving patients presenting with acute abdominal pain in the right iliac fossa (FID). Datas interesting medical caracteristics , biologic and imaging were collected at baseline. diagnosis of acute appendicitis is confirmed by positive histological exam. Results :400 patients were enrolled and completed follow-up .the mean age of the study population was  33 +/-7 years. The sex ratio was 1.4 . Among these patients , for only 240 ( 60%) the diagnosis of appendicitis was comfirmed histologically  . The most common reason for consultation in this series is FID pain,this sign is present in 77.5% in the confirmed group group with p = 0.016. Univariate analysis identified other signs as  significantly predictifs ( p = 0.001 ) : radiation of pain from epigastrum to the umbilicus ,  positive rovsing sign and sensitive abdomen in palpation.In  multivariate analysis, our score was estabished, containing 7 variables : Vomiting>=2 épisode =1 point) , pain project From the epigastrium to the umbilicus =  2 point ,  positive  Rovsing sign =1 point , positive Blumberg sign = 1 point, sensitive abdomen =2 point , défense de la FID=  2 point and  White blood cells >10000 (hyperleucocytosis) =2 point .

The descrimination power is represented by the ROC curve. Area under the ROC curve of the appendicitis score was 0.874.This score can have a sensitivity of 99% and a specifity of 80%.

Conclusion :  many  scores have been developed (Alvarado, Andersson, François, ...), but are not common practice. A model based on variables easily available at ED, like our appendicitis score , can help ED physicians to diagnosis the acute appendicitis.