Objective: to determine how often the urinalysis (UA) contributes to clinical decision making and/or disposition decisions in the emergency department (ED).

Methods:

During 12 consecutive days, the records of all adult patients presenting to our ED were reviewed to see whether or not they a UA was ordered during their ED visit. In addition to this variable, patient demographics, and whether it influenced clinical decision-making (based on the medical decision-making section of the physician chart) or disposition decision were abstracted.

Results:

A total of 559 patients presented during the study period, of which 66% were female. The median age was 51, with an interquartile range of 35 to 68 years. 294 (38%) presented on a weekend, defined as Friday 7pm to Monday 7 am.101 (35%) presented during the night shift, defined as arriving between the hours of 7pm-7am.

265 (65%) were first seen by a physician assistant (PA) and then seen by an MD. 138 (25%) were seen by a PA alone.  A total of 232 patients (42%) were admitted. 287 patients (51%) had a UA ordered in the ED.

193 (35%) had a UA ordered by the PA. 94 (17%) had a UA ordered by the physician. The UA was cancelled in 50 patients.

Patient disposition decision was made prior to UA resulting in 60 cases (25%).

Of these, 36 (60%) were women, and the median age was 65, with an interquartile range of 49 to 73 years.

29 (48%) were seen on the weekend. 20 (33%) were seen on the night shift. 56 (93%) not seen by PA.18 (30%) ordered by PA. 42 (70%) ordered by MD. 100% UA cancelled

The UA was used in clinical decision making in 118 (66%). Univariable correlates included:

Being female (P=0.0050, 95% CI 0.0068 - 0.378)

Being older (P<0.0001, 95% CI -0.010 to -0.004)

Being first seen by a PA then a physician (P=0.0486, 95% CI= 0.0048 - 0.1555)

More often in discharged patients (P<0.0001 95% CI -0.6749 to -0.4487)

Conclusion: Our results suggest that a routine UA may not impact clinical decision making up to 33% of the time, nor alter or disposition decision one out of four times. Unnecessary tests place additional burden on the patient, and the ED personnel, and perhaps should be reconsidered.

Introduction

We investigated whether impaired cognition is associated with adverse outcomes in older emergency department (ED) patients, because this association could have large implications for ED management and follow-up after disposition. 

Methods 

A prospective multi-center cohort study was performed in all acutely presenting older patients visiting the ED (APOP study). Demographic data, disease severity and geriatric characteristics were collected during the first hour of the ED visit. Cognition was measured using the 6 Item Cognitive Impairment Test (6CIT). Cognitive impairment was defined as a 6CIT ≥11, self-reported dementia or the inability to perform the cognition test. Adverse outcome after three and twelve months was defined as a 1 point decrease in Katz-ADL, new institutionalization or mortality. Multivariable regression analysis was used to assess whether impaired cognition independently associates with adverse outcome. 

Results 

Of the 2131 included patients 588 (27.6%) had cognitive impairment. A total of 375 (24.5%) patients with normal cognition suffered from adverse outcomes after three months, compared to 280 (47.8%) patients with impaired cognition. The association remained after correction for baseline functional status, disease severity and comorbidities (OR 1.71, 95%CI 1.36-2.15). After twelve months 332 (27.9%) patients with normal cognition suffered from adverse outcome, compared to 240 (54.5%) patients with impaired cognition (adjusted OR 1.89, 95%CI 1.46-2.46). 

Key conclusions 

Cognitive impairment is highly prevalent in older ED patients and is associated with adverse outcome after three and twelve months, independent of baseline functional status, disease severity and comorbidities. This emphasizes the importance for ED physicians to assess cognition and possibly intervene.

Introduction

Older patients often experience adverse health outcomes after an Emergency Department (ED) visit, which potentially affects quality of life (QOL). Self-rated health (SRH) is a way of exploring QOL and is an important outcome of interest in older adults. There are only a few reports on SRH and its determinants in older patients visiting the ED. The aim of this study was to identify the determinants of decline in SRH in older patients three months after visiting the ED. 

Methods 

This study is an analysis of the data from the Acutely Presenting Older Patient (APOP) study in which all patients aged ≥ 70 years, attending the EDs of the Leiden University Medical Center (LUMC) and Alrijne Hospital in the Netherlands were included. At presentation and after three months, patients were asked to score their general health during the last month excluding the reason of their visit to the ED, with zero being the worst and ten being the best imaginable situation. The main outcome was a decline in SRH defined as a transition of a SRH ≥6 at baseline to a SRH

Results 

At baseline there were 1219 (81.2%) patients with a sufficient SRH (SRH ≥6) and 283 (18.8%) patients had an insufficient SRH (SRH <6). Three months after the ED visit 870 patients had a stable SRH (71.4%), 209 patients declined in their SRH (11.5%) and 142 patients died or there was no follow-up SRH available (17.1%). Independent factors associated with a decline in SRH were: male gender (OR 1.84, 95 % CI 1.19-2.85), living alone (OR 1.58, 95 % CI 1.01-2.47), living in residential care or nursing home (OR 2.76, 95 % CI 1.21-6.27), number of different medications (OR 1.08, 95 % CI 1.03-1.13), using a walking device (OR 1.73, 95 % CI 1.05-2.82) and the Katz-ADL score (OR 1.23, 95 % CI 1.02-1.48). Patients who experienced functional decline three months after an ED visit, show a steeper decline in mean SRH (0.68 points) compared to patients who did not experienced functional decline (0.12 points, p<0.001).  

Key conclusions 

Decline in SRH after an ED visit in older patients is mainly dependent on factors of functional capacity and functional decline. Preventive interventions to maintain functional status could be the solution to maintain SRH. 

Background: Older patients comprise a major proportion of all emergency admissions and associated costs. As this population grows, there will be a mounting demand for health care services and emergency services in particular. In this study, we investigated the burden and costs related to older patients’ emergency department (ED) use.

Methods: Consecutive patients aged 80 years or over admitted to a high-volume, collaborative ED during a two-year study period (January 2015 to December 2016) were included. The hospital provided primary and tertiary care emergency services to a population of 226,696 inhabitants (10,991 aged 80 years or over). Patient demographics, diagnoses, costs of ED care were retrieved from hospital records. Only in-hospital costs of ED care and examinations were included. The key factors under analysis were the incidence of emergencies and the associated costs of ED care.

Results: A total of 12,177 patients (median age 85 years, range 80-114 years; 65% female) had 24,441 ED admissions (14% of all ED admissions) during the two-year study period. The incidence of emergencies increased from 387/1,000/year (133/1,000 inhabitants of this age group required emergency services) in patients aged 80-89 year to 511/1,000/year (147/1,000) in those aged 90 years or over (p<0.001). High-frequency users (≥5 admissions/year, n=621, range 5-46 admissions) covered 6% of all ED admissions in patients aged ≥80 years.

Older patients were most often diagnosed to suffer from different types of non-specific symptoms (24%), cardiovascular diseases (18%), injuries (17%), respiratory diseases (8%), genitourinary diseases (8%) and gastrointestinal diseases (5%). Typical specific diagnosis included pneumonia (5%), femoral fracture (3.1%), cerebral infarction (2.3%), acute pyelonephritis (2.1%) and acute myocardial infarction (1.4%).

Twenty-two per cent of patients required tertiary care in our hospital, 38% were discharged home and the rest (40%) to other hospitals, to primary care centres or to nursing homes. Only 0.2% was admitted to intensive care unit. There was a steady increase in the costs according to age; population-size adjusted costs of ED care in inhabitants aged 90 years or more were over 1.3-fold (430 euros/same aged inhabitant) compared to that of those aged less than 90 years (324 euros). The mean costs of a single admission in high-frequency users did not differ significantly from those of requiring emergency evaluation only once. Patients requiring multiple admissions covered 88% of all costs of ED care in older patients.

Conclusions: A large share of older people needs ED services annually and many have repeated visits. Despite high use of ED resources and consequent costs, no specific diagnosis could be made in one-fourth of cases. Potentially avoidable ED admissions and repeat admissions could be a target for cost-reductive initiatives.

Background

The management of the elderly or patients with severe conditions has increased in emergency field. In the prehospital setting, teams are often confronted with the absence of data allowing to rule on therapeutic limitations. Emergency physicians must therefore discuss and apply therapeutic limitations, i.e. End-of-Life (EoL) decisions. These decisions should be recorded in the medical transport sheet (MTS). The aim of our study is to assess the EoL decisions rate on the Emergency Medical Service (EMS) MTS of patients considered as fragile.

Methods
We performed a monocentric, 1.5-month retrospective analysis of the medical records of patients managed in a mobile intensive care unit of an EMS located in an urban zone.
The inclusion criteria were: patient age > 85 years with a lost of autonomy and patients with an incurable disease.
The primary interest criterion was the reported EoL decisions rate, i.e. decided by the EMS and indicated on the MTS.
Secondary criteria were patients’ characteristics: the pathology concerned, the EoL decisions rate taken before the team’s arrival, the destination service when transported, and the rate of contact with the family to participate in decision-making recorded in the MTS.

Results
From mid-October to late November 2016, 63 patients met the inclusion criteria. Thirty-five (56%) were men; median age was 88 [IQR: 81-91] years. The management took place at home, at a nursing home or at a rehabilitation care service in respectively 45 (71%), 12 (19%) and 6 (10%). Pathology concerned were cardiac arrest, neurology, respiratory, cardiology, metabolic and others in respectively 18 (29%), 16 (25%), 15 (24%), 5 (8%), 3 (5%) and 4 (6%) cases.

EoL decisions were known before EMS intervention in three cases. For the others, EoL decisions were written on the MTS for 15 patients. The reported EoL decisions rate was 24% (95% CI: 14% - 36%). After medical evaluation, three (5%) were left alive at home, 20 (32%) died on scene and 40 (63%) were sent to hospital. On those, 38 (60%) patients were sent to an emergency room and two (3%) were sent to an intensive care unit with a massive haemorrhagic stroke. Family was contacted in 17 (27%) cases to participate in decision-making.

Conclusion

Reported EoL decisions rate for elderly patients without autonomy or patients deemed incurable was low. Furthermore, transports’ rate to emergency department was high and the number of patients left alive on scene was low. This could be considered as a gap in the ethical care of very fragile patients. A service procedure will be implemented to improve practices.

In emergency departments (ED), elderly patients are an increasing part of visiting patients. Their admission rate is higher than young patients and their lenght of stay is longer partially because admission can lead to loss of autonomy. Assessing autonomy level and home carers presence is not always done through ED visit. However it could help anticipate their care pathway after ED visit. We want to assess what do elderly patients visiting ED become depending on their autonomy level and the presence of carers at home before the event. We also want to draw the epidemiological portray of elderly patients and assess their mortality rate.  

Method : Prospective multicenter cohort study with inclusions done on a given day in 147 Emergency Departments. Patients ≥ 80 years old have been included and questionnaire filled in by the doctor in charge. It was dealing with patient characteristics, emergency situation, medical care, autonomy, home carers, and situation on day 30. Our main aim was to assess their mortality rate. Secondary objectives were to analyse patients characteristics and especially in terms of autonomy and home assistance. We also wanted to evaluate what do these patients become through hospitalization and institutionalization rate at day 30. We completed statistical analysis through descriptive statistics and a second part of this work will be to perform logistic regressions in order to assess association between mortality, hospitalization, institutionalization and existence of home assistance. This last part has not been done yet. Regression will adjust for age, sexe, comorbidities, severity, loss of autonomy, socioeconomic category.

Results : n= 1659 patients were included. Mean age was 86,9 ±4,7 years old. 60,7% were women. 72% were living at home (among which 79,5% with general home carers and 44,8% with professional carers). Only 2,2% had no medical history, 62,9% had more than 3 daily treatments and 36,6 % had cognitive impairment. Among patients living at home, 60,1% had mild impairment in Activity of Daily Living and 2,5% had extreme loss of autonomy. 13,7% of visiting patients had severe conditions and 3,7% were admitted in intensive care. 64,7% have been admitted after ED visit. On day 30, mortality rate was 8,3% and 30,3% of admitted patients were still hospitalized or had been institutionalized. Among patients living at home : 29,8% of patients with home carers were still admitted or had been institutionalized on day 30 vs 24,2% of patients without home carers, p<0,05. 

 Conclusion : Elderly patients are mainly living at home, most of them have at least mild loss of autonomy and 44,8% have professional carers to help them deal with their dependance. Admission and mortality rate are high. On day 30, a third of elderly patients are still hospitalized. Logistic regressions are needed to go further and to analyze association between the existence of home carers in dependent patients and hospitalization rate after visiting ED.

Background

ED work systems encompass a multitude of work stressors that impact ED professionals’ well-being and delivery of patient care. Little is known about effective interventions to improve the psychosocial ED work environment with positive effects on professionals’ mental health and quality of care. The aim of this intervention study was to analyze the prospective effects of an employee-centered intervention (“health circles”) with regard to psychosocial work stressors, mental well-being, and patient satisfaction.

Methods

This study established a two-wave interrupted time series design with a time lag of one year. The study setting comprised a multidisciplinary German ED with an annual volume of approx. 84000 patients. All ED employees (nurses, physicians, and administrative staff) were invited to participate in a survey. Validated and standardized instruments were used to measure psychosocial work stressors and mental well-being. Additionally, patients were surveyed on-site with a short questionnaire about their satisfaction with quality of care on 40 randomized days at both waves. Between baseline and follow-up, ten interdisciplinary moderated “health circles” with ED nurses and physicians were conducted on different topics of ED work organization and ED leadership. Differences over time and associations between study variables were calculated with SPSS 23.0. 

Results

Overall, N = 149 surveys were completed. 40 ED employees responded at both waves. A total of 1418 patients was surveyed. Employees reported high levels of interruptions, time pressure, and low participation opportunities throughout both waves. However, improvements after one year were reported in autonomy (p=.014), while employees’ perceptions of staffing levels (p=.046) and social support (p=.002) deteriorated. Concerning mental well-being, general job satisfaction declined (p=.013) and depersonalization increased (p=.027). Psychosocial work stressors and ED professionals’ mental well-being were strongly associated at both waves. There was evidence on divergent trends in the evaluation of psychosocial work stressors and mental well-being between nurses, physicians, and administrative staff. However, patient satisfaction with organization of care, with interactions and information from care providers, and with waiting times significantly improved from baseline to follow-up (all scales p<.001).

Discussion and Implications

To our knowledge, this is the first systematic study of a participative intervention in an ED which evaluates longitudinal effects on psychosocial work stressors, mental well-being, and patient satisfaction. We observed significant changes in autonomy, staffing, and social support of ED employees, their job satisfaction and depersonalization, and finally, significant improvements in patient satisfaction with quality of care. Our results suggest that employee-centered interventions that target the psychosocial work environment in EDs might improve quality of care.

Background

An elevated blood lactate level (hyperlactatemia) is a sensitive marker that may be used to identify critically ill patients. Capillary lactate measurement using handheld devices may allow for rapid determination of test results and these devices can be used in the pre-hospital setting. The present study aimed to investigate the agreement of capillary lactate measured using handheld lactate analyzer compared to the reference- venous blood lactate level assessed using a point of care test (POCT) blood gas analyzer in the Emergency Department (ED).

Methods

Prospective observational study of patients presenting to the ED in Hong Kong. Patients triaged as ‘urgent’ (Category 3 of the 5 category triage scale), aged 18 years or above, who presented to the ED during 2016 were recruited. Venous and capillary blood samples were collected for lactate analysis. Venous lactate levels measured by blood gas analyzer were used as a reference (VL-Ref). Capillary lactate levels were measured using two handheld analyzers (Nova StatStrip Xpress Lactate Meter and Lactate Scout+ Analyzer) (CL-Nova and CL-Scout+). Venous lactate measurements were also performed using two handheld analyzers (VL-Nova and VL-Scout+). Agreement of lactate levels from handheld analyzers with the reference blood gas analyzer was determined using Bland-Altman agreement analysis.

Results

Two hundred and forty patients (mean age 69.9 years; 54.2% males) were recruited between March and July 2016. The result of VL-Ref ranged from 0.70 to 5.38 mmol/L, with a mean of 1.96 mmol/L. 63.75% and 36.25% showed lactate level (VL-Ref)

Discussion

An overall low systemic bias were observed in CL-Scout+ (bias: -6.2%) and VL-Scout+ (bias: 13.0%), suggesting the potential clinical utility of Scout+ handheld analyzer for screening patients who should or should not have further formal lactate measurement  using a POCT blood gas analyzer or analysis in the central laboratory. In addition, POCT lactate may not be available in all EDs, or in the pre-hospital setting. Screening lactate levels using a handheld analyzer could provide information to hasten the identification of patients at risk, to make early decisions for further treatment.

Title: Agreement of emergency department and hospital diagnosis of septic shock.

Background: Sepsis is the leading cause of shock in the emergency department (ED). Clinical suspicion of infection is crucial to early identification of septic shock. No studies of agreement between real-time emergency physician (EP) impression and hospital diagnosis of septic shock have been identified in the literature.

Objectives: The primary objective was to evaluate agreement between real-time EP impression and hospital diagnosis of septic and non-septic shock.

Methods: This was an observational cohort study on patients presenting with shock in an academic tertiary ED from January 2015 to January 2017. Subjects were identified through an interactive shock alert tool that alerts EPs instantaneously when a patient has either a systolic blood pressure < 90mmHg or lactate ≥ 4mmol/L. The alert requires the EP to click their impression. Two-by-two tables for ED impression at the time of alert against hospital diagnosis were computed. Agreement of real-time EP impression was evaluated by calculating sensitivity, specificity, predictive values and likelihood ratios with 95% confidence intervals (CIs).

Results: A total of 2208 ED visits met inclusion criteria. After applying exclusion criteria, 1520 remained and were included in the study. The mean age was 61.1 (SD 18.2) years, and 56.7% were men. There was a good hospital agreement with the EP impression of septic shock, with the following performance: sensitivity 77.3% (95% CI 73.7-80.5), specificity 89.2% (95% CI 87.0-91.0), positive predictive value (PPV) 81.7% (95% CI 78.3-84.7), negative predictive value (NPV) 86.2% (95%CI 83.9-88.3), positive likelihood ratio 7.153 (95% CI 5.919-8.644) and negative likelihood ratio 0.255 (95% CI 0.219-0.296). Dehydration was most common EP impression of non-septic shock, among those who turned out to have hospital diagnosis of septic shock.

Conclusion: Good agreement between real-time EP impression of septic and non-septic shock and hospital diagnoses was shown by PPV of 81.7% (95% CI 78.3-84.7), and NPV of 86.2% (95%CI 83.9-88.3). This outperforms available lab testing in diagnosing sepsis.

Title: Risk factors helping to decide for whom to isolate, when suffering from acute gastroenteritis.

Background:

Isolation of contagious patients with gastroenteritis requires more caregiver time and delays the examination, start of treatment and reduces the level of care. But isolation is, especially in an emergency department (ED) with high patient flow, necessary to prevent spreading of communicable diseases.

The aim of the study was to identify risk factors helping to identify patients with acute gastroenteritis infected with Norovirus or toxic Clostridium difficile requiring isolation, in order to choose the right room before or at the patients’ arrival.

Method:

At four regional hospitals all patients, acutely admitted due to acute gastroenteritis, were interviewed and stool samples analyzed for Norovirus, toxic Clostridium difficile and pathogenic gut bacteria. Vital parameter at admission and anamnestic factors (gastrointestinal symptoms before admission, travel history, previous and recent treatment with antibiotics) were obtained.

Results:

191 patients were included, 54 patients were not able to deliver any fecal sample. 81 samples were negative, 22 samples were positive for pathogenic gut bacteria, 32 were positive for infectious gastroenteritis (Norovirus or toxic Clostridium difficile) and 2 were positive for infectious gastroenteritis and pathogenic gut bacteria (Campylobacter one combined with norovirus, once combined with toxic Clostridium difficile).

The following risk factors were found significant for Norovirus: a sub febrile temperature (37.5 -38.5 Celsius OR 3.5; 95% CI 1.1 -11.6), length of diarrhea (more than three days OR 0.3; 95% CI 0.01- 0.3), length of vomiting (one day OR 4; 95% CI 1.2 – 13.2), number of vomiting’s (more than 10 on the day of symptom debut OR 6.9; 95% CI 1.7 – 28.1) and appearance of another patient infected with Norovirus with in the previous week (OR 4.3; 95% CI 1.4 - 12.7).

Mucus in stools was significant for toxic Clostridium difficile (OR 3.5; 95% CI 1.02 – 12.3) as well as previous treatment with antibiotics (completed cure one month before admission OR 15.5; 95% CI 3.4 – 71.2) and low pulse (<60/minute OR 7.8; 95% CI 1.5 – 40.2) as well as length of diarrhea (more than three days OR 4.9; 95% CI 1.1- 23.0).

Conclusion:

An algorithm to identify patient with infectious gastroenteritis will be developed by using the identified risk factors. As Norovirus and toxic Clostridium difficile can be significant in the same factor but with opposite meaning (length of diarrhea for Noro OR 0.3 and toxic Clostridium difficile OR 4.9) both factors may not be combined to one algorithm for infectious gastroenteritis.

Introduction: Recent studies have demonstrated the existence of social inequalities in health and healthcare access worldwide. Having a general practitioner (GP) and a greater continuity of care is associated with decreased emergency department (ED) use at any age of life. Some studies have demonstrated that interventions aiming to enhance follow-up after ED visit are associated with a better healthcare continuity and a reduction of ulterior ED visits. But no data is available concerning quality of continuity of care after an ED visit.

Objectives: To identify the determinants of GP visit after an ED visit.

Method: We included all adult patients that have presented in an ED during a 7 days period. Patients admitted to the hospital were excluded.  Collected data included socio-economic and medical characteristics of patients as well as GP visit in the month following ED visit. A mutivariate logistic regression has been used to identify the determinants of GP consultation.

Results: The study included 243 patients among which, 122 (50%) consulted their GP in the month following ED visit. Among all GPs, 75 (31%) were located in an area of less than 2km from the ED. Older age (p=0,001), poor self-reported health status (p=0,001), self-reported functional limitation (p=0,020), good perceived accessibility of GP (p=0,001) and prescription of work stoppage (p=0,029) were associated with an increased frequency of GP visit. In multivariate analysis, only age (aOR=1.03), poor self-reported health status (aOR=2.95) and prescription of work stoppage (aOR=2.95) were associated with increased likelihood of GP consult. Only 57 patients who had consulted their GP brought the medical report from ED visit.

Conclusion: Our study showed that half of patients consulted their GP after an ED visit and about 30% of GPs were located in a 2km area. Primary care use was partly explained by age, poor reported health status and prescription of work stoppage. 

Introduction
We have joined the National Emergency Airway Registry (NEAR) which is a multicenter registry that has compiled data about intubations conducted at academic teaching institutions since the 1990s. Between 2002 and 2012 the registry recorded 17,583 intubations at 13 facilities. A new data collection cycle began in January 2016 and our institution joined in February 2016.
Objectives
The goal of this study was to analyze the data for our institution and compare it to the published national registry data for 2002-2012.
Materials & Methods
We analyzed the data in the NEAR registry for our institution for February 2016 to February 2017. Using descriptive statistics we examined the indications for intubation, operators, success rate, and adverse event rates for emergency department intubations at our facility and compared them to published NEAR data.
Results
Over 12 months we reported 380 intubations to NEAR. About 2/3rds of intubations were indicated for medical emergencies with the remaining 1/3 being done in trauma cases. Our overall first pass success rate was 84% which is on par with the published national rate. Resident physicians performed 95% of intubations while attendings performed the remaining 5%. Adverse events occurred in ~11% of intubation patients at our institution and events included vomiting, cardiac dysrhythmias, laryngospasm, hypoxia, and misplacement of the tube. This percentage is also similar to the published national average.  Small differences were seen in the induction agents used at our facility compared to national rates: etomidate 83%, ketamine 13%, propofol 3%, midazolam 1% vs 91%, 1%, 3.2 %, 1.4 % respectively. A more significant difference was found in the use of paralytic agents: we used rocuronium in 66% and succinylcholine in 34% of intubations requiring paralytics compared to the national rates of 23% for rocuronium and 75 % for succinylcholine.
Conclusions
Our data so far shows similar rates of first pass intubation success and adverse event rates when compared to the previous cycle NEAR data. The preference of paralytic agents at our institution appears to be the reverse of the national trends.  Continued monitoring will help us identify deficiencies in practice and opportunities for improving training and patient care.
References
1) Brown CA, Bair AE, Pallin DJ, et al. Techniques, success, and adverse events of emergency department adult intubations. Annals of Emergency Medicine. 2015. 65:363-370

Purpose of the study: In trauma setting, difficult airway (DA) emergencies require prompt intervention, and may result in significant morbidity and mortality. Direct airway trauma, accompanied with cervical immobility, and tenuous haemodynamics further complicate decision-making proccess. An unanticipated DA often results in an adverse outcome if the concerned trauma physician is either not abreast with current guidelines or is not familiar with the use of variety of airway adjuncts. The Difficult Airway Society (DAS) guidelines provide framework for the management of the unanticipated DA, ending with the emergency ‘front-of-neck access’ (FONA) algorithm in the ‘can't intubate, can't oxygenate’ (CICO) scenario. In the 2015 DAS guidelines, ‘scalpel-bougie’ (SB) technique has been advocated, because it requires equipment readily available to most clinicians regardless of clinical setting. In addition, other techniques, such as needle cricothyroidotomy (CCT), are proposed, depending on individual experience, training, comfort of use, and case specifics. Recent scientific evidence regarding the technical and human factors superiority of one technique over another remains largely speculative. In our study we aimed to investigate European Trauma Course (ETC) instructors’ management preferences during CICO emergencies. Materials and methods: A total of 44 (69%) instructors, actively teaching on ETC in Austria throughout 2016, completed an online survey. The survey consisted of demographic data, and 13 open questions regarding DA management in CICO scenarios. Results: There were 29 (66%) male instructors, aged from 30 to 71 years (median 42). The majority of instructors were anesthetists (57%), followed by emergency physicians, and trauma surgeons in descending order. Nearly two thirds (73%) of responders were aware of protocolled FONA algorithms for the CICO scenarios, instituted in place of their own operating rooms. However, only half of them would consider these proposed institutional algorithms in real life CICO emergencies. Despite the 2015 DAS FONA algorithm guidelines, promoting SB technique, nearly half of our instructors are still in favor of a CCT technique. Our instructors expressed the strongest agreement with the statement that cannula techniques, when compared to surgical ones, potentially offer advantages from a human factors perspective, if supported by appropriate educational programs. Conclusions: Our results suggest our instructors have a strategy of utilizing well-practiced algorithms at a moment’s notice when faced with a critical trauma patient during the CICO scenarios. However, using a scalpel still remains a rare intervention for most of them. Directing resources towards demystification and better training in the scalpel techniques, may improve our instructors’ willingness of performing SB interventions. 

Background& Aim: Stroke is a leading cause of mortality and has a subsequent serious long-term disability among survivors. This study evaluated the relationship between sTWEAK (soluble Tumor necrosis factor-like weak inducer of apoptosis) protein levels and the lesion area measured in diffusion-weighted imaging (DWI) in acute ischemic stroke patients.

Patients and Methods: Forty-one patients with acute ischemic stroke and 41 control cases were included in the study. The age, sex, chronic illnesses, emergency department admission times, emergency department examinations, GCS and 7-day prognostic status of the patients were evaluated.

Results: The symptoms of stroke started within the first 3 hours in 32 (78%), between 4-6 hours in 6 (14.7%) and between 7-12 hours in 3 of the patients (7.3%). There was no difference between onset time of complaints, age, regular medication usage, medications, evaluation findings in emergency department, number of findings and GCS (p>0.05). However there were statistically significant differences between the number of findings noted during the emergency evaluation of patients, GCS and the ischemic area volumes measured in magnetic resonance imaging (MRI) (p=0.001, p=0.022, respectively). There was also a statistically significant difference in blood urea nitrogen, creatinine and the volume of ischemic area measured in MRI among the patients who died (19.5%) within the first 7 days and alive group (p=0.011, p=0.029, p=0.004, respectively). A statistically strong negative correlation between the ischemic area volume measured in the DWI and the GCS (r=-0.61), and intermediate positive correlation between BUN (r=0.40) and creatinine (r=0.36) were detected (p<0.05). There was a statistically significant difference in sTWEAK levels between stroke patients and healthy controls included into the study (p<0.001). sTWEAK levels of stroke patients were significantly higher than the healthy controls [AUC:0.86 (0.77-0.94); p<0.001] and the cut-off value was determined as 995.5pg/ml. This cut-off value for sTWEAK had a sensitivity of 80.5% and specificity of 82.5% with a positive predictive value of 82.5% and negative predictive value of 80.5%.

Conclusion: sTWEAK is a valuable marker for the diagnosis of acute stroke but is not significant in predicting early prognosis.

Introduction:

The inflammation is well known in the initiation and propagation of acute coronary syndrome. The aim of study was to assess the ability of C - reactive protein (CRP) to predict in hospital morbidity of patients with non ST elevated myocardial infarction (NSTEMI).

Methods:

It was an observational prospective study conducted in an emergency department (ED) during six months (July-December 2015). We included patients who met criteria of NSTEMI aged more than18 years. The prognosis was evaluated on the occurrence of myocardial infarction (MI) and hospitalization in cardiac intensive care unit (CICU) within 30 days.

Results:

We enrolled 89 patients. The mean age was 59 years. Sixty eight were males. Sixty seven percent of patients were smokers, 47% had hypertension, 33% diabetes, 13% dyslipidemia and 25% had coronary disease. A depressed ST segment was found in 11.2% of cases, inversed T wave in 10.1%, and left bundle bloc in 5%. The mean CRP of patients admitted to CICU was significantly higner than CRP of others (not admitted to CICU) with 35.54 ± 33.18 vs 13.36 ± 20.2 (p˂0.000). The mean CRP of patients with MI was significantly higner than CRP of others with 39.55 ± 27.39 vs 16.9 ± 29.38 (p˂0.000).

Conclusion:

CRP can be used as an indepedent factor to predict morbidity in patients with NSTEMI in emergency department.

Background

The national early warning score (NEWS) is a combined measure of vital signs and is used for triage in the ED. The NEWS is a strong short-term outcome predictor. However, patients with normal vital signs (low NEWS) may also be at risk of a negative outcome and thus have need for clinical attention. Soluble urokinase plasminogen activator receptor (suPAR) is an inflammatory biomarker that has been shown to be a strong marker of patient prognosis. Here, we aimed to investigate whether suPAR in combination with NEWS can improve risk prediction.

Methods

This study includes 17,312 patients admitted to the acute medical department, Copenhagen University Hospital Amager and Hvidovre, between 18 November 2013 and 30 September 2015. Patients were followed for 90 days via national registries. suPAR measurements and data on vital signs, admission NEWS, diagnoses, and vital status were combined for the index admission. Endpoints were in-hospital-, 30-day-, and 90-day mortality. Statistical analysis was carried out with Kruskal-Wallis test, multivariate Poisson regression analysis, and receiver operating characteristics (ROC) curve analysis.

Results

NEWS was available for 16,244 patients (93.8%) and ranged from 0-16. The majority of patients (59.7%) had a NEWS of 0-1. Median suPAR increased with NEWS (P<0.0001), and suPAR and NEWS were weakly positively correlated (Kendall’s tau-b 0.23, P<0.0001).

The frequency of patients who died increased with NEWS score (P<0.0001) for in-hospital-, 30-day-, and 90-day mortality. Furthermore, mortality rates for all endpoints increased with increasing NEWS group compared with patients with NEWS 0-1 in Poisson regression adjusted for age and sex.

The median suPAR level at the index admission was significantly higher in patients who died compared with patients who survived at all three endpoints (P<0.0001). High suPAR was significantly associated with increased mortality rates in all NEWS groups and for all endpoints, except for in-hospital mortality for patients with a NEWS of 6. The mortality rate ratio for a doubling in suPAR was highest for patients with NEWS 0-1.

ROC curve analyses were carried out for predicting in-hospital-, 30-day-, and 90-day mortality. The AUCs for all three endpoints were markedly improved when adding age and sex to the NEWS. The addition of suPAR further improved the prediction (P<0.0001). For in-hospital mortality, the AUC for NEWS alone was improved from 0.87 (95% CI, 0.85-0.88) to 0.92 (95% CI 0.91-0.92) after adding age, sex, and suPAR.

Conclusion

In this study of acute medical patients, we found that NEWS and suPAR were both strongly associated with risk of in-hospital-, 30-day-, and 90-day mortality and suPAR improved the predictive value of the NEWS. The suPAR level increased with increasing NEWS and there was a strong association between suPAR and mortality across NEWS scores; suPAR was a stronger predictor of mortality in patients with low NEWS scores. 

Background. The laboratory turn-around time for results from central laboratories (CL) can take over 60min compared to 10-15min with point-of-care bedside testing (POCT). However, many studies on POCT, focused on selected tests and limited patient populations, have suggested reduced length of stay (LOS). Many have also reported, where POCT strategy alone has not necessarily improved LOS or had effect on only certain group of patients.  

In this study, we hypothesized that POCT would reduce LOS in emergency department (ED) when compared to central laboratory testing and be a factor in patient discharge destination, home or hospital.

Methods. Single centre observational study was performed in random ED patients, excluding ambulatory and fast-track, at Jorvi, Helsinki University Central Hospital, Finland. Blood testing was performed either with POC instruments iSTAT (Abbott) for blood gases and chemistry panel, and PocH-100i (Roche) for full blood count, and Afinion (Alere) for CRP or at central laboratory or combination of both. Blood draw and POCTs were performed by experienced nurses. Time to blood draw, results availability, and disposition of patients either to home or hospital were captured and analysed by Mann-Whitney U test and a p value less than 0.05 considered as statistically significant. Patients with any missing data were eliminated from the analysis. This study was approved by local institutional ethics committee.

Results. During the four-week study period, 2618 patients underwent sample testing (POCT: n=726, central lab: n=1669; both n=726). The average time for blood draw after registration ranged from 1:12±0:56 to 1:30±1:16 hours and it did not depend on the method of laboratory testing. POCT provided results significantly faster than the other two methods of testing (mean±SD for POC 1:02±1:56, CL 2:31±3:18, Combined 3:18±3:36 hours, p<0.0001). The overall ED LOS was also reduced (POC 6:40±3:36, CL 8:05±4:59, Combined 8:13±5:17 hours, p<0.0001). The mean ED LOSs were not statistically significant when the patients were discharged to hospital/care unit (POC 7:33±2:10, CL 8:32±1:07, Combined 8:47±1:05 hours, p=ns), whereas the patients with POCT were discharged home at least 2 hours earlier than those who had testing done by other two methods (POC 5:58±1:18, CL 7:48±1:58, Combined 7:22±1:32 hours, p<0.0001). The percentages of patients discharged were: to home POC 16%, CL 50%, Combined 34% and to hospital: POC 10%, CL 56%, Combined 34%.

Conclusion. POCT shortened laboratory process significantly and made results available significantly faster than the central lab or combined testing, resulting in overall LOS reduction in ED. This also provides options to discharge patients home quicker than to hospital/care unit that may be delayed due to the need for additional diagnosis, or availability of hospital beds. Thus, with proper training and education to the ED care team, POCT can be used as an effective tool for managing patient flow in ED.

BACGROUND: Non-traumatic chest pain is a common presenting complaint among patients seeking care in the Emergency Department (ED). A substantial proportion of patients with chest pain are admitted for inpatient care in order to rule-out acute coronary syndrome (ACS) and only a small proportion had abnormal tests and lead to a change in management. These admissions and investigations in patients without ACS cause a substantial health care burden. At the same time, 2-4% of patients with ACS are erroneously discharged from the ED. The aim of this study is to assess the accuracy of the Diamond Forest clinical decision rule (CDR) to select candidates for coronary CT in patients with non-traumatic chest pain and suspicious of ACS and the adequacy of coronary CT requests in emergency department.

METHODS: We prospectively enrolled adults (age ≥18 years) who presented with chest pain at emergency department of Cruces University Hospital (a tertiary hospital with a cover population of 320,000 people) over 12 months. Physicians completed standardized data collection forms before diagnostic testing. The primary adjudicated outcome was acute myocardial infarction, revascularization, or death of cardiac or unknown cause within 3 months. To include patients in the study we stablish three premises: normal/no diagnosis of ACS in EKG, chest radiograph performed without an alternative diagnosis of ischemic heart disease (IHD) and negative troponin. To stablish the pretest probability (PTP) of IHD the Diamond-Forrest scale (DFS) was calculated according to the characteristics of the pain (typical/atypical/non-anginal), age and sex. If the PTP was from 15-65% a coronary CT was performed. Significant stenosis was considered if the decrease in vessel size in one or more vessels was >50%.

RESULTS: We included 232 patients (mean age 51.7 years, 74.1% male, 12.3% admitted to hospital). 48.1% presented typical angina, 12.3% atypical angina and 39.6% non-anginal pain according to the DFS. We calculate diagnostic accuracy of the Diamond Forest clinical decision rule (CDR) to select candidates for coronary CT, with the following characteristics: sensitivity 87.5% (95% confidence interval [CI] 69.0–95.7%), specificity 51.9% (95%CI 45.2–58.6%), positive predictive value 17.4% (95%CI 11.6–25.1%) and negative predictive value 97.3% (95%CI 92.4–99.1%). 46.1% had PTP <15% for IHD, 3 with significant coronary stenosis (SCE)> 50%. 43.1% had PTP 15-65%, 13 (13%) had SCE > 50%. 8.2% had PTP 66-85%, 31.6% had SCE > 50% and from 6 cases with PTP > 85%, 33.3% had IHD. In 4 cases cardiac catheterization was performed and it was not possible in 2 cases.

DISCUSSION: Coronary CT has been increasing its importance in the management of ACS being a fast, safe and efficient diagnostic tool for patients with low-intermediate risk of ACS in the ED. The DFS is not an adequate CDR to select candidates for coronary CT in patients with non-traumatic chest pain at the ED.