Wednesday 27 September
08:30

"Wednesday 27 September"

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A40
08:30 - 09:00

Keynote Lecture 3

Moderator: Christian HOHENSTEIN (PHYSICIAN) (BAD BERKA, Germany)
08:30 - 09:00 Constructive alignment: Curriculum, examination, training & beyond. Eric DRYVER (Consultant) (Speaker, Lund, Sweden)
Trianti Hall
09:10

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A41
09:10 - 10:40

Resilience

Moderators: Dr Barbara C HOGAN (Past President of the European Society for Emergency Medicine, EuSEM) (HAMBURG, Germany), Jan STROOBANTS (Head of the Emergency Department) (Brecht, Belgium)
Coordinator: Christoph DODT (Coordinator, München, Germany)
09:10 - 09:40 Resilience in emergency response systems. Raed ARAFAT (Speaker, Romania)
09:40 - 10:10 Burnout in Emergency Medicine. Pr Pinchas HALPERN (department chair) (Speaker, Tel Aviv, Israel, Israel)
10:10 - 10:40 Management instruments in the ED: tools for creating ED resilience. Dr Barbara C HOGAN (Past President of the European Society for Emergency Medicine, EuSEM) (Speaker, HAMBURG, Germany)
Trianti Hall

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B41
09:10 - 10:40

Falck Foundation - Paramedic-led research

Moderators: Demetrios PYRROS (Greece), Nagi SOUAIBY (Chief Editor) (Byblos, Lebanon)
Coordinator: Christoph DODT (Coordinator, München, Germany)
09:10 - 09:40 Creating a research supportive EMS organisation. Karen SMITH (Speaker, MELBOURNE, Australia)
09:40 - 10:10 Doing research as a paramedic. Veronica LINDSTRÖM (Researcher, Lecture) (Speaker, Stockholm, Sweden)
10:10 - 10:40 Best paramedic-led research papers 2011-2016. Marc SABBE (Medical staff member) (Speaker, Leuven, Belgium)
Mitropoulos

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C41
09:10 - 10:40

Mountain Medicine (Game Changers)

Moderators: Steffen HERDTLE (MD) (Jena, Germany), Peter PAAL (Head of Department) (Salzburg, Austria)
Coordinator: Christian HOHENSTEIN (Coordinator, BAD BERKA, Germany)
09:10 - 09:40 "high-level CPR": BLS with AED in Mountain Medicine. Peter PAAL (Head of Department) (Speaker, Salzburg, Austria)
09:40 - 10:10 "high-level science": the EURAC simulation center. Hermann BRUGGER (Head of Institute) (Speaker, Bolzano/Bozen, Italy)
10:10 - 10:40 "high-level HAP(P)ENESS": New strategies in management of HAPE. Philip SCOTT (Anaesthetic Registrar) (Speaker, Bristol, UK)
Banqueting Hall

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D41
09:10 - 10:40

YEMD - Research
Best abstracts

Moderators: Alice HUTIN (PH) (Paris, France), Jennifer TRUCHOT (MEDECIN) (Paris, France)
Coordinator: Basak YILMAZ (Coordinator, BURDUR, Turkey)
09:10 - 09:25 Tips to write a really good abstract and present it at EUSEM. Yonathan FREUND (PUPH) (Speaker, Paris, France)
09:25 - 09:40 From the abstract to the article. Colin GRAHAM (Director and Professor of Emergency Medicine) (Speaker, Hong Kong, Hong Kong)
09:40 - 09:55 3 best YEMD articles. Youri YORDANOV (Médecin) (Speaker, Paris, France)
09:55 - 10:10 #11057 - OP118 Predicting Utilization of Advanced Medical Imaging at Emergency Department Triage Using Patient-reported Reason for Visit and Immediately Available Medical Information.
OP118 Predicting Utilization of Advanced Medical Imaging at Emergency Department Triage Using Patient-reported Reason for Visit and Immediately Available Medical Information.

Background Emergency department (ED) crowding is associated with negative health outcomes, patient dissatisfaction, and longer length of stay (LOS) during the ED visit. Advanced imaging procedures are major contributors to increased ED LOS; earlier and improved prediction of patients’ need for advanced imaging may improve overall ED efficiency. We used information immediately available at ED triage including free text data regarding a patient’s reason for visit to predict utilization of advanced medical imaging (AMI): CT, Ultrasound (US), and MRI. Methods We used the 2012 and 2013 US National Hospital Ambulatory Medical Care Survey data to examine factors associated with the utilization of CT, US, MRI, and multiple AMI during a patient’s ED stay. We incorporated natural language processing (NLP) in multivariable logistic regression models to examine whether patient-reported reasons for visit available at time of ED triage improved prediction for AMI use.

Results: Among the 50,976 ED visits from 642 hospitals, 9,488 (18.6%) resulted in advanced medical imaging use including 7,240 CTs (14.2%), 1,585 ultrasounds (3.1%), 178 MRIs (0.35%) and 485 (0.95%) multiple types of AMI. Black patients had lower odds for all AMI use compared to whites (OR 0.64; 0.59-0.68). Odds of AMI use increased for patients with history of dementia (OR 4.0; 3.4-4.7), cerebrovascular disease (OR 3.1; 2.7-3.5), and diabetes (OR 1.7; 1.6-1.9). The predictive accuracy of the multivariable logistic models for all types of AMI use improved with the inclusion of patient-reported information using NLP: c-statistic increased from 0.74 to 0.82 for CT use, 0.76 to 0.83 for US use, 0.70 to 0.78 for MRI use, and 0.73 to 0.79 for multiple AMI use.

Conclusions: Patient-reported information available during ED triage can be used to predict the use eventual use of advanced medical imaging.  Models such as this which employ immediately available data and patient reported reasons for visit may help to identify patients earlier who will require various types of imaging during their ED stay.  These findings the potential to impact radiology and ED workflow. 


Justin SCHRAGER (Atlanta, USA), Rachel PATZER, Xingyu ZHANG, Joyce KIM
10:10 - 10:25 #11616 - OP119 An Analytical Approach to the Risk Stratification Screening of Sepsis utilizing The Systemic Inflammatory Response Criteria (SIRS) versus the Quick Sepsis Organ Failure Assessment (QSofa) in Portiuncula University Hospital, Ireland.
OP119 An Analytical Approach to the Risk Stratification Screening of Sepsis utilizing The Systemic Inflammatory Response Criteria (SIRS) versus the Quick Sepsis Organ Failure Assessment (QSofa) in Portiuncula University Hospital, Ireland.

In February 2016, the 3rd International Consensus for Sepsis Definitions were revised. A major change in the approach to sepsis was replacing the widely used SIRS criteria with the new qSofa Score. As the new Sepsis Guidelines replace existing medical practices, we can expect considerable impacts in terms of identification, management, and treatment of sepsis.
The objective of this paper was to analyze and compare the sensitivity and specificity between the SIRS criteria and the 2016 new qSofa Score in the detection and recognition of sepsis.
A retrospective study was carried out between the period of July 2015 to November 2015 where patients that were admitted due to sepsis (n=79). These patients were studied in terms of recognition in triage based on the SIRS criteria and the new qSofa Score which comprises of hypotension, altered mental status, and tachypnea. This study includes: the elements of recognition at triage, patient demographics (age and sex), common qsofa criteria, prevalence of type of sepsis that is captured most by the qSofa Score, a termed “Evolving qsofa” for patients whom at triage were qsofa negative but Developed qsofa Positive whist in the Emergency Department.
The total number of patients studied that were SIRS positive and admitted for sepsis were 79 (n=79). The mean age was 67, 35 males and 44 females. 28 had a respiratory source and 29 urinary tract infection. 43 sepsis cases were recognized using the qSofa (54.4% CI,43:79). Patients that developed a positive qsofa Score (whom were previously negative) were termed “Evolving qsofa” and were numbered at 10 (12.6% CI, 10:79). This brings the total to 53 positive qsofa in the time of study (67.08% CI, 53:79) (P>0.01). The mean time taken for a septic patient to be seen recorded at 39.17minutes. ICU admissions were 23 in total (29.11%, 23:79). All ICU admissions were patients with a positive qsofa (100% CI, 53:23). Positive Cultures numbered at 62 (78.4%, 62:79). The breakdown of positive qsofa criteria was as follows: Tachypnea numbered 34 (64.15% CI 34:53), Hypotension numbered 38 (71.69%, 38:53), Altered mental status numbered 26 (49.05%, 26:53). There were no mortalities resulting from sepsis in the ED during the term of the study.
Conclusively, this study stresses the consideration for the continuum of sepsis and proves that the qsofa has an extremely high specificity and overall accuracy in identifying septic debilitated patients whom will require ICU, and therefore superior to SIRS. However, the SIRS Criteria with its lowered Receiver operating Characteristics [ROC], possesses high sensitivity, enabling a wider cohort of patients presenting with infection to be triaged as likely sepsis and ensure robust Sepsis Screening.


Marcus JEE POH HOCK (Galway, Ireland), Kiren GOVENDER
10:25 - 10:40 #11751 - OP120 High-Dependency Observation Units: which parameters to identify patients at high risk of ICU transfer?
OP120 High-Dependency Observation Units: which parameters to identify patients at high risk of ICU transfer?

Aims: To evaluate independent predictors of ICU (Intensive care Unit) transfer in a multicentre population of patients admitted in two Emergency Department High Dependency Units (ED-HDU).

Methods: From June, 2014, to July, 2016, we recorded all patients admitted in the ED-HDU of University Hospital Careggi and in the ED-HDU in the Azienda Ospedaliero - Universitaria Policlinico - Vittorio Emanuele in a standardized database;; after 25 months, we analyzed the database in order to identify predictive parameters of an adverse outcome. To standardize comorbidity, Charlson index was calculated; SOFA score calculation was employed to evaluate organ dysfunction. The primary end-point was ICU admission.

Results: During the period June 2014-July 2016, 3311 patients were admitted in the two Units, 1822 in Florence and 1489 in Catania, mean age 72±16 years; overall HDU mortality rate was 5% (n=171). The most frequent admission diagnosis were COPD exacerbations (9%), ischemic (11%) and congestive (19%) heart disease, trauma (7%) and cardiac arrhythmias (18%). Overall 18% of patients presented a respiratory failure requiring non-invasive ventilation and 7% had a shock requiring vasoactive medications.

At HDU admission, 32% of patients presented an infections; respectively 4 and 8% of patients showed a respiratory (pH <7.3 with pCO2 >45 mmHg) or metabolic acidosis (Base excess ≥ -5 or lactate level 1.5 time the reference level); mean SOFA score, calculated on the basis of the worst values in the first 24 hours, was 3.8±3.3. Overall 208 (7% of HDU survivors) patients were transferred to an Intensive Care Unit (ICU): compared with patients with a good prognosis, age was comparable between patients transferred to ICU and the others (71±15 vs 72±16, p=NS), while comorbidity burden (Charlson index 3.1±2.5 vs 2.8±2.6, p=0.046) was only slightly higher in patients admitted to ICU . Presence and number of organ insufficiency actually differentiated patients’ disposition: compared with patients transferred to an ordinary ward, number of organ failure was significantly higher in patients transferred to ICU (1.0±0.9 vs 0.6±0.7, p<0.001) as well as the presence of respiratory (41 vs 15%), renal (39 vs 32%) and cardiovascular (18 vs 7%) failure.  A sepsis (23 vs 10%), as well as a septic shock (11 vs 4%), was more frequent among patients transferred to an ICU.

In a multivariable analysis which included all variables significantly different according to ICU transfer (SOFA score, Charlson index, presence of acidosis and presence of infection at admission) SOFA score was independently associated with a untoward prognosis in the whole study population (RR 1.23; 95%CI 1.16-1.29, p<0.001); the result was confirmed among patients admitted in Catania Center (RR 1.39; 95%CI 1.26-1.52, p<0.001) and Florence center (RR 1.23; 95%CI 1.15-1.32, p<0.001).

Conclusions: a higher SOFA score was the only independent predictor of ICU admission in an unselected population of HDU patients. 


Federico MEO, Arianna GANDINI (Florence, Italy), Paola NOTO, Giuseppe MANGANO, Giuseppe CARPINTERI, Francesca INNOCENTI, Riccardo PINI
Skalkotas

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F41
09:10 - 10:40

Free Papers Session 12

Moderators: Dr George NOTAS (DOCTOR) (HERAKLION, Greece), Anastasia ZIGOURA (Greece)
09:10 - 09:20 #11104 - OP100 How often does a routine urinalysis help with emergency department clinical decision making ?
OP100 How often does a routine urinalysis help with emergency department clinical decision making ?

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.

 

 


Bethany BALLINGER (Orlando), Latha GANTI, Ambika ANAND
09:20 - 09:30 #10850 - OP101 Impaired cognition is highly prevalent and independently associated with adverse outcomes in older patients presenting to the emergency department; the APOP study.
OP101 Impaired cognition is highly prevalent and independently associated with adverse outcomes in older patients presenting to the emergency department; the APOP study.

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.


Jacinta LUCKE (Haarlem, The Netherlands), Jelle DE GELDER, Christian HERINGHAUS, Jaap FOGTELOO, Sander ANTEN, Gerard-Jan BLAUW, Bas DE GROOT, Simon MOOIJAART
09:30 - 09:40 #10952 - OP102 Determinants of Self-Rated Health in older adults before and three months after an emergency department visit; a prospective study.
OP102 Determinants of Self-Rated Health in older adults before and three months after an emergency department visit; a prospective study.

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. 


Floor VAN DEUDEKOM, Jelle DE GELDER, Jacinta LUCKE, Anneleen OOSTENDORP - LANGE, Sander ANTEN, Blauw GERARD JAN, Bas DE GROOT, Simon MOOIJAART (LEIDEN, The Netherlands)
09:40 - 09:50 #10982 - OP103 Emergency admissions in older patients: a population-based survey.
OP103 Emergency admissions in older patients: a population-based survey.

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.


Mika UKKONEN (Tampere, Finland), Esa JÄMSEN, Rainer ZEITLIN, Tuuli LÖFGREN, Satu-Liisa PAUNIAHO
09:50 - 10:00 #11823 - OP104 End-of-Life decisions rate in the prehospital field for fragile patients.
OP104 End-of-Life decisions rate in the prehospital field for fragile patients.

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.


Margot CASSUTO (Garches), Paul-Georges REUTER, Cécile URSAT, Pauline DESWARTE, Caroline PÉTISNÉ, Anna OZGULER, Michel BAER, Thomas LOEB
10:00 - 10:10 #11925 - OP105 Loss of autonomy and home carers in elderly patients visiting the Emergency Department.
OP105 Loss of autonomy and home carers in elderly patients visiting the Emergency Department.

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.


Anne-Laure FERAL-PIERSSENS (Bobigny), Fatima SEHIMI, Gustave TOURY, Clement CARBONNIER, Marie BALLESTER, Philippe JUVIN
10:10 - 10:20 #11263 - OP106 Improving ED working conditions, employee well-being, and patient satisfaction: An intervention study.
OP106 Improving ED working conditions, employee well-being, and patient satisfaction: An intervention study.

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.


Anna SCHNEIDER (Munich, Germany), Markus WEHLER, Matthias WEIGL
10:20 - 10:30 #11364 - OP107 Capillary lactate vs POCT venous lactate in the emergency department.
OP107 Capillary lactate vs POCT venous lactate in the emergency department.

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.


Ronson Sze Long LO, Dr Kevin Kei Ching HUNG (Hong Kong, Hong Kong), Ling Yan LEUNG, Kwok Hung LEE, Chun Yu YEUNG, Suet Yi CHAN, Colin GRAHAM
10:30 - 10:40 #11770 - OP108 Agreement of emergency department and hospital diagnosis of septic shock.
OP108 Agreement of emergency department and hospital diagnosis of septic shock.

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.


Miriam V. THYGESEN (Aarhus, Denmark), Casey M. CLEMENTS, Vitaly HERASEVICH, Hans KIRKEGAARD, Bo E. MADSEN
Kokkali

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E41
09:10 - 10:40

EM development: The International ways

Moderators: Panos AGOURIDAKIS (IRAKLION, Greece), Bernard FOEX (Consultant in Emergency Medicine and Critical Care) (Manchester, United Kingdom)
09:10 - 09:40 The Development Tendency of Emergency Medicine in China. Wang ZHONG (Speaker, China)
09:40 - 10:10 Cultural contamination for a better European EM. The exchange program for young doctors. Roberta PETRINO (Head of department) (Speaker, Italie, Italy), Pr Riccardo PINI (Director, E.D. High Dependency Unit) (Speaker, Florence, Italy)
10:10 - 10:40 Development of EUSEM Research Network. Said LARIBI (PU-PH, chef de pôle) (Speaker, Tours, France)
MC-3
11:10

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A42
11:10 - 12:40

Toxicology

Moderators: Kurt ANSEEUW (Medical doctor) (Antwerp, Belgium), Pr Bruno MEGARBANE (Professor, head of the department) (Paris, France)
Coordinator: Senad TABAKOVIC (Coordinator, Zürich, Switzerland)
11:10 - 11:40 Paracetamol poisoning: basics for EP, novel techniques and upcoming research. Davide LONATI (MD, Clinical Toxicologist, Invited speaker) (Speaker, PAVIA, Italy)
11:40 - 12:10 Novel phycho-active substances in the ED. Kurt ANSEEUW (Medical doctor) (Speaker, Antwerp, Belgium)
12:10 - 12:40 ECMO for treatment of cardiotoxic intoxications. Pr Bruno MEGARBANE (Professor, head of the department) (Speaker, Paris, France)
Trianti Hall

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B42
11:10 - 12:40

EUSEM journal club

Moderators: Pr Rick BODY (Professor of Emergency Medicine) (Manchester), Senad TABAKOVIC (Medical director emergency department) (Zürich, Switzerland)
Coordinator: Senad TABAKOVIC (Coordinator, Zürich, Switzerland)
Speakers: Pr Rick BODY (Professor of Emergency Medicine) (Speaker, Manchester), Colin GRAHAM (Director and Professor of Emergency Medicine) (Speaker, Hong Kong, Hong Kong), Youri YORDANOV (Médecin) (Speaker, Paris, France)
11:10 - 11:40 - Nine papers that question current practice.
11:40 - 12:10 - The top 3 papers in Emergency Medicine, 2016-17.
12:10 - 12:40 - How to bring science to the people.
Mitropoulos

"Wednesday 27 September"

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C42
11:10 - 12:40

Ethical and legal issues in EM (How To)
Ethical dilemmas in the ED

Moderators: Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, Greece), Robert LEACH (Head of Dept.) (BRUXELLES, Belgium)
Coordinator: Pr Rick BODY (Coordinator, Manchester)
11:10 - 11:40 We can do almost everything, but should we do it? Marc SABBE (Medical staff member) (Speaker, Leuven, Belgium)
11:40 - 12:10 Family-witnessed resuscitation in the Emergency Department. Helen ASKITOPOULOU (Chair Ethics Committee) (Speaker, Heraklion, Greece)
12:10 - 12:40 Withholding and withdrawing life sustaining treatments in the ED. Bernard FOEX (Consultant in Emergency Medicine and Critical Care) (Speaker, Manchester, United Kingdom)
Banqueting Hall

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F42
11:10 - 12:40

Free Papers Session 13

Moderators: Youri YORDANOV (Médecin) (Paris, France), Anastasia ZIGOURA (Greece)
11:10 - 11:20 #10860 - OP109 Risk factors helping to decide for whom to isolate, when suffering from acute gastroenteritis.
OP109 Risk factors helping to decide for whom to isolate, when suffering from acute gastroenteritis.

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.


Florence SKYUM, Vibeke ANDERSEN, Ming CHEN, Court PEDERSEN, Pr Christian Backer MOGENSEN (Aabenraa, Denmark)
11:20 - 11:30 #11603 - OP110 Socio-economic determinants of general practitioner consultation after emergencies visit.
OP110 Socio-economic determinants of general practitioner consultation after emergencies visit.

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. 


Julie ROTIVAL, Diane NAOURI, Youri YORDANOV (Paris), Erwan DEBUC, Dominique PATERON
11:30 - 11:40 #10964 - OP111 TTUHSC EP Intubation Results from the National Emergency Airway Registry (NEAR).
OP111 TTUHSC EP Intubation Results from the National Emergency Airway Registry (NEAR).

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


Robert KILGO, Radosveta WELLS (El Paso, USA), Scott CRAWFORD, Sabrina TAYLOR, Michael TRAN, Brett TRULLENDER, Sam SNEAU, Stormy MONKS, Susan WATTS
11:40 - 11:50 #11906 - OP112 Trauma setting ‘can’t intubate, can’t oxygenate’ emergencies: European Trauma Course Austria instructors' perspective.
OP112 Trauma setting ‘can’t intubate, can’t oxygenate’ emergencies: European Trauma Course Austria instructors' perspective.

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. 


Ileana LULIC, Dr Dinka LULIC (Zagreb, Croatia), Florian TRUMMER, Adi DEIXLER, Katja KALAN USTAR, Christian SCHREIBER, Michael HÜPFL
11:50 - 12:00 #11422 - OP113 The correlation and prognostic value of high sTWEAK protein levels and ischemic area volume detected by diffusion weighted imaging in acute ischemic stroke patients.
OP113 The correlation and prognostic value of high sTWEAK protein levels and ischemic area volume detected by diffusion weighted imaging in acute ischemic stroke patients.

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.


Ertan CÖMERTPAY, Nermin DINDAR BADEM, Sevilay VURAL (Yozgat, Turkey), Oğuz EROĞLU, Figen COŞKUN
12:00 - 12:10 #11532 - OP114 C - reactive protein as a prognosticator in non ST elevated myocardial infarction.
OP114 C - reactive protein as a prognosticator in non ST elevated myocardial infarction.

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.


Saloua AMRI, Najeh HAJJEM, Imene MEKKI (Tunis, Tunisia), Mohamed Walid MHAJBA
12:10 - 12:20 #11582 - OP115 suPAR improves risk prediction with national early warning score in acute medical patients.
OP115 suPAR improves risk prediction with national early warning score in acute medical patients.

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. 


Line Jee Hartmann RASMUSSEN (HVIDOVRE, Denmark), Steen LADELUND, Thomas Huneck HAUPT, Gertrude ELLEKILDE, Jesper EUGEN-OLSEN, Ove ANDERSEN
12:20 - 12:30 #10903 - OP116 Comparison of point-of-care testing to conventional laboratory process in urban emergency department.
OP116 Comparison of point-of-care testing to conventional laboratory process in urban emergency department.

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.


Veli-Pekka HARJOLA (Helsinki, Finland), Marika HOLMA-ERIKSSON, Meri KANKAANPÄÄ, Sami KAPANEN, Merja HEITTO, Sari BERGSTRÖM, Leila MUUKKONEN
12:30 - 12:40 #11036 - OP117 Evaluation of the accuracy of a clinical decision rule to rule out acute coronary syndrome and adequacy of coronary CT requests in emergency department.
OP117 Evaluation of the accuracy of a clinical decision rule to rule out acute coronary syndrome and adequacy of coronary CT requests in emergency department.

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.


Magdalena CARRERAS, Veronica GARCÍA DE PEREDA, Iciar BARREÑA, Maria Victoria MONTEJO, Nora IBARGOYEN, Juan Carlos BAYON, Irma ARRIETA, Marta LAZARO, Ainhoa GANDIAGA, Eunate ARANA-ARRI (Berango, Spain)
Kokkali

"Wednesday 27 September"

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E42
11:10 - 12:40

General Emergency Medicine

Moderators: Raed ARAFAT (Romania), Said LARIBI (PU-PH, chef de pôle) (Tours, France)
11:10 - 11:40 Advances in the technologies and processes of care in emergency care. Tiziana MARGARIA STEFFEN (Speaker, Ireland)
11:40 - 12:10 Post traumatic stress disorder in the ED. Togay EVRIN (Speaker) (Speaker, Ankara, Turkey)
12:10 - 12:40 ARDS: The challenge for early intensive care in the ED. Juliusz JAKUBASZKO (Chair) (Speaker, Wroclaw, Poland)
MC-3

"Wednesday 27 September"

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D42
11:10 - 12:40

Choosing wisely in the ED

Moderators: Dr George NOTAS (DOCTOR) (HERAKLION, Greece), Michael RADEOS (USA)
11:10 - 11:40 Laboratory tests in the ED: Sometimes ‘Less is More’. Dr George NOTAS (DOCTOR) (Speaker, HERAKLION, Greece)
11:40 - 12:10 How can we reduce unnecessary radiology tests? Tony KAMBOURAKIS (Director Medical Services) (Speaker, Melbourne, Australia)
12:10 - 12:40 Focusing on the front door: Streaming strategies and pitfalls. Nikolas SBYRAKIS (Consultant Emergency Physician) (Speaker, Heraklion, Greece)
Skalkotas
12:40

"Wednesday 27 September"

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A43
12:40 - 13:40

EUSEM 2017 Closing Ceremony

Trianti Hall