Monday 03 October
Time Room A-FESTSAAL Room B-ZEREMONIENSAAL Room C-PRINZ EUGEN SAAL Room D-FORUM Room E-GEHEIME RATSTUBE Room F-RITTERSAAL Room G-GARTENSAAL Room OP-SCHATZKAMMERSAAL Room M5-Maria-Theresien-App. I
08:30
08:30-09:00
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KS1
Keynote Session 1

Keynote Session 1

Moderator: Pr Rick BODY (Professor of Emergency Medicine) (Manchester)
08:30 - 09:00 Clinical Decision Making in the Resus Room. Simon CARLEY (Consultant in Emergency Medicine) (Keynote Speaker, Manchester)

09:10
09:10-10:40
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A21
State of the Art
Pre-hospital

State of the Art
Pre-hospital

Moderators: Dr Abdo KHOURY (PROFESSEUR ASSOCIE) (Besançon, France), Eric REVUE (Chef de Service) (Paris, France)
09:10 - 09:40 Capnography in Prehospital Medicine. Stefan TRENKLER (Speaker, Košice, Slovakia)
09:40 - 10:10 Prehospital Stroke Management. Eric REVUE (Chef de Service) (Speaker, Paris, France)
10:10 - 10:40 The efficiency of helicopter emergency missions for STEMI: Time and intervention. Carmen Diana CIMPOESU (Prof. Head of ED) (Speaker, IASI, Romania)

11:10-12:40
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A22
State of the Art
Resuscitation

State of the Art
Resuscitation

Moderators: Lance BECKER (USA), Wilhelm BEHRINGER (Chair) (Vienna, Austria)
11:10 - 11:40 How to get the patient back after cardiac arrest. Gavin D. PERKINS (Speaker, United Kingdom)
11:40 - 12:10 How to keep the patient alive after sucessful resuscitation. Lance BECKER (Speaker, USA)
12:10 - 12:40 Cardiac Arrest in special circumstances. Koen MONSIEURS (Director) (Speaker, Antwerp, Belgium)

14:10-15:40
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A23
State of the Art
Geriatric

State of the Art
Geriatric

Moderators: Jay BANERJEE (Leicester, United Kingdom), Pr Christian NICKEL (Vice Chair ED Basel) (Basel, Switzerland)
14:10 - 14:40 Management of Confusion in older patients in the ED. Jacinta A. LUCKE (Emergency Phycisian) (Speaker, Haarlem, The Netherlands)
14:40 - 15:10 Evaluation and resuscitation of older patients in the pre hospital and ED settings. Mehmet Akif KARAMERCAN (Chair of EuSEM Research Committee) (Speaker, ANKARA, Turkey)
15:10 - 15:40 Management of Brain Injury in Older Patients in the ED. Richard WOLFE (Chief of emergency medicine) (Speaker, Boston, USA)

16:10-17:40
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A24
State of the Art
Pain Management & Procedural Sedation

State of the Art
Pain Management & Procedural Sedation

Moderators: Pr Jim DUCHARME (Immediate Past President) (Mississauga, Canada), Christian HOHENSTEIN (PHYSICIAN) (BAD BERKA, Germany)
16:10 - 16:40 Migraine - patient handling and treatment options. Carsten KLINGNER (Speaker, Germany)
16:40 - 17:10 Acute Pain Management in the ED. Pr Jim DUCHARME (Immediate Past President) (Speaker, Mississauga, Canada)
17:10 - 17:40 Regional blocks for dental trauma and facial lacerations. Andy NEILL (Doctor) (Speaker, Dublin, Ireland)

09:10-10:40
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B21
Austria, Germany, Switzerland Invites
Politik und Qualifikation

Austria, Germany, Switzerland Invites
Politik und Qualifikation

Moderators: Robert SIEBER (Switzerland), Christian WREDE (Head of Department) (Berlin, Germany)
09:10 - 09:40 Facharzt Notfallmedizin in der Schweiz: nächste Schritte. Robert SIEBER (Speaker, Switzerland)
09:40 - 10:10 Struktur der Notfallversorgung. Christian WREDE (Head of Department) (Speaker, Berlin, Germany)
10:10 - 10:40 Entwicklung der notfallmedizinischen Supraspezialität in der Schweiz. Ulrich BÜRGI (Speaker, Switzerland)

11:10-12:40
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B22
Austria, Germany, Switzerland Invites
Ausbildung Notfallpflege innerklinisch

Austria, Germany, Switzerland Invites
Ausbildung Notfallpflege innerklinisch

Moderators: Michael LAMP (Austria), Mareen MACHNER (Germany)
11:10 - 11:40 Curriculum Notfallpflege Österreich. Michael LAMP (Speaker, Austria)
11:40 - 12:10 Curriculum in der Schweiz. Christian ERNST (Speaker, Switzerland)
12:10 - 12:40 Curriculum in Deutschland. Mareen MACHNER (Speaker, Germany)

14:10-15:40
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B23
Austria, Germany, Switzerland Invites
Pflege - Notfallpflegekompetenz

Austria, Germany, Switzerland Invites
Pflege - Notfallpflegekompetenz

Moderators: Florian GROSSMANN (Clincal Nurse Specialist) (BASEL, Switzerland), Susanne SCHUSTER (Germany)
14:10 - 14:40 Notfallpflegekompetenz aus der Perspektive der Schweiz. Florian GROSSMANN (Clincal Nurse Specialist) (Speaker, BASEL, Switzerland)
14:40 - 15:10 Notfallpflegekompetenz aus der Perspektive Deutschlands. Susanne SCHUSTER (Speaker, Germany)
15:10 - 15:40 Notfallpflegekompetenz aus der Perspektive Österreichs. Thomas WAGNER (Speaker, Austria)

16:10-17:40
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B24
Austria, Germany, Switzerland Invites
Diverse klinische Themen

Austria, Germany, Switzerland Invites
Diverse klinische Themen

Moderators: Harald DORMANN (Nürnberg, Germany), Mathias ZÜRCHER (Switzerland)
16:10 - 16:40 Mildes Schädelhirntrauma. Dieter VON OW (Speaker, Switzerland)
16:40 - 17:10 Allergische Reaktion. Dieter VON OW (Speaker, Switzerland)
17:10 - 17:40 Urogenitale Notfälle. Beat LEHMANN (Speaker, Switzerland)

09:10-10:40
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C21
Philosophy & Controversies
P&C Pain Management & Procedural Sedation

Philosophy & Controversies
P&C Pain Management & Procedural Sedation

Moderators: Philip EISENBURGER (Head) (Vienna, Austria), Christian HOHENSTEIN (PHYSICIAN) (BAD BERKA, Germany)
09:10 - 09:40 The painful following of clinical guidelines - does implementation of clinical guidelines improve pain management in the ED? Pr Jim DUCHARME (Immediate Past President) (Speaker, Mississauga, Canada)
09:40 - 10:10 Intubation of the not fastened patient for procedural sedation - the safer option? Christian HOHENSTEIN (PHYSICIAN) (Speaker, BAD BERKA, Germany)
10:10 - 10:40 Alleviating symptoms and generating them at the same time - Ketamine for agitation and delirium? Andy NEILL (Doctor) (Speaker, Dublin, Ireland)

11:10-12:40
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C22
Philosophy & Controversies
P&C Pre-hospital

Philosophy & Controversies
P&C Pre-hospital

Moderators: Christoph REDELSTEINER (Prof) (Wien, Austria), Stefan TRENKLER (Košice, Slovakia)
11:10 - 11:40 Prehospital staff controversy: Physicians, Nurses, Paramedics. Carmen Diana CIMPOESU (Prof. Head of ED) (Speaker, IASI, Romania)
11:40 - 12:10 Relation between electrical and mechanical myocardial activity during cardiac arrest. Roman SKULEC (Deputy head for research and science) (Speaker, Kladno, Czech Republic)
12:10 - 12:40 New challenges: Telemedicine. Eric REVUE (Chef de Service) (Speaker, Paris, France)

14:10-15:40
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C23
Philosophy & Controversies
P&C Resuscitation

Philosophy & Controversies
P&C Resuscitation

Moderators: Gavin D. PERKINS (United Kingdom), Peter STRATIL (VIENNA, Austria)
14:10 - 14:40 ECMO Pros and Cons: You must choose wisely. Lance BECKER (Speaker, USA)
14:40 - 15:10 To epinephrine or not to epinephrine during cardiac arrest? Gavin D. PERKINS (Speaker, United Kingdom)
15:10 - 15:40 Targeted temperature management after cardiac arrest: when, how deep, and how long? Wilhelm BEHRINGER (Chair) (Speaker, Vienna, Austria)

16:10-17:40
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C24
Philosophy & Controversies
P&C Geriatric

Philosophy & Controversies
P&C Geriatric

Moderators: Olivier GANANSIA (Chef de service) (Paris, France), Richard WOLFE (Chief of emergency medicine) (Boston, USA)
16:10 - 16:40 Screening and Detection of Delirium in Older patients: Are CAM-ICU, mCAM-ED, RASS, bCAM helpful in the ED? Pr Christian NICKEL (Vice Chair ED Basel) (Speaker, Basel, Switzerland)
16:40 - 17:10 Management of Acute Chest Pain in Older patients in the ED: Is there any differences with other patients? Pr Martin MÖCKEL (Head of Department, Professor) (Speaker, Berlin, Germany)
17:10 - 17:40 Screening Instruments to Predict Adverse Outcomes in Older Patients in the ED: Is it feasible? Pr Abdelouahab BELLOU (Director of Institute) (Speaker, Guangzhou, China)

09:10-10:40
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D21
EUSEM meets ERC

EUSEM meets ERC

Moderators: Maaret CASTREN (Professor) (HELSINKI, Finland), Marc SABBE (Medical staff member) (Leuven, Belgium)
09:10 - 09:40 Resuscitation academy. Maaret CASTREN (Professor) (Speaker, HELSINKI, Finland)
09:40 - 10:10 A new way to produce and use guidelines. Koen MONSIEURS (Director) (Speaker, Antwerp, Belgium)
10:10 - 10:40 ERC Guidelines for traumatic cardiac arrest: Why was the approach changed. Dr Anatolij TRUHLAR (Medical Director EMS) (Speaker, Hradec Kralove, Czech Republic)

11:10-12:40
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D22
Administration Management
Resilience - EM more than just medicine? Leadership, resilience & career satisfaction - the how to guide!

Administration Management
Resilience - EM more than just medicine? Leadership, resilience & career satisfaction - the how to guide!

Moderators: Dr Tajek HASSAN (Board Chair for Europe, IFEM) (Leeds), Marc SABBE (Medical staff member) (Leuven, Belgium)
Speakers: Colin GRAHAM (Director and Professor of Emergency Medicine) (Speaker, Hong Kong, Hong Kong), Dr Tajek HASSAN (Board Chair for Europe, IFEM) (Speaker, Leeds), Dr John HEYWORTH (Consultant) (Speaker, Southampton), Marc SABBE (Medical staff member) (Speaker, Leuven, Belgium)

14:10-15:40
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D23
EUSEM meets ACCA/ESC

EUSEM meets ACCA/ESC

Moderators: Pr Abdelouahab BELLOU (Director of Institute) (Guangzhou, China), Pr Martin MÖCKEL (Head of Department, Professor) (Berlin, Germany)
14:10 - 14:40 Major bleeding in patients on oral anticoagulants (VKA or NOAC). Kurt HUBER (Speaker, VIENNA, Austria)
14:40 - 15:10 Management of acute hypertension in the ED. Pr Abdelouahab BELLOU (Director of Institute) (Speaker, Guangzhou, China)
15:10 - 15:40 Strategies to rule in and rule out causes of acute chest pain in the ED. Madalenna LETTINO (ACCA President Elect) (Speaker, Italy)

16:10-17:40
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D24
EUSEM meets SAEM

EUSEM meets SAEM

Moderators: Andra BLOMKALNS (USA), Roberta PETRINO (Head of department) (Italie, Italy)
16:10 - 16:40 Quality and Safety Management in US Emergency Departments: Is there any improvement after the 15 years of "To Err is Human"? Andra BLOMKALNS (Speaker, USA)
16:40 - 17:10 The evolution of academic Emergency Medicine in Europe. Roberta PETRINO (Head of department) (Speaker, Italie, Italy)
17:10 - 17:40 Opioid drug abuse in the US: what is the role of the Emergency Department? Mark COURTNEY (Speaker, Casuarina, Australia)

09:10-10:40
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E21
Research
Geriatric

Research
Geriatric

Moderators: Jay BANERJEE (Leicester, United Kingdom), Pr Abdelouahab BELLOU (Director of Institute) (Guangzhou, China)
09:10 - 09:40 The Boarding Patients in the ED: Are Older Patients the Major Cause ? Pr Abdelouahab BELLOU (Director of Institute) (Speaker, Guangzhou, China)
09:40 - 10:10 Assessing for Cognitive Impairment in Older Patients: Results of the UK Clinical Audit. Jay BANERJEE (Speaker, Leicester, United Kingdom)
10:10 - 10:40 Pre-Hospital Initiatives to Decrease the Number of Older Patient ED visits. James WALLACE (Consultant in Emergency Medicine) (Speaker, Warrington, United Kingdom)

11:10-12:40
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E22
State of the art
Psychosocial Emergencies

State of the art
Psychosocial Emergencies

Moderators: Gregor PROSEN (EM Consultant) (MARIBOR, Slovenia), Karin RHODES (USA)
11:10 - 11:40 Screening and intervention for intimate partner violence. Karin RHODES (Speaker, USA)
11:40 - 12:10 The role of ED in Mental Health Emergencies. Anne HICKS (Consultant in Emergency Medicine) (Speaker, Plymouth, United Kingdom)
12:10 - 12:40 Hypnosis and therapeutic communication at the emergency department. Franck VERSCHUREN (MD, PhD) (Speaker, Brussels, Belgium)

14:10-15:40
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E23
Research
Pre-hospital

Research
Pre-hospital

Moderators: Roman SKULEC (Deputy head for research and science) (Kladno, Czech Republic), Dr Jana SEBLOVA (Emergency Physician) (PRAGUE, Czech Republic)
14:10 - 14:40 EuSM prehospital systems survey 2016. Dr Jana SEBLOVA (Emergency Physician) (Speaker, PRAGUE, Czech Republic)
14:40 - 15:10 EMS systems´comparison across the cases. Christoph REDELSTEINER (Prof) (Speaker, Wien, Austria)
15:10 - 15:40 Cardiac arrest on board: How safe are we on the plane? Dr Anatolij TRUHLAR (Medical Director EMS) (Speaker, Hradec Kralove, Czech Republic)

16:10-17:40
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E24
Research
Resuscitation

Research
Resuscitation

Moderators: Wilhelm BEHRINGER (Chair) (Vienna, Austria), Michael HOLZER (Austria)
16:10 - 16:40 Cooling during cardiac arrest, what’s on the horizon? Michael HOLZER (Speaker, Austria)
16:40 - 17:10 Strategies to Improve Cardiac Arrest Survival: A Time to Act. Lance BECKER (Speaker, USA)
17:10 - 17:40 Resuscitation in the 24th century. David HÖRBURGER (Physician internal medicine) (Speaker, St. Gallen, Switzerland)

09:10-10:40
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F21
YEMD
Developing your portfolio career

YEMD
Developing your portfolio career

Moderators: Blair GRAHAM (Research Fellow) (Plymouth, United Kingdom), Amy HUGHES (Cambridge, United Kingdom)
09:10 - 09:40 A career in Emergency, Pre Hospital, Humanitarian and Disaster Medicine. Amy HUGHES (Speaker, Cambridge, United Kingdom)
09:40 - 10:10 Over and above service provision: pathways to developing portfolio interests as a trainee. Blair GRAHAM (Research Fellow) (Speaker, Plymouth, United Kingdom)
10:10 - 10:40 Adventure and Education in a University Emergency Department and in the Himalayas. Dr Monika BRODMANN MAEDER (Senior Consultant, Head of Education and Mountain Emergency Medicine) (Speaker, Bern, Switzerland)

11:10-12:40
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F22
YEMD
Best articles of the year

YEMD
Best articles of the year

Moderators: Blair GRAHAM (Research Fellow) (Plymouth, United Kingdom), Jennifer TRUCHOT (MEDECIN) (Paris, France)
Speakers: Benjamin BLOOM (Consultant in EM) (Speaker, Londres), Yonathan FREUND (PUPH) (Speaker, Paris, France), Basak YILMAZ (Faculty) (Speaker, BURDUR, Turkey)

14:10-15:40
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F23
YEMD
Point of care Ultrasound: batman returns

YEMD
Point of care Ultrasound: batman returns

Moderators: Gregor PROSEN (EM Consultant) (MARIBOR, Slovenia), Senad TABAKOVIC (Medical director emergency department) (Zürich, Switzerland)
14:10 - 14:40 POCUS, hype or reality: will it replace the stethoscope? James CONNOLLY (Consultant) (Speaker, Newcastle-Upon-Tyne)
14:40 - 15:10 The times they are A-changin` - where US is replacing Xray today and where tomorrow. Pr Joseph OSTERWALDER (Head of Hospital) (Speaker, St. Gallen, Switzerland)
15:10 - 15:40 Can point of car ultrasound turn into a weapon of mass destraction. Gregor PROSEN (EM Consultant) (Speaker, MARIBOR, Slovenia)

16:10-17:40
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F24
YEMD
EM in Extreme environments

YEMD
EM in Extreme environments

Moderators: Dr Monika BRODMANN MAEDER (Senior Consultant, Head of Education and Mountain Emergency Medicine) (Bern, Switzerland), Dr Pieter Jan VAN ASBROECK (Consultant in Emergency Medicine) (Genk, Belgium)
16:10 - 16:40 Emergency medicine in the Antartic: Ins and outs. Béatrice LAUDET (interne) (Speaker, PARIS, France)
16:40 - 17:10 SAVE: Military Emergency Medecine management of multiple victims in extreme situations. Yann-Laurent VIOLIN (Speaker, PARIS, France)
17:10 - 17:40 Mass casualties and emergency medicine in the Himalayas. Dr Monika BRODMANN MAEDER (Senior Consultant, Head of Education and Mountain Emergency Medicine) (Speaker, Bern, Switzerland)

09:10-10:40
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G21
Paediatric track
Hot Topics

Paediatric track
Hot Topics

Moderators: Javier BENITO FERNANDEZ (DIRECTOR) (BILBAO, Spain), Silvia BRESSAN (Moderator) (Padova, Italy)
09:10 - 09:40 Set 1 - In situ simulation in the PED: pros and cons. Marco DAVERIO (Speaker, Padova, Italy)
HFNC use - steps towards evidence based practice.
09:40 - 10:10 Set 2 – Point of care US: tips and trick for the PED. Mark HADEN (Speaker, London, United Kingdom)
Telemedicine: new frontiers and barriers
10:10 - 10:40 Set 3 – High-tech PEM: how technology can make your life easier. Johan SIEBERT (Speaker, Geneva, Switzerland)

11:10-12:40
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G22
Paediatric track
Safety in the Emergency Department

Paediatric track
Safety in the Emergency Department

Moderators: Javier BENITO FERNANDEZ (DIRECTOR) (BILBAO, Spain), Santiago MINTEGI (Section Head. Pediatric Emergency Department) (Bilbao, Spain)
11:10 - 11:30 What is meant by safety in the ED, how to measure and to improve the care of children. Javier BENITO FERNANDEZ (DIRECTOR) (Speaker, BILBAO, Spain)
11:30 - 11:50 Lessons learned from diversity in PEM - Diversity in PEM in Europe, lessons learned from 100.000 children in 5 ED’s. Dorine BORENSZTAJN (PhD) (Free Paper Speaker, Rotterdam, The Netherlands)
11:50 - 12:10 Lessons learned from diversity in PEM - Antibiotic use in febrile children in paediatric emergency care – variability among Europe. Rianne OOSTENBRINK (pediatrician) (Free Paper Speaker, Rotterdam, The Netherlands)
12:10 - 12:30 Lessons learned from diversity in PEM - Variability in pediatric poisoning. Santiago MINTEGI (Section Head. Pediatric Emergency Department) (Free Paper Speaker, Bilbao, Spain)
12:30 - 12:40 Paediatric abstracts. Henriette MOLL (paediatrician) (Speaker, rotterdam, The Netherlands)

12:55-13:55
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G-EB
Getting to know the EBEEM
Q&A for specialist educators, trainees and candidates

Getting to know the EBEEM
Q&A for specialist educators, trainees and candidates

Moderators: Ruth BROWN (Speaker) (London), Cornelia HÄRTEL (Medical Director of the ED, Consultant in EM, Director of Medical Education in EM) (STOCKHOLM, Sweden)

14:10-15:40
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G23
Paediatric track
Research

Paediatric track
Research

Moderators: Javier BENITO FERNANDEZ (DIRECTOR) (BILBAO, Spain), Mark LYTTLE (Bristol, United Kingdom), Ian MACONOCHIE (United Kingdom), Santiago MINTEGI (Section Head. Pediatric Emergency Department) (Bilbao, Spain)
14:10 - 15:20 Workgroup session with experts. Henriette MOLL (paediatrician) (Speaker, rotterdam, The Netherlands), Mark LYTTLE (Speaker, Bristol, United Kingdom), Liviana DA DALT (PHYSICIAN) (Speaker, PADOVA, Italy), Laurence LACROIX (Consultant) (Speaker, Geneva 14, Switzerland)
1. Systematic review, 2. observational trials, randomised controlled trials, 3. information resources, 4. REPEM + PERN. Groups of 10 participants rotate to each table every 20 minutes.
15:20 - 15:40 Paediatrics abstracts. Henriette MOLL (paediatrician) (Speaker, rotterdam, The Netherlands)

16:10-17:40
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G24
Paediatric track
Major Incident Management

Paediatric track
Major Incident Management

Moderators: Dr Thomas BEATTIE (Senior lecturer) (Edinburgh, United Kingdom), Pr Hezi WAISMAN (Director, Dept. of Emergency Medicine) (Petach-Tikva, Israel)
16:10 - 17:40 Workgroup Session.

09:10-10:40
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OP21
Oral Papers 21

Oral Papers 21

Moderators: Dr Kim GEYBELS (Emergency and prehospital physician) (Zottegem, Belgium), John HOLCOMB (USA)
09:10 - 09:20 #7469 - OP028 The Physiology component of Trauma Triage Tool has the highest PPV.
The Physiology component of Trauma Triage Tool has the highest PPV.

Introduction: Injuries are a major cause of morbidity and mortality in both developing and industrialized regions 1.  Injury severity scores are simply a way to describe and quantify the severity of traumatic injury and also provide some sense of the probability of survival of the victims2. The Injury Severity Score (ISS) is a widely accepted method of measuring severity of traumatic injury 3.This study aims at evaluating the component of trauma triage tool with highest positive predictive value to identify major trauma patients.

Objective:

 

To determine the component of pre-hospital tool (Trauma Triage tool) with highest positive predictive value?

 

 

Methodology:

 

 A Retrospective database analysis of Major trauma patients presenting to QEHB during the period January 2013 to January 2014 was performed. All Major trauma patients (TTT positive) presenting to QEHB during this period were included.  The patients who were TTT Negative were excluded.

 

Data were coded and entered on Excel file and statistical analysis was done using the Statistical Package for Social Science (SPSS) version 16.0. Descriptive analysis was conducted to determine the sensitivity and specificity of pre- hospital TTT and each of its components (vital signs, anatomy, injury mechanism and special conditions). Pearson Chi- Square test, Fisher’s exact test and Independent Student's t- test were used to evaluate the association between the severity of injury and certain variables: Mechanism of injury, Glasgow Coma Score (GCS) level and patient's age.

 

 

 

Results:

There were 694 trauma patients presented during study period. Only 597 patients met the inclusion criteria and were included in the study. The majority of our sample was male (70.7%), with a mean age of 53 years. About one third of these patients had involved in RTCs. Approximately 60 % of the study group had been alerted in as major trauma cases.

Out of the 597 trauma patients, 316 patients were identified as a major trauma cases (true positive cases) that had an estimated ISS more than 15 (Positive Predictive Value (PPV) = 0.529 at 95% CI 0.49, 0.57; p= 0.000).

The Trauma Triage Tool consists of four components: Vital signs, Anatomy, Mechanism of injury and Special conditions. The Physiology component had the highest PPV of 0.79 at 95% CI 0.73, 0.85, which was followed by the Mechanism of injury with PPV equals 0.618 at 95% CI 0.55, 0.69, then the Anatomy component (PPV= 0.523 at 95% CI 0.46, 0.69), then the Special conditions components which had PPV of 0.448 at 95% CI 0.39, 0.51.

 

Conclusion:

Within the pre-hospital management of seriously injured trauma victims the accuracy of the field triage is of utmost importance. The clinicians significantly depend upon the pre hospital information to activate the resources.  Hence greater the PPV of TTT better the trauma team remix can be planned.

Our results clearly suggest the correlation of abnormal physiological parameters with high probability of ISS>15. Even when combined with other components of the TTT the PPV of the physiological component remains the highest.


M Azam MAJEED (Birmingham, United Kingdom), M Saif REHMAN, Asif NAVEED, Shereen NABIL
09:20 - 09:30 #7049 - OP029 Compared analysis of London, Boston and Paris attacks : learning from each other to become stronger.
OP029 Compared analysis of London, Boston and Paris attacks : learning from each other to become stronger.

Background

In 2005, 2013 and 2015 respectively, London, Boston and Paris (November events for this study) were targeted by major terrorist attacks. Despite their differences these attacks caused many common difficulties and issues for rescue organizations in countries with mass casualty plans that differ widely. The aim of the present study was to analyze and compare the specific responses of each city to a similar kind of crisis.


Participants and methods

We used publications and official reports about the London bombings [1], Boston bombings [2] and Paris terrorist attacks [3,4]. We detailed, when available, response timelines for each attack, the resources committed, the pre-hospital organization and hospital dispatch. 


Results

In London, 4 suicide-bomb attacks (3 aboard London Underground trains and 1 on a double-decker bus) killed 52 civilians and injured over 700 more. In Boston, 2 pressure cooker bombs placed near the finish line of the Boston marathon killed 3 civilians and injured 264 more. In Paris, suicide bomb attacks, mass shooting and hostage taking killed 130 civilians, including 89 on one closed site of mass shooting, and injured over 413 more. Three different dispatch strategies were used: proximity dispatching in London, equal pre-defined dispatching in Boston and regional partially medical dispatching in Paris. If not already activated, national crisis management facility was operational in less than 40 minutes. 7 to 17 hospitals were involved in caring the victims. In all cities, evacuation of the victims was achieved in less than about 6 hours after the beginning of the attack.

 

 

Discussion

Several key points can be extracted from the three responses. A pre-defined idea of the capacities of each hospital as well as a real-time assessment proved extremely helpful. A unique dispatch and control center allows a good overview of the destination of the patients. Dedicated communication channels between all the critical national infrastructures allow swifter alert of all the involved services. Good communication is always a major issue, particularly in areas where networks are saturated, switched off, degraded or destroyed. When the network is on, giving the right information to the right persons at the right time is both vital but very difficult. Mass casualties require material, vehicles and personnel in numbers that need to be organized in advance if we want to respond without delay. Dealing with the uncertainty of the situations and reacting quickly requires response systems that are simple and robust and that favor the autonomy of the operational teams. Finally, drills, exercising, and repeating procedures again and again are absolutely crucial if we are to be agile and effective in our responses. 

 

1. Report of the Official Account of the Bombings in London on the 7th July 2005

2. After Action Report for the Response to the 2013 Boston Marathon Bombings, dec 2014

3. Hirsch M et al., The medical response to multisite terrorist attacks in Paris, Lancet 2015 Dec 19;386(10012):2535-86.

4. Lesaffre X, Attacks on Paris: what can we learn, oral presentation


Sophie MONTAGNON, Xavier LESAFFRE (Paris), Daniel JOST, Stéphane BOIZAT, Olivier BON, Michel BIGNAND, Patrick PLAISANCE, Jean-Pierre TOURTIER
09:30 - 09:40 #7126 - OP030 Major incident triage: the civilian validation of the Modified Physiological Triage Tool (MPTT).
OP030 Major incident triage: the civilian validation of the Modified Physiological Triage Tool (MPTT).

Introduction:

Triage, the process of categorising patients based on clinical acuity, is a key principle in the effective management of a major incident (MI).  There are at least three different triage systems in use worldwide, and previous attempts to validate them have demonstrated limited performance. 

Using a military cohort and regression analysis, the Modified Physiological Triage Tool (MPTT) was developed and when compared to existing triage methods, demonstrated an improved performance at predicting need for life-saving intervention and yielded the lowest rate of under-triage (30.1%).  Within the adult civilian population, where blunt trauma predominates and there is an older population, no such work has been undertaken to develop an improved system of triage.

The purpose of this study was to perform a comparative analysis and initial validation of the MPTT within a civilian environment. 

Methods:

A retrospective review of the Trauma Audit Research Network (TARN) database was performed for all adult patients (>18 years) presenting to a UK Emergency Department (ED) between 1 January 2006 and 31 December 2014. Patients were defined as Gold Standard Priority One if they had received one or more life-saving interventions from a previously defined list.  Only patients with complete physiological data and who received treatment at a single hospital were included in the analysis.

Using first recorded physiological data (HR/RR/GCS/SBP), patients were categorised as Priority One or Not Priority One by the newly derived MPTT (12 > RR < 22, HR > 100, GCS < 14) and existing major incident triage tools (START - ST, CAREFLIGHT - CF, Modified Military Sieve – MMS and Triage Sieve – TS). Performance characteristics of all triage tools were evaluated using sensitivity, specificity and AUROC, and rates of over and under-triage were compared. AUROC were compared for triage tools with similar performance.

Results:

The TARN registry held records for 218,453 adult patients during the study period, of which 129,647 (59.3%) had complete data and were included in the analysis.  55% of patients were male, with a median age of 61 (range 18-111).  25,452 patients (19.6%) were defined as Priority One, with a median ISS of 9.  Blunt trauma predominated (96.5%), with falls < 2m the most common injury mechanism (53.9%).

The MPTT outperformed all existing triage methods with the highest sensitivity (58.1%) and demonstrated an absolute reduction in under-triage of 44.5% when compared to the existing MIMMS Triage Sieve.  With an AUROC increase of 1.3, ROC comparison demonstrated significance between the MPTT and MMS (c2 = 83.91, p < 0.001), statistically supporting the use of the MPTT.


Conclusion:

This study has defined the performance of the MPTT (a tool derived using a military cohort) in a civilian environment, where it has been shown to outperform all existing MI triage systems in its ability to predict need for life-saving intervention.  As a result of this validation, its use within a civilian major incident context is recommended.

 

 


Jason SMITH, James VASSALLO (Bristol, )
09:40 - 09:50 #7176 - OP031 Additional value of d-dimer and the disseminated intravascular coagulation score in predicting outcome after out-of-hospital cardiac arrest.
OP031 Additional value of d-dimer and the disseminated intravascular coagulation score in predicting outcome after out-of-hospital cardiac arrest.

Background: Chances of survival in out-of-hospital cardiac arrest (OHCA) patients decrease with increasing duration of hypoperfusion. The pathophysiological changes after prolonged resuscitation efforts and consecutive hypoperfusion appears comparable to those in severe sepsis leading to post-resuscitation coagulopathy. The occurrence of overt disseminated intravascular coagulation (DIC) is associated with poor outcomes and high mortality risk in various medical conditions. Similarly, the occurrence of DIC in cardiac arrest patients seems to be associated with an unfavorable prognosis. 

Objective: Recent data suggest an overt DIC rate of 33% in OHCA patients with sustained return of spontaneous circulation (ROSC). The current study determined the prevalence of overt DIC, its association with outcome, and the predictive value of d-dimer in an Austrian collective of OHCA patients.

Methods: All patients with available coagulation parameters from 2006-2014 were extracted from a prospectively compiled OHCA registry. Primary outcome was the prevalence of overt DIC. Binominal logistic regression analysis was applied to ascertain predictors of overt DIC, 30-day mortality and neurologic outcome. The discrimination of the fitted logistic models was assessed using the area under the receiver-operating-characteristic (ROC) curve.

Results: Out of 1179 OHCA patients, coagulation parameters were available in 410 (72% male; 57years, 48-69). The rate of overt DIC was 10% (95%CI, 7-13; n=39) overall and 7% (95%CI, 5-10; n=30) in the sustained ROSC subgroup. The odds ratio for 30-day mortality (46%, 95%CI 41-51; n=188) increased with the DIC score and was 9.6 (crude OR; 95%CI, 3.7-25) in patients with overt DIC on admission (n=39). The regression model including d-dimer, lactate levels, no-flow interval and initial rhythm (χ2(4)=125.1; p<0.001; HLT=0.20) best predicted 30-day mortality (R2= 0.58); The inclusion of d-dimer levels into the model significantly increased the area under the ROC curve from 0.78 (95%CI, 0.73-0.85) to 0.90 (95%CI, 0.85-0.94; p=0.001).

Conclusion: The current study identified increasing no-flow intervals (indicating the extent of non-perfusion), a non-shockable initial heart rhythm and elevated lactate levels (indicating the magnitude of tissue hypoxia) as the main predictors of overt DIC patterns in OHCA. The inclusion of d-dimer levels into a prediction model, however, improved its accuracy, and d-dimer levels may serve as an additional, independent surrogate parameter to assess outcome in OHCA.

 


Nina BUCHTELE (Vienna, Austria), Bernd JILMA, Andreas SCHOBER, Christian SCHOERGENHOFER, Fritz STERZ, Michael SCHWAMEIS
09:50 - 10:00 #7419 - OP032 Ultrasound-Guided Reduction of Distal Radius Fractures.
Ultrasound-Guided Reduction of Distal Radius Fractures.

Introduction: Distal radius fractures are a common traumatic injury, particularly in the elderly population. In the present study we examined the effectiveness of ultrasound guidance in the reduction of distal radius fractures in adult patients presenting to emergency department (ED). Methods: In this prospective case control study, eligible patients were adults older than 18 years who presented to the ED with distal radius fractures. 130 consecutive patient consisted of two group of Sixty-Five patients were prospectively enrolled for around 1 years. The first group underwent ultrasound-guided reduction and the second (control group) underwent blind reduction. All procedures were performed by two trained emergency residents under supervision of senior emergency physicians. Results: Baseline characteristics between two groups were similar. The rate of repeat reduction was reduced in the ultrasound group (9.2% vs 24.6%; P = .019). The post reduction radiographic indices were similar between the two groups, although the ultrasound group had improved volar tilt (mean, 7.6° vs 3.7°; P = .000). The operative rate was reduced in the ultrasound groups (10.8% vs 27.7%; P = .014). Conclusion: Ultrasound guidance is effective and recommended for routine use in the reduction of distal radius fractures


Anita SABZGHABAEI (TEHRAN, Islamic Republic of Iran), Majid SHOJAEE, Saeed HASANPOOUR, Taghian SAHAR
10:00 - 10:10 #7583 - OP033 Willingness to work of hospital staff in disasters, a national survey of the fight or flight study group.
OP033 Willingness to work of hospital staff in disasters, a national survey of the fight or flight study group.

Objectives: To evaluate the willingness to work of hospital staff and factors promoting it  in different mass casualty settings.

Background: When disaster strikes, getting care to the victims is at the top of everyone's attention. But who will provide that care? A part of the hospital personnel will be absent as they are inflicted in the incident whereas the management expects that the rest deploys a higher engagement to cope with the surge. However, care for inflicted family and fear of becoming a secondary victim could prevent people to go to work.

Material and methods:

4 groups (physicians, nurses, administration and supportive services) in Belgian hospitals were presented an online questionnaire checking for demographics, knowledge of and intention to work in 11 potential MCI disaster scenarios.

Results:

The Ebola outbreak, a train derailment with toxic release and the Paris / Brussels attacks raised national awareness which allowed us to score in 18 hospitals after the 7 hospital pilot. Ten more are ready to join giving a nationwide coverage.

Preliminary results reveal an overall highest response rate in the physician group where more than 1/3 works unconditionally. The supportive services score second best (27%) followed by the nurses (22%) and administration (21%). Highest response rate in all groups is found in seasonal influenza epidemics (54% works unconditionally). Ebola has the lowest rate of unconditional response (13%). Incidents where people will not respond to work, even with the risk of losing their job, are Ebola and nuclear incidents (9.5% and 8.8% respectively).  Since the West African Ebola outbreak, there is a clear downwards trend in willingness to work in these circumstances.

The majority of personnel will work under conditions. Factors that convince people to respond are in order of importance: availability of appropriate personal protective equipment, free availability of preventive medication or antidotes, insurance that family is safe, regular feedback on the evolution of the incident, previous training and communication channels with the family.

Conclusion:

Hospital managers should be aware that just a part of their personnel would come to work unconditionally in case of a disaster. Local evaluation can help identifying promoting measures to maximize response.


Luc MORTELMANS (Antwerp, Belgium), Christel HENDRICKX, Marc SABBE
10:10 - 10:20 #7626 - OP034 A REFUGEE CAMP IN THE CENTER OF EUROPE: CLINICAL CHARACTERISTICS OF ASYLUM SEEKERS IN BRUSSELS IN SEPTEMBER 2015.
A REFUGEE CAMP IN THE CENTER OF EUROPE: CLINICAL CHARACTERISTICS OF ASYLUM SEEKERS IN BRUSSELS IN SEPTEMBER 2015.

Background and purpose

In the summer of 2015, the exodus of Syrian war refugees and saturation of refugee camps in neighbouring countries led to the influx of many asylum-seekers in some European countries, including Belgium.

This study aims to document demographics of asylum-seekers arriving in a refugee camp in Brussels in September 2015 and to describe diagnoses and comorbidities of patients presenting to a Field Hospital.

The study hypothesis is that among asylum-seekers in a huddled refugee camp – even in a well-developed country with all medical facilities – respiratory, digestive and other medical problems typical of refugee camps wherever in the world, will emerge soon.

Patients and methods

Using a cross-sectional observational study design, physicians of Médecins du Monde prospectively registered age, gender, origin, medical complaints and diagnoses of all patients presenting to an erected Field Hospital in Brussels in September 2015. Diagnoses were post-hoc categorised according to the International Classification of Diseases. Of 4037 patients examined, 3907 were included and analysed for this study: 86% were male, median age was 28 years (range 0-93;IQR 12), and patients came from 63 different countries, mostly from Iraq (52%), Syria (20%), Morocco (10%), Afghanistan (3%), and Palestine (3%). Some 1% were stateless.

Results

The most common primary diagnoses were upper respiratory tract infections (31%), dental caries (8%), skin infections (8%), gastroenteritis (7%), skin wounds and burns (6%), musculoskeletal disorders (6%), and accidental trauma (6%). Mental disorders were present in 2%. One per cent was victim of intentional violence in the country of origin, or during the journey to Brussels. Two women had just delivered and five new-born babies attended, of which one had to be hospitalised for bronchiolitis with severe dyspnoea.

When classified, the most frequent diagnosis categories were respiratory disorders (36%), far ahead of injury (12%), dental (10%), skin (9%), digestive (8%), and musculoskeletal diagnoses (6%).

Comorbidities consisted mainly of arterial hypertension and diabetes. Referrals were organised for 11% patients to dentists (5%), to Emergency Departments (3%), to psychotherapists (2%), and to new-born care (1%).

Features of infection were found in 49% of patients, with an even higher proportion (63%) in children younger than 5. A multiple logistic regression analysis indicates that the risk of being infected is significantly higher for asylum-seekers from Syria and Iraq, and for children.

Conclusions

Asylum seekers arriving in a refugee camp in Brussels after a long and hazardous journey suffer mostly from respiratory, dental, skin and digestive diseases, and one of seven is injured. Half of this population shows features of infection; with asylum-seekers from Syria and Iraq, and children being most vulnerable, urging even developed countries to take measures to prevent the spread of infections. Early shelter, overcrowding reduction, adequate sanitary facilities, and accessible healthcare may avoid short and long term complications, leading to higher healthcare expenditure for the hosting population.

These findings should be anticipated when composing Emergency Medical Teams and Interagency Emergency Health Kits to be used in a Field Hospital, even in a Western European country.


Dr Gerlant VAN BERLAER (Brussels - BELGIUM, Belgium), Francisca BOHLE CARBONELL, Sofie MANANTSOA, Xavier DE BÉTHUNE, Ronald BUYL, Michel DEBACKER, Ives HUBLOUE
10:20 - 10:30 #7632 - OP035 COMORBIDITIES AND DIAGNOSES IN NORTHERN SYRIAN CHILDREN AFTER FOUR YEARS OF CIVIL WAR.
OP035 COMORBIDITIES AND DIAGNOSES IN NORTHERN SYRIAN CHILDREN AFTER FOUR YEARS OF CIVIL WAR.

Background and purpose

The civil war that started in Syria since 2011, led to one of the most complex humanitarian emergencies in history. This ongoing disaster, in which warring parties deliberately target healthcare infrastructure and services, has detrimental consequences affecting the health of children as one of the most vulnerable populations.

The purpose of this study is to document the medical threats, comorbidities, diagnoses and disease categories in Syrian children after four years of conflict, and estimate the need for relief efforts needed to provide efficient medical care to Syrian children.

Patients and Methods

A cross sectional observational sample study was conducted in May 2015. By means of a prospectively designed medical registry, Qatar Red Crescent healthcare workers especially trained for this study, collected demographic information, comorbidities, and diagnoses in children visited home by home and in internally displaced persons camps in four Syrian governorates. Diagnoses were post-hoc categorised according to the ICD-10 classification.

Of 1080 filled-out records, 1001 were complete and included in this study. Children originated from Aleppo (41%), Idleb (36%), Hamah (15%) and Lattakia (8%). Median age was 6 years (0-15;IQR 3-11), 61% were boys.

Results

Most primary acute diagnoses in examined children were upper respiratory tract infections (14%), lower respiratory tract infections (9%), gastroenteritis (8%), suspected meningitis (7%), asthma (6%), convulsions (6%), eye infection (5%), clinical anaemia (5%), and skin infection (5%). Four per cent showed signs of malnutrition, some children had been victim of injury (3%) or violence (1%), and 2% of children suffered from a mental disorder.

When categorised according to ICD-10, most children suffered from respiratory (29%), neurological (19%), digestive (17%), eye (5%) or skin (5%) diseases, 4% was injured, and 2% suffered from a mental disorder. Overall, 55% of patients had features of infectious diseases.

Most common chronical illnesses were mental health diseases (25%), epilepsy (11%), malnutrition related conditions (5%), and flaccid paralysis (4%).

Statistical analysis indicates that the risk for children to suffer from infectious diseases is significantly higher when they reside in Aleppo or Idleb. The risk of being injured is significantly higher in Aleppo, while intentional violence is most occurring in Lattakia. Mental problems are more prominent in Hamah. These problems are not linked to gender or age, except for infectious risks: younger children are more at risk to have an incomplete vaccination state, and suffer more from preventable dangerous infections.

Conclusions

After years of civil war, more than half the children in Northern Syria suffer from infections, mostly from respiratory, neurological and digestive origin, while 4% is injured or victim of dirty weapons.

Substandard paediatric healthcare circumstances and worsening vaccination state put Syrian children at risk for serious infections, outbreaks and morbidity, and should be urgently addressed by humanitarian relief efforts.

An immediate coordinated and global action is needed to deal with this complex humanitarian emergency, and to prevent worsening of health threats for children in Syria.


Dr Gerlant VAN BERLAER (Brussels - BELGIUM, Belgium), Abdallah Mohamed ELSAFTI, Mohamed AL-SAFADI, Michel DEBACKER, Ronald BUYL, Atef REDWAN, Ives HUBLOUE
10:30 - 10:40 #7635 - OP036 CHILDREN IN THE SYRIAN CIVIL WAR: IMPACT OF ON-GOING VIOLENCE ON THEIR SOCIAL, EDUCATIONAL AND PUBLIC HEALTH STATE.
CHILDREN IN THE SYRIAN CIVIL WAR: IMPACT OF ON-GOING VIOLENCE ON THEIR SOCIAL, EDUCATIONAL AND PUBLIC HEALTH STATE.

BACKGROUND AND PURPOSE

The Syrian civil war since 2011 led to one of the most complex humanitarian emergencies in history. This protracted disaster has but negative aspects, especially on children.

Purpose of this study is to document the impact on the social, educational and public health state of Syrian children.

 

PATIENTS AND METHODS

A cross sectional observational sample study was conducted in May 2015. Healthcare workers, especially trained for this study, visited families home by home with a prospectively designed questionnaire in four Northern Syrian governorates.

Of 1080 filled-out questionnaires, 1001 were complete and included in this study. Children originated from Aleppo (41%), Idleb (36%), Hamah (15%) and Lattakia (8%). Median age was 6 years (0-15;IQR 3-11), 61% were boys.

 

RESULTS

Almost 20% of children were Internally Displaced Persons. The father was deceased or missing in respectively 5% and 4%, and similarly for the mother in 2% and 3% of the children. Almost 15% had no access to safe drinking water, and 23% could not access appropriate sanitation. About 16% had insufficient access to nutrition, and almost 27% suffered from malnutrition. Access to specific mother and child healthcare providers was disturbed in 64%, and vaccination state was inadequate in 72%. More than half of all school-aged children had no access to education at the time of the study.

Statistical analysis indicates that the risk for children to have unmet depends mainly on the governorate in which they reside. Most affected governorates are Idleb and Lattakia for water, sanitation, education, and healthcare; and Aleppo for missing vaccines. These problems are not linked to gender or age, except for the vaccination state: the smaller the children, the more they are at risk to have an incomplete vaccination state.

 

CONCLUSIONS

After four years of civil war in Syria, many children have lost their parents, are being displaced, and live in substandard life quality circumstances. Most children miss education, undermining their own future and that of the country. Limited access to water, sanitation, and to regular and healthy food, together with increasing malnutrition rates, worsening of the immunisation state and accessibility to specific healthcare facilities add up to the factors that put Syrian children at risk for increased morbidity and mortality.

Urgent coordinated and global action is needed to deal with this complex humanitarian emergency, and to prevent worsening of social, educational and public health threats for children in Syria.


Abdallah ELSAFTI ELSAEIDY, M.D., M.SC (Egypt, Qatar), Garlant GERLANT VAN BERLAER, M.D., M.SC, Mohammad AL SAFADI, M.D., Michel DEBACKER, M.D., Ronald BUYL, PH.D., Atef REDWAN, M.D., PH.D., Ives HUBLOUE, M.D., PH.D.

11:10-12:40
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OP22
Oral Papers 22

Oral Papers 22

Moderators: Hayette MOUSSAOUI (Emergency Physician) (London), Inger SONDERGAARD (PHYSICIAN) (ALLEROED, Denmark)
11:10 - 12:40 #6398 - OP037 Impaired cognition is associated with adverse outcomes in older patients presenting to the emergency department; the APOP study.
Impaired cognition is associated with adverse outcomes in older patients presenting to the emergency department; the APOP study.

Background: The number of emergency department (ED) visits by the elderly is increasing. Cognitive impairment is a risk factor for functional decline and mortality but its assessment takes too much time in older patients in the Emergency Department. Information about cognition at arrival might be of great value to assist clinicians in making treatment decisions, to detect risk of delirium in an early phase and to reduce the risk of adverse health outcomes by implementing targeted interventions. Therefore, the aim was to investigate if the relatively brief Six-Item-Cognitive-Impairment-Test (6-CIT) is an independent predictor of functional decline and mortality, a pre-requisite to be used as a screening-tool in the acute setting.

 

Methods: A multicentre prospective observational follow-up study was conducted in patients aged 70-years or older, visiting the ED of the Leiden University Medical Center (LUMC) and Alrijne Hospital in the Netherlands. At baseline, the Six Item-Cognitive-Impairment-Test (6CIT) and functional status, as assessed with the Katz-ADL, was assessed. Cognitive impairment was defined as a 6CIT score ≥11. Multivariable logistic regression analysis with the primary outcomes mortality and functional decline (composite endpoint adverse outcome), at three and twelve months (LUMC only) after the ED visit was used.


Results: 1632 patients were included (LUMC n=751, Alrijne n=881). 326 patients (21.4%) had cognitive impairment. Compared to normal cognition, cognitive impairment is associated with increased risk of adverse health outcomes, independent of age, sex, education and triage urgency, with corrected odds ratios of 1.87 (95%CI:1.42-2.46) at three months. Patients with impaired cognition had increased risk of mortality after three and twelve months (HR 2.27(95%CI1.54-3.34)).


Conclusion
Cognitive impairment, measured with the 2-3 minute 6CIT, is independently associated with adverse health outcomes in older ED patients.


Jacinta LUCKE (Haarlem, The Netherlands), Jelle DE GELDER, Bas DE GROOT, Christian HERINGHAUS, Jaap FOGTELOO, Sander ANTEN, Gerard-Jan BLAUW, Simon MOOIJAART
11:10 - 12:40 #6419 - OP038 Clinical characteristics and outcome of nonagenarians and centenarians in a medical ICU.
Clinical characteristics and outcome of nonagenarians and centenarians in a medical ICU.

Background:

As a result of demographic transition, the proportion of « very elderly » (≥ 90 years) patients is increasing worldwide and more of these patients are nowadays admitted to intensive care units (ICU). Among physicians the discussion about appropriateness of these ICU admissions still remains controversial. mostly due to questionable outcome, limited ressources and costs. The aim of the study was to determine and evaluate the clinical characteristics and outcome in a very old population admitted to a medical ICU in an urban hospital.

Methods:  

We present here a retrospective and monocentric study. We reviewed the charts of all patients (≥ 90 years) admitted to a medical ICU between 2005 and 2015. We collected epidemiological, clinical and biological parameters and all therapeutic measures during the ICU stay. A long-term survival follow-up was also performed. 185 patients were included for statistical analysis.

Results:

A total of 185 patients were included, which represented 1.8% of admissions to the ICU during this 10 year period. The mean age was 92.7 +/- 2.2 years, the sex ratio was 0.34. Most of patients (39%) were admitted from the emergency department (ED) and 34% directly from pre-hospital care (EMS). The mean Charlson comorbidity score was 7.6 (95% CI: [7.3-7.8]) and the mean McCabe score was 1.36 (95% CI: [1.28-1.43]). The admission diagnosis in the ICU was mainly respiratory distress (48%), septic shock (13%), coma (11%) and cardiac arrest (10%). The average SAPS-II score within 24 hours of ICU admission was 58.1+/-23.2. 20% of these patients suffered of previous dementia. 50% of patients required support by mechanical ventilation (mean duration 7.1 days) and 6% of patients received renal replacement therapy. ICU and hospital mortality rates were 40% and 46% respectively. Overall survival at three months after hospital discharge was 48%. For 34% of these patients, a limitation of active treatment was decided (on average after two days of stay). For 66% there was no justification for limiting care because of a well-established treatment plan (with family, GP, ICU team).

Conclusion:

The proportion of elderly patients remains low, but they are increasingly being treated in intensive care units. The in-hospital mortality is high (40%) compared to the average mortality in our ICU over the same period (20%). The prognosis is often not as poor as perceived by physicians. The indication for ICU treatment in our study was mostly justified ; in the setting of  consistent patient care and good clinical practice. It remains therefore appropriate to discuss every ICU admission of elderly patients without any restriction related to age.


Pierrick LE BORGNE (Strasbourg), Sophie COURAUD, Charles-Eric LAVOIGNET, Jean-Etienne HERBRECHT, Alexandra BOIVIN, Quentin MAESTRAGGI, Pascal BILBAULT, Francis SCHNEIDER
11:10 - 12:40 #7128 - OP039 Intelligent Assistance Services and Personalized Learning Environments for Support of Knowledge and Performance in Interdisciplinary Emergency Care.
Intelligent Assistance Services and Personalized Learning Environments for Support of Knowledge and Performance in Interdisciplinary Emergency Care.

Background:

During the past decade emergency medicine evolved to an increasing challenge for clinics of all stages of patient care due to a substantial and continous change of medical knowledge, limits of time and health care economics as well as an enormous rise of patient cases. Thus, continuous medical education for all employees involved in the preclinical or clinical phase of emergency care represents an essential prerequisite for high quality patient-centered care to overcome these problems. However, in this special setting of rush, stress and highly intense workload conventional learning techniques do not allow for continous training on the job. To address this problem we developed novel learning and teaching strategies based on digital technologies for both academic and non-academic staff members within interdisciplinary emergency care departments (ED).

 

Methods:

For medical students and trainees we created a podcast and an emergency care software for simulation of emergency cases in order to prepare for the work within the ED in comparison to control groups without access to these learning tools. Acceptance, frequency of usage and effects of these techniques were assessed prior to and after the occupation within the ED by standardized questionnaires and tests. For nurses and paramedics we first assessed the information demands during all processes of emergency patient care in the preclinical and clinical phase. Based on these needs intelligent assistance services were established in cooperation with two technological partners to support daily workflow via web-based services.

 

Results:

Introduction of the podcast and the emergency care software prior to the start within the ED resulted in a significant improvement of skills and expert knowledge for both medical students and trainees in comparison to the control groups (p< 0.002). Both innovative tools were widely accepted and frequently used by each proband. Analysis of processes within the preclinical and clinical phase of emergency care revealed information demands for paramedics and nurses especially with respect to invasive/non-invasive techniques, first aid standard operating procedures, medications and medical devices. Content for these assistance services was developed and subsequently digitalized for web-based usage via mobile devices (tablets). Preliminary results of these applications will be demonstrated and evaluated in a pilot study.

 

Conclusions:

Introduction of novel learning and teaching strategies within the ED allows for a continuous medical education and training on the job in the special setting characteristics of emergency care. Results of our studies revealed a significant improvement of technical skills and medical expertise thus leading to a better performance of the academic staff within the ED. Further studies with non-academic employees now have to evaluate the effects of these innovative strategies within the preclinical and clinical phase of emergency care.


Sabine BLASCHKE (Goettingen, Germany), Bjoern SELLEMANN, Carsten ULLRICH, Michael SCHMUCKER, Katrin WEDLER, Sabine REY, Stefan ROEDE, Markus ROESSLER, Otto RIENHOFF, Felix WALCHER, Martin HAAG, Christoph IGEL
11:10 - 12:40 #7243 - OP040 Use of Physical restraint on elderly people in emergency department.
Use of Physical restraint on elderly people in emergency department.

Background: Confusion in elderly people presenting to Emergency Department (ED) is often associated with a state of agitation with or without aggressivity. Recommendations for the management of these patients exist. Physical restraint (PR) is sometimes necessary to protect them but it is a source of morbidity and mortality. The aim of our study was to examine how emergency physicians prescribe physical restraint for elderly people presenting to ED. The primary outcome was association chemical treatment (benzodiazepines and / or neuroleptic) or not to PR.

Methods: Elderly people (age > 75 years old) with prescription of PR were included in this retrospective study between november 2014 and march 2015 in Lariboisière University Hospital, Emergency Department . Two groups were compared on such criteria: 1 / PR alone (group A); 2 / PR + chemical treatment (group B). The primary outcome was the association chemical treatment (benzodiazepines and / or neuroleptic) or not to PR. The secondary outcomes were justified prescription of PR, revaluation of the indication of PR and monitoring of the PR. The student test was used for quantitative variables. The Chi 2 test was used for qualitative variables.


Results: One hundred thirty-eight consecutive patients were analyzed (66 [48%] in group A and 72 [52%] in group B) with no significant difference between the 2 groups (p = 0.32). The prescription of benzodiazepine associated with PR was significantly higher compared to the prescription of neuroleptic. The number of justified prescription of PR was higher but not significantly different (p = 0.05) in group B (n = 18 [25%]) than in group A (n = 8 [12%]). Half of justified prescription of PR was linked to an act of nursing care. The daily revaluation of the PR was significantly higher in group B (respectively 11 [15%] vs 0 in group A, p <0.01).

Conclusion: Elderly people having PR did not always have an associated chemical treatment as provided by the recommendations. The prescription of PR were insufficiently justified. The daily revaluation of the indication of the PR and clinical-biological monitoring were almost non-existent causing a risk of increased morbidity and mortality. This study justified the establishment of a protocol to guide the prescription of the PR in elderly people in our ED.


Erwin HANSCONRAD (Vincennes), Anthony CHAUVIN, Patrick PLAISANCE
11:10 - 12:40 #7415 - OP041 Adverse events in elderly patients admitted to a medical short stay unit.
Adverse events in elderly patients admitted to a medical short stay unit.

Introduction

Elderly patients are at particular risk of experiencing adverse events of hospitalisation, and they are more vulnerable to adverse events compared to younger patients. The aim of this study was to compare the occurrence of adverse events during hospitalisation or within 30 days after discharge to either a short stay unit or a department of internal medicine in elderly internal medicine patients.

Methods

This retrospective study evaluated adverse events during hospitalisation of elderly internal medicine patients either in an emergency department based short stay unit called ‘Quick Diagnostic Unit’ (QDU) or an internal medicine department (IMD) at Holbaek Hospital, Denmark, from January 1st 2014.. Eligible patients were 75 years or older and admitted for any internal medicine disease and they should have a non-emergent (green) triage level at admission. IMD patients were matched with QDU patients by 1) year of birth and 2) date of admission. Medical records were reviewed in a two-stage process by physicians to detect adverse events. Earlier studies have shown that up to 37 % of elderly patients experience an adverse event during a hospitalisation; to detect a 33 % risk reduction based on alpha=0.05 and beta=0.08, a sample size of 450 patients was required. The primary outcome was the occurrence of any adverse event on a list of 19 predefined events during hospitalisation or up to 30 days after discharge. Secondary outcome measures included types of adverse events and mortality. A p-value <0.05 was considered significant.

Results

We screened a total of 833 patients’ hospital charts for inclusion and 450 patients met the inclusion criteria, 225 patients in each group. The median age of patients were 82 years (IQR 78-86 years) for both groups. There were no significant differences in baseline variables. For both groups, the median Charlson Comorbidity Index score was 6 with IQR 5-7. Adverse events were significantly less common in the QDU-group than in the IMD-group, i.e., 68 (30 %) patients in the QDU-group and 92 (41 %) patients in the IMD group had one or more adverse events of hospitalisation, (p=0.02). The relative risk of an adverse event was 0.80 (95 % CI 0.65-0-99) in the QDU-group and 1.23 (95% CI 1.02-1.15) in the IMD group, respectively. The most common adverse events were 1) transfer during hospitalisation, 2) unplanned readmission, 3) nosocomial infection in both groups. We found no significant difference in 90-day mortality QDU-group compared to the IMD-group, 65 (29 %) versus 84 (37%) (HR 0.729 (95% 0.414-1.284)).

Conclusions

Adverse events was significantly less common in elderly patients treated in a medical short stay unit compared to an internal medicine ward. Hospitalisation in a short stay unit seems not only feasible, but in selected cases maybe even preferable, for elderly medical patients.  


Dr Camilla STRØM (Copenhagen, Denmark), Lars Simon RASMUSSEN, Thomas Andersen SCHMIDT
11:10 - 12:40 #7631 - OP042 Attitudes and knowledge of emergency medicine health care professionals toward elder abuse and neglect.
Attitudes and knowledge of emergency medicine health care professionals toward elder abuse and neglect.

Introduction: Elder abuse is a significant public health problem. The population of elder people is increasing steadily. According to World Health Organization (WHO), by the year 2050, it is expected that the number of elder people would have come up to 20 percent of world population. Although the elder abuse and neglect prevalence is higher than supposed, it is much lower to identify and report these cases, especially in emergency medicine departments. The aim of this study is to assess the knowledge and attitudes of emergency medicine health care professionals toward the identification and management of elder abuse and neglect cases.

Methods: This cross-sectional descriptive study was performed in two universities and two training and research hospitals’ emergency departments in Ankara.  The research tool was a 26-item questionnaire that was applied on 184 emergency medicine health care professionals including doctors, nurses, emergency medicine technicians.  Analysis was completed with SPSS 15.0. In addition to descriptive statistics, chi square analysis were used to determine differences between groups.

Results: Although 78% of participants had identified an abuse elder person before, 64% of them have never reported about elder abuse. The main reasons of not reporting are not to feel proficient (41%) and not know how to do that (27%). Significant percent of responders answered that they haven’t had any education about elder abuse and neglect in undergraduate education (73%) and post-graduate education (87%).

Conclusion: This study indicates that emergency medicine health care professionals confronts with abused elder frequently but they abstain from reporting these cases because they feel lack of knowledge about elder abuse and neglect especially.

References:

  1. Mandiracioglu A, Govsa F, Celikli S, Yildirim GO. Emergency health care personnel’s knowledge and experience of elder abuse in Izmir. Archives of Gerontology and Geriatrics 43 (2006) 267–276.
  2. Fulmer T, Paveza G, Abraham I, Fairchild S. Elder neglect assessment in the emergency department. Journal of emergency nursing: 2000 vol: 26 (5) pp: 436-443.
  3. Almogue A, Weiss A,  Marcus EL, Beloosesky Y. Attitudes and knowledge of medical and nursing staff toward elder abuse. Archives of Gerontology and Geriatrics 51 (2010) 86–91.

Acknowledgements: There is no funding received for this work from any organizations. The authors declare that they have no conflict of interest.


Aysegul GUVEN CEBECI (Ankara, Turkey), Isa KILICASLAN, Fikret BILDIK, Sezer ESFER, Reyhan SAHNAOGLU
11:10 - 12:40 #7906 - OP043 Triage training in mass casualty incidents: the added value of virtual simulation in e-learning and classroom teaching.
Triage training in mass casualty incidents: the added value of virtual simulation in e-learning and classroom teaching.

Background: The traditional model of education in medical schools is based on the belief that students will successfully transfer knowledge gained in classroom lectures, completed by self-education trough e-learning. More educational programs are also starting to integrate simulation based learning into their teaching methods. Several studies suggest that clinical simulation is an effective teaching strategy, although it is very depending on the context, topic and method.  Finding out what is the most impactful methodology leading to the best learning and knowledge retention over time is desirable.

The present study was designed to evaluate the added value of virtual simulation programs in teaching START triage to medical students, compared with e-learning and classroom teaching.

 

Methods: Twenty medical students were randomly assigned into two groups: group A and group B. Both groups were given the same classroom lecture, supported by a PowerPoint presentation on how to perform START triage in Mass Casualty Incidents (MCI). Immediately following this lecture, a 30-item paper-based test was administered to assess the student’s ability to understand and apply START triage.

Both groups received a more extensive online presentation with examples and video’s through e-learning. Group B had an additional interactive session with virtual simulation training and professional feedback.

One month later a new test was given to assess and compare knowledge between both groups.

 

Simple descriptive statistics were used to analyse findings, with the independent samples T-test to compare groups where appropriate. For further analysis nonparametric statistics were used due to some indications of possible non-normality.

Alpha was set at p < 0,05 to determine statistical significance. All analyses were conducted using SPSS® software.

 

Results: The baseline test showed a mean score of 15,65 out of 30. For the second test, taken after the thirty-minute classroom teaching session an average score of 26,15 out of 30 was observed. This statistically significant change (Independent‐SamplesMann‐Whitney‐U test, p < 0,001) showed a strong improvement in knowledge after a brief classroom teaching session. After one month of e-learning group A had an average score of 28,6 out of 30. Group B, who received the additional virtual simulation session, scored 28,875 out of 30.

This result didn’t reveal any statistically significant difference between both groups (Independent-Samples Mann-Whitney-U test, p = 0,696).

Also examined was the number of over- and undertriaged casualties, but no significant differences were found between either group. No differences between men and women were noted.

 

Conclusion: Although virtual simulation training has been described in literature as an effective teaching strategy, no significant differences in scores on knowledge tests were found between two test populations of which one received ‐ in addition to classroom lecture and e‐learning ‐ a computer‐based virtual reality simulation training.

Nevertheless, certain findings in this study were surely intriguing opportunities for further research. A comparable study with a larger test group, a more extensive teaching subject and/or a longer time interval between the tests could be interesting pathways to investigate.


Sofie-An VAN BIESEN (Aalst, Belgium), Nima TABRIZI-HOSSEINPOUR, Joost BIERENS, Ives HUBLOUE
11:10 - 12:40 #7987 - OP044 Methodological characteristics and outcomes used in simulation randomized controlled trials in the field of Emergency Medicine: a systematic review.
Methodological characteristics and outcomes used in simulation randomized controlled trials in the field of Emergency Medicine: a systematic review.

Background: Simulation is defined as a technique used to replace or amplify real experiences with guided experiences that evoke or replace substantial aspects of the real world in a fully interactive manner. The use of simulation in emergency medicine began decades ago with the use of low-fidelity simulations and has evolved at an unprecedented pace. The literature on simulation is abundant in emergency medicine. But the methodological quality of these studies had not yet been assessed. The aim of this study was to conduct a systematic review of published randomized controlled trials (RCT) assessing a simulation intervention and to examine their methodological characteristics.

Methods: We performed a systematic review on MEDLINE via PubMed of randomized controlled trials, assessing a simulation intervention, published from January, 1st 2012 to December, 31th 2015 in the 6 general and internal medicine journals, and the 10 emergency medicine journals with the highest impact factor according to the Institute for Scientific Information Web of Knowledge. Two researchers independently performed the trials selection and extracted the data, if necessary a third researched stepped in to resolve disagreements. For each trial, researchers extracted the RCT general characteristics, the participants, intervention, comparator and outcomes as reported in the trial report. The Cochrane Collaboration risk of bias tool was used to assess the trials risk of bias, using the tool main domains (sequence generation, allocation concealment, blinding of participants, blinding of outcome accessors, incomplete data management and selective reporting). Methodological quality was evaluated using the MERQSI score. The MERSQI is a tool used to assess educational interventions.

Results: 1 394 RCTs were screened, 270 (19%) were considered as in the field of emergency medicine and 69 (26%) assessed a simulation intervention. Fifty-five RCTs were monocentric. The average time of acceptance was 143 days (SD=86). Studies included on average 144 participants. United States of America were the most frequent place of study. In included trials, cardiopulmonary resuscitation (CPR), was the most frequent topic (n=55; 80%). The usual procedure was the comparator in half studies (n=37). 30 (43%) of RCTs were evaluated for CPR quality outcomes. A total of 10% (n=7) were registered on a public registry or had an available protocol. The random sequence generation and allocation concealment were correctly performed respectively in 68% (n=47) and 43% (n=30).The participants and assessors blinding were correctly performed in 20% (n=14) and 62% (n=43). The attrition bias was low in two-third in studies (n=50). The reporting bias was low in nearly all studies (n=65; 95%).Methodological quality by MERQSI score averaged 12.3/18 (SD=3).

Conclusions: Trials assessing simulation count fo one quarter of published RCTs in emergency medicine. Their quality remains unclear and should make us very cautious when interpreting their results. In our sample authors particularly failed to correctly describe the blinding and allocation concealment. These trials characteristics being associated with the magnitude of the intervention effect based on previously published meta-epidemiological studies.


Chauvin ANTHONY (Paris), Jennifer TRUCHOT, Dominique PATERON, Patrick PLAISANCE, Youri YORDANOV
11:10 - 12:40 #7997 - OP045 The Phenomenon of Older Emergency Department Frequent Attenders.
The Phenomenon of Older Emergency Department Frequent Attenders.

Introduction:

Characteristics of older frequent users of Emergency Departments (EDs) are poorly understood. Our aim was to examine the characteristics of the ED frequent attenders (FAs) by age (<65 and ≥65 years).   

Methods: 

We examined the prevalence of FA attending the ED of an urban teaching hospital in cross-sectional study between 2009 and 2011. FA was defined as a person who presented to the ED four or more times over a 12-month period. Randomly selected groups of FA and non-FA from two age groups (<65 and ≥65 years) were then examined to compare characteristics between older FAs and non-FAs and older FAs and younger FAs. Logistic regression was used to calculate the odds ratio (OR) and 95% confidence intervals for 12-mortality in FA compared to non-FA aged ≥65years.

Results: 

137,150 ED attendances were recorded between 2009 and 2011. 21.6% were aged ≥65years, 4.4% of whom were FAs, accounting for 18.4% of attendances by patients over 65 years. There was a bi-modal age distribution of FA (mean ±SD; <65years 40±12.7; and ≥65years 76.9±7.4). Older FAs were 5 times more likely to present outside normal working hours and 5.5 times more likely to require admission. Cardiovascular emergencies were the most common complaint, in contrast with the younger FA group, where injury and psychosocial conditions dominated. The OR for death at 12-months was 2.07 (95% CI 0.93, 4.63), p=0.07, adjusting for age and gender. 

Conclusion:

1-in-5 ED patients over 65years are frequent attenders. Older FAs largely presented with complex medical conditions. Enhanced access to expert gerontology assessment should be considered as part of effective intervention strategies for older ED users.  


Geraldine MCMAHON, Megan Power FOLEY (Dublin, Ireland)

14:10-15:40
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OP23
Oral Papers 23

Oral Papers 23

Moderators: Anthony CHAUVIN (PU-PH) (Paris, France), Jeffrey KEEP (London, United Kingdom)
14:10 - 14:20 #6343 - OP046 Emergency Department blood-borne Virus Screening Study (EDVS STUDY). Feasibility and results in an urban inner city Emergency Department.
Emergency Department blood-borne Virus Screening Study (EDVS STUDY). Feasibility and results in an urban inner city Emergency Department.

Introduction

Recent data suggests >2/1000 people live with HIV in the Dublin area. British HIV Association guidelines advise universal HIV testing at this threshold. Reported prevalence of Hepatitis C (HCV) in Ireland is 0.5- 1.2%. Hepatitis B (HBV) prevalence is unknown. The aim of this study was to assess the feasibility of a HIV, HBV and HCV panel screening programme in an urban Emergency Department (ED).

 Methods

With ethical approval, opt-out serum screening was piloted from March 2014 to January 2015. Patients who underwent venepuncture in ED were offered an additional panel viral screen of HIV, HBV and HCV testing. An extensive staff education programme was conducted before the study commenced. Visual and verbal reminders were instituted at daily staff handovers. The study organisers provided regular study updates.

Results

Of 10,000 samples, 8839 were analysed following removal of duplicates. A sustained uptake of >50% of samples was attained by Week 3.

97, 44 and 447 patients tested positive for HIV, HBV and HCV respectively. Of these, 7, 20 and 58 were new diagnoses of HIV, HBV and HCV respectively. The incidence and prevalence of all three viruses are outlined below

HIV- incidence 0.8 per 1000, prevalence 11 per 1000

HBV- incidence 2.26 per 1000, prevalence 5.05 per 1000

HCV- incidence 6.5 per 1000, prevalence 50.5 per 1000

Conclusions

The results demonstrate a high prevalence of blood borne viruses in our population. Opt-out serum screening for blood borne viruses is feasible and acceptable in a busy urban ED for both staff and patients. It has now become standard of care in our Emergency Department.


Darren LILLIS (Dublin, Ireland), S O'CONNELL, A COTTER, S O'DEA, H TUITE, Darragh SHIELDS, S NORRIS, B CROWLEY, Pk PLUNKETT, C BERGIN
14:20 - 14:30 #6507 - OP047 The diagnostic value of optic nerve sheath diameter measurements by ultrasonography in elevated intracranial pressure in stroke patients.
The diagnostic value of optic nerve sheath diameter measurements by ultrasonography in elevated intracranial pressure in stroke patients.

Indtroduction:Stroke is the most common 4th cause of death around the world. Due to brain edema elevated ICP is a reason of clinical deterioration in stroke patients  (%33).  ONSD measurement with ultrasonography is an indirect and non invasive technique to detect EICP.

Aim:The aim of this study is to invastigate the diagnostic value of ONSD measurements in EICP in stroke patients.

Methods:The paper involves data concerning a control group 50 individuals with study group of 105 patients diagnosed with acute stroke at the Adult Emergency Department of Hacettepe University between February 1,2015 and June 30,2015.  Symptoms and physical examinations of the patients were recorded. We performed ON-US to all patients and ONSD measurements by US were compared with the results of study group MRI-ONSD measurements. 

Results:MRI-ONSD measurements were used to diagnose EICP and the cut off for EICP was 5.0 mm in MRI-ONSD. The study group divided in two subgroups as EICP (n=47) and non-EICP (n=58) groups. Of the 155 patients studied, 81 (%52,3) were male and 74 were (%47,6) female. The means of ONSD by US; for non-EICP group for right and left eye were 4,52 mm/4,58 mm, for EICP group were 5,01 mm/5,03 mm. The means of MRI-ONSD for EICP group were 5,05 mm/5,06 mm and non EICP group were 4,56 mm/4,61 mm. Greater than 5,0 mm ONSD by US predicted EICP with sensitivity %95,7; specificity %100, general truth value %91,4 and kappa %82,8. The means of ONSD by US were significantly correlated with MRI-ONSD measurements. Symptoms such as headache, confusion and vomiting were significantly higher in EICP group and these symptoms predicted EICP with sensitivity %95,7; specificity 87,9. The intensive care requirement was increased in EICP group rather than non-EICP group (%25,5/%6,9).  Especially MCA infarction associated with brain edema (%65,7) and elevated mortality rate (%14,3). 5 patients (%4,76) were exitus in intensive care unit and all the patients had MCA infarction.

Conclusion:As a result, ONSD measurements by US is sufficient, reliable and practical in the diagnosis of acute stroke. ICP assessment with ON-US in acute stroke patients could be used to predict treatment process, prognosis and mortality.


Ali BATUR, Mehmet Ali KARACA (ISTANBUL, Turkey), Volkan ARSLAN, Mustafa BOZ, Bulent ERBIL, Zaur IBRAHIMOV, M.ruhi ONUR
14:30 - 14:40 #7143 - OP048 The Efficieny Of Ultrasonography For Reduction of Distal Radial Fractures In The Emergency Deapartment.
The Efficieny Of Ultrasonography For Reduction of Distal Radial Fractures In The Emergency Deapartment.

Introduction: Distal radius fracture is the most common fracture of the wrist. Adequacy of reduction is evaluated through two-way post-reduction graphies. In the event that inadequate reduction is ascertained in the wake of the evaluated graphies, sedation and reduction procedures are performed on the patient once again. Ultrasonography (USG) can be used in the management of the patients with distal radius fractures, however, there are no adequate number of studies suggesting the efficiency of USG alone in showing the status of reduction success. The aim of the study is to evaluate the efficiency of the use of bedside USG for determining reduction success distal radius fractures and  to investigate the detecttability of the possible causes leading to unsuccessful reduction when using USG. 

Methods: Consecutive patients applied to the emergency department of the Faculty of Medicine of Ege University between the period, April 2013–September 2013, were incorporated into this prospective double-blind cross-sectional study. The patients aged over 18, who had wrist trauma and distal radius fracture and on whom reduction was performed were included to the study. Pre- and postreduction ultrasonographic images were recorded by a research asistant trained in extremity ultrasonography, images were recorded in longitudinal and horizontal axes. 

Separately, emergency medicine specialist (EMS)also, by examining the ultrasonographic images, evaluated the angulation of the distal fragment towards the dorsal or volar part, and whether or not there was any shortening in the radius, and whether there were any multiple fragments in the dorsal part of the distal fragment. The post-reduction graphies were re-evaluated in terms of reduction success by another orthopedic surgeon uninformed about the performed procedures. The orthopedic surgeon evaluated the reduction success and, the radial height: ≥5mm, radial angulation: between 15⁰-25⁰ , and the volar tilt angle: between  0⁰-20⁰  were considered as normal values. Evaluation of orthopedic surgeon was accepted as gold standart and compared with EMS. Sensitivity, specificity, and positive and negative predictive values were measured.  

Results: Ulltrasonography was 97,5% sensitive and 95% specific in determining the reduction success, the positive predictive value (PPV) was found as 97,5%, whereas the negative predictive value (NPV) was found as 95%. When direct graphy was accepted to be the golden standard, the direction of the distal fragment was determined with 100% sensitivity and 100% specificity through ultrasonography (PPV:100%, NPV:100%). The number of the multiple fragments was determined with 86% sensitivity and 73% specificity with use of ultrasonography (PPV: 84%, NPV: 77%), while the presence of radial shortening was ascertained with 67% sensitivity and 65% specificity (PPV: 79%, NPV: 50%).

Both ultrasonography and direct graphy was determined that distal fragment located towards the volar and presence of multiple distal fragments had negatively affected the reduction success significantly. However ultrasonography was failed to determine reduction success in the presence radial shortening (p=0,582)  when direct graphy succesfully determined the reduction success (p=0.008). 

Conclusion: Ultrasonography can be helpful in determining the reduction success for distal radius fractures which needs reduction. In the future, using ultrasonography may boost reduction success prominently in the ED.


Ozgur BOZKURT, Pr Murat ERSEL (IZMIR, Turkey), Funda KARBEK AKARCA, Sercan YALCINLI, Sadiye MIDIK, Levent KUCUK
14:40 - 14:50 #7380 - OP049 Emergency Department Applicability of SOFA Sepsis – Is There a Middle Ground?
Emergency Department Applicability of SOFA Sepsis – Is There a Middle Ground?

Background – 2016 has seen the publication of new definitions for sepsis and further evaluation of the SOFA sepsis scoring system. With little involvement from Emergency Department (ED) physicians, the problem now is applying them to the first few hours of patient care. The ED requires a system that sits between the blunt triage tool of 'quick SOFA' (qSOFA) and the intensive-care based and considerably more detailed SOFA Sepsis score.  The key area of difficulty with applying the SOFA score is that it relies on changes from patient’s baseline. This baseline information, however, is rarely available in its entirely in the critical period of the patient’s initial care in the ED. Assuming a baseline score of 0 for all patients will clearly result in overdiagnosis of sepsis in the ED.

Aims

  • to illustrate the difficulties in applying the SOFA score within a representative ED population in comparison to the qSOFA and National Early Warning Score (NEWS)
  • to develop and test an adapted SOFA score (EDdeltaSOFA) with specific, pragmatic assumptions for the ED relating to existing physiological baseline and pre-existing disease.

Methods

A retrospective analysis was performed of one month’s patients notes who had been coded for ‘infection’ within an ED database. The NEWS and qSOFA score were calculated from recorded vital signs at triage. These scores were then applied against the SOFA score (calculated from blood tests and physiological parameters within the ED) necessarily assuming a baseline as 0 and then against an adapted score.

This adapted SOFA score, the 'EDdeltaSOFA' utilises all the same categories as the SOFA score but allows for a few pragmatic assumptions based on prior knowledge or reasoned clinical suspicion of the patient’s baseline physiology. For example, for renal impairment, where previous creatinine is not known but the patient has a history of chronic renal impairment, it seems reasonable to assume a baseline SOFA score of 1 rather than a baseline score of 0.

Results

Within the sample of 169 patients who met criteria, 34 patients were excluded with missing data. 57 patients were positive for SOFA sepsis within the sample with only 42 meeting criteria with the adapted EDqSOFA score. NEWS and qSOFA performed poorly for predicting SOFA sepsis when the patient’s baseline physiology score was assumed to be zero. NEWS sensitivity 54% (C.I.s 41-67) specificity 43% (C.I.s 31-54) and qSOFA 55% (C.I.s 42-68) specificity 66% (C.I.s 54-76). They performed better when the EDqSOFA score was applied. NEWS sensitivity 88% (C.I.s 74-96) specificity 49% (C.I.s 39-59) and qSOFA 71% (C.I.s 55-84%) specificity 69% (C.I.s 58-78%)

Conclusion:

The new definitions of 2016 are an extremely welcome step forward in our understanding of the elusive clinical entity of sepsis. It is now the role of Emergency Physicians to apply the knowledge to our clinical environment. The data presented above suggests that there is a promising method of adapting the SOFA sepsis score. It is the authors’ intention to develop this tool further and conduct a series of larger validation trials for its use.


Tom ROBERTS, Danny YOOKEE, Matt EDWARDS (London, United Kingdom), Jeff KEEP
14:50 - 15:00 #4547 - OP050 Follow-up review of the impact of national jaundice guidance (NICE CG98) on inappropriate attendances to a paediatric emergency department.
Follow-up review of the impact of national jaundice guidance (NICE CG98) on inappropriate attendances to a paediatric emergency department.

Background

NICE guidelines (NICE CG98) launched in May 2010 on neonatal jaundice mandate quantitative bilirubin testing in every neonate noticed to be visibly jaundiced. The guidelines were implemented locally in August 2011, and consequently, caused a significant surge in the number of attendances to our paediatric emergency department (ED) for bilirubin level assessments, straining emergency services significantly, as seen in a review done in 2012. Transcutaneous bilirubinometers were purchased for local midwifery teams to enable quantitative bilirubin testing in the community. This study was undertaken to review the impact of the NICE guidelines and the provision of trancutaneous bilirubinometers since.

Materials

Review of hospital episode statistics from November 2014 to August 2015 as recorded on EPIC and comparison of ED attendances against the local birth rates and inpatient admissions with neonatal jaundice as a diagnosis; and comparing this against a similar review of the data undertaken in 2012. Review of the proportion of admissions and bed days for feeding and observation compared to phototherapy and septic screens.

Results

From the previous review done in 2012 in the department, pre-guideline implementation saw an average of 14.5 patients per month present to the paediatric ED with jaundice, rising dramatically to an average of 49 patients per month post-guideline implementation. Local birth rates remained stable at about 490 births per month. Over the same time period, admission of neonates to a paediatric inpatient ward with jaundice did not rise significantly at approximately 15 admissions per month. Over the period of November 2014 to August 2015, with the introduction of transcutaneous bilirubinometers for community midwives, which allows for quantitative assessment of bilirubin levels in the community, the attendance of patients to the paediatric ED with jaundice has fallen back to baseline of an average of 13.5 patients per month (Fig. 1). This is assuming that the local birth rate remained stable. Of these attendances, 15.5% were recalls to ED for serial serum bilirubin readings. Of these recalls, 25% were recalled for two serial bilirubin tests, while the other 75% were recalled once. Of these patients, most of them had an initial presentation of jaundice alone with no other worrying features (e.g. lethargy, fever, loss of weight). All these patients were discharged with no further follow-up.

Conclusion

Before the implementation of national guidelines, a careful assessment and anticipation of its downstream effects is required. Simple investigations made available in the community will help mitigate attendances to the emergency department, and will help reduce healthcare costs and inconvenience to patients and families. Similarly, providing, encouraging or enabling utilisation of services in the community that prevent the initial problem will help in reducing attendances at the ED and admissions for observations and support services that are already available in the community. 


Xue-En CHUANG (Bury St. Edmund's, United Kingdom), Peter HEINZ
15:00 - 15:10 #8005 - OP051 Consultus Interruptus: Unscheduled Interactions within the Emergency Department.
Consultus Interruptus: Unscheduled Interactions within the Emergency Department.

Introduction

It is well recognised that the job of an EM consultant involves multitasking and dealing with multiple unscheduled interactions (UI). The fluid, unpredictable, time pressurised and multi-professional nature of EM makes it particularly susceptible to UI. An increasing number of UI can result in increased error. An Increasing number of decisions, irrespective of complexity can lead to error and decision fatigue. We aim to map the number of UI an EM consultant faces when on shift.

Objectives

This study attempted to answer the following questions:

  • In a day how many unscheduled interactions does the senior EM physician deal with?

  • How many of these are interactions are clinical interactions?

  • What is the average length of time spent dealing with these unscheduled interactions?

Methods

This prospective observational study took place at a single centre urban ED in the West Midlands. The study period was from 1.12.15 to 23.12.15. An EM consultant was trailed on shift by a medical student who noted down all the non-patient interactions that the consultant had. The consultant had no input into data collection. The nature of the UI, the time spent and the outcome was recorded on a simple data collection form. This was then collated and analysed.

 Results

  • A total of 23 shifts over 135hrs 34min were observed.

  • There was a mix of early (0800-1600), late (1600-2100) and weekend shifts.

  • All 10 members of the consultant body were followed.  

Total Number of UI in study period:  2082

Average Number of UI per hr:  17.95 UI/hr.

UI rate (time per UI) 3min 21seconds

Average time per UI 87.5sec   (Range 10s–34 mins)

Clinical Interaction vs Non Clinical Interactions: 94% vs 6%

Conclusion

In this single centre study of an urban UK emergency department 40% of shop floor consultant time is spent dealing with UI. The majority (94%) of these UI related to clinical interactions. In this study this equates to 17.95 UI per hour with an average time spent dealing with each interaction of 87.5 seconds

Discussion

The nature of modern EM necessitates a senior EM physician running a shift on order to cope with the vast number of UI that must be resolved. Combining the intensity of this role with an individual patient load  is not feasible and departments should consider the initiation of a ‘captain of the ship’ ‘Fat Controller’ role along with a second senior EP to provide individual consultant level care to the sickest individuals who require senior input.


Sandeep GILL (Smethwick, United Kingdom), Raj PAW, Peter DOYLE, Ameer SHAH, Sarah SHAKKSHIR, Munir ABUKHDER
15:10 - 15:20 #8142 - OP052 Assessment of fluid responsiveness in the critically ills: which role for echocardiography?
Assessment of fluid responsiveness in the critically ills: which role for echocardiography?

Background: Volume expansion is a key component of therapy in critically ill patients, although its effect is difficult to predict using conventional measurements. Dynamic parameters, evaluated by echocardiography, have demonstrated a good diagnostic accuracy in several studies, but conflicting results have been reported. Aim of this study was to examine the feasibility and diagnostic accuracy of vena cava collapsibility index (VCCI) and velocity time integral variation after passive leg raising (PLR) in an unselected population of critically ill patients admitted to a sub-intensive clinical setting.

Methods: This is a prospective, observational, pilot study. Unselected critical patients admitted in an Emergency Department High-Dependency Unit (ED-HDU) were evaluated by transthoracic echocardiography to measure vena cava collapsibility index (VCCI) and aortic velocity (AoV)  variation during PLR. According to VCCI, patients were considered fluid-responders when the value was ≥50%, non-fluid responders when the collapse was <10% and indefinite response for intermediate values. According to AoV variation after PLR, a positive hemodynamic response was defined as an increase in AoV ≥ 10%. Whenever possible, both VCCI and AoV variation during PLR were evaluated. According to echocardiographic evaluation, three therapeutic options were considered: no intervention, administration of fluids or diuretics. Any change in the therapeutic strategy by the treating physician in the following 12 hours was annotated into the clinical records.

Results: we enrolled 29 patients, mean age 75±13 years; the two most frequent reasons for ED-HDU admission were sepsis (69%) and COPD re-exacerbation (14%). VCCI was feasible in 25 (86%) patients, while PLR could be performed in 13 (45%, p=0.004). According to VCCI, 11 (38%) patients were fluid-responder, 7 (24%) were non fluid-responders and in 7 patients VCCI showed an intermediate value; PLR was concordant with VCCI in 7 patients and it gave a diagnostic result in 6 patients in whom VCCI was not feasible or not diagnostic. According to the echocardiographic evaluation, 6 patients did not receive any treatment, 16 were treated with fluids and 7 with diuretics: the therapeutic option was maintained for the following twelve hours in 23 patients, while it was modified in the remaining 6 patients. This group of patients have been evaluated only by VCCI; 3 of them were fluid-responders, 2 non fluid-responders and 1 in the intermediate group. In these patients left ventricular systolic function was slightly depressed (left ventricular ejection fraction 47±9 vs 54±17% in the remaining patients) and lactate dosage was  normal (1.3±0.7 vs 2.4±3.6 mEq/L): these differences were not statistically significant, probably in part as a consequence of the limited population size, and need to be confirmed in a larger study group.

Conclusions: VCCI appears to be very feasible in an unselected population of critically ill patients; the proportion of patients with an indefinite value, who need a further evaluation, is not negligible as well as the proportion of patients in whom the therapeutic option based on VCCI measurement had to be modified in the following hours. PLR has a limited feasibility but it shows a very good diagnostic performance.   


Caterina SAVINELLI (Firenze, Italy), Salvatori MATTIA, Federico MEO, Alessandro COPPA, Francesca INNOCENTI, Riccardo PINI
15:20 - 15:30 #8174 - OP053 Factors associated with recurrent diabetic ketoacidosis in the emergency department.
Factors associated with recurrent diabetic ketoacidosis in the emergency department.

 

Introduction:

   Diabetic ketoacidosis (DKA) is one of the most commun diagnosis in the emergency department(ED). Many studies reported that DKA is the leading cause of mortality .In addition to the risk of fatality,recurrent DKA has a major impact on the quality of life of patients and many factors can be  associated with it.

Objective:

  The aim of this study was to identify the factors that influence recurrent DKA  in the ED.

Methods:

  We carried out a prospective observational cohort study in patients who were hospitalized in the ED for DKA during four years (2012-2015) .The epidemiological data ,clinical signs, etiology and  treatment were studied. An univariate linear regression analysis was carried out to find out the variables associated with recurrent DKA.

Results :

  Inclusion of 176 patients.136 with type 1 diabetes and 40 with type 2 diabetes. Mean age was 34 +/- 16 years. Sex ratio = 0,81. The major clinical signs were vomiting (69%) and dyspnea (53%). The leading precipitating causes of DKA were the poor compliance with insulin therapy (44%) and  infection (42%). A total of 145 patients presented with the first time DKA and 31 with recurrent episodes. Compared with the first-time DKA patients, those with recurrent episodes were younger (27 ±13 years vs 35 ± 16, p=0,003),had type 1 diabetes (97 % vs 78 %,p=0,008), duration of diabetes less than 5 years ( 61% vs 54 %, p=0,02 ), had more hyperventilation (Paco2= 18 ± 5 mm hg vs 22 ± 7, p=0,004),and a short delay of visit to ED (39 ± 3 hours vs 66 ± 10 , p=0,008).

Conclusion:

  The younger age , a short delay of visit ED , a low Paco2 and duration of type 1 Diabetes less than 5 years  were associated with recurrent DKA .The recognition  of such factors and the institution of specific programs might reduce DKA recurrence .


Wided BAHRIA (tunisie, Tunisia), Hanene GHAZALI, Wided BOUSSELMI, Anware YAHMADI, Farah RIAHI, Mahbouba CHKIR, Monia NGACH, Sami SOUISSI
15:30 - 15:40 #8209 - OP054 Point of care Ultrasound for the approach to respiratory distress in pediatric age: a feasibility study.
Point of care Ultrasound for the approach to respiratory distress in pediatric age: a feasibility study.

Objectives

Point of Care Ultrasound (POCUS) in emergency medicine (EM) is a goal directed analysis integrated with the clinical examination of the critically ill patient presenting to the Emergency Department (ED). Its overall scope is to provide rapid dichotomous answers to questions that arise during the assessment to rule-in or rule-out the diagnosis. In adult the integration of chest US with a bedside  ecocardiography (ECHO) improves diagnostic accuracy of acute dyspnea allowing an appropriate management of the patient. There are no data available for its impact on pediatric patient management in the ED.

 Methods

This is a prospective, single center, observational study with the aim to verify the diagnostic performance and reproducibility of  POCUS evaluation including chest, heart, and IVC in the differential diagnosis of respiratory distress in children admitted to a pediatric ED, comparing this procedure with the standard approach in use. Moreover we want to estimate the time needed to complete POCUS assessment compared to the standard approach.

The study was leaded on a sample of patients aged 29 days to 18 years with respiratory distress, for whom two clinicians performed independent evaluations. We compared the diagnosis of the first clinician assessor with the diagnosis resulted by the POCUS approach performed by the researchers. The following outcome measures were used: 1) time to the diagnosis, 2) diagnostic accuracy of the two assessments, 3) concordance of diagnosis set with the two approaches with the gold standard. We considered as gold standard the discharge diagnosis from the ED, Observation Unit or ward.

 Results

During the enrollment period 579 patients with respiratory distress were evaluated in our ED. We enrolled 68 patients so this resulted in 511 (88%) missed eligible. The sample of the patients enrolled was similar to the missed eligible by age, gender and for the presence of risk factors. There were not significant differences between the average time needed for the standard clinical evaluation and for the POCUS examination (p=0.22). The average time for POCUS examination was significantly lower than the time needed to make a diagnosis in the subset of patients that underwent chest XR (p=0.02) and significantly lower than the time needed to obtain the discharge diagnosis from the ED or Observation Unit (p<0.05). The overall agreement of the diagnostic hypotheses compared to the gold standard was moderate for both POCUS (k =0.60) and the standard assessment (k=0.54). Finally for the patients who were admitted, we calculated the agreement between the diagnosis based on the standard approach and POCUS assessment with the discharge diagnosis that resulted respectively moderate (k=0.45) and perfect (k=0.85).

In patients who presented for wheezing, POCUS assessment showed a significantly higher specificity than the clinical evaluation alone (respectively 87% 95%CI 69.2-96.2 and 43% 95% CI 25.5-62.6, p <0.05).

Conclusions

Our study showed that POCUS evaluation is useful to address a more accurate and faster diagnosis of respiratory distress in children compared to the sole standard clinical approach. In the context of pediatric emergency medicine awareness is required to apply POCUS in clinical practice


Niccolò PARRI, Martina GIACALONE (Firenze, Italy), Elisa GUERRINI, Francesca BRONZINI

16:10-17:40
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OP24
Oral Papers 24

Oral Papers 24

Moderators: Jeffrey KEEP (London, United Kingdom), Gregor PROSEN (EM Consultant) (MARIBOR, Slovenia)
16:10 - 16:20 #4506 - OP055 Intravenous Caffeine versus Intravenous Ketorolac for the Management of Moderate to Severe Migraine Headache in the Emergency Department; a Randomized Controlled Trial.
Intravenous Caffeine versus Intravenous Ketorolac for the Management of Moderate to Severe Migraine Headache in the Emergency Department; a Randomized Controlled Trial.

Objective: Ketorolac is a standard agent for abortive management of migraine headache in the emergency department (ED). The objective of this study was to determine if intravenous caffeine is as effective as intravenous ketorolac for the treatment of moderate to severe migraine headaches.

Methods: This randomized double blind clinical trial was conducted between January and December 2014 in two EDs in Tehran, Iran. Patients who met International Classification of Headache Disorders, 2nd edition criteria for migraine were enrolled. Based on an online random number generator, patients received 60 mg caffeine citrate or 60 mg ketorolac infused intravenously over 10 minutes. Visual analog scales (VAS) were used to measure pain at baseline and one hour and two hours after infusion. Therapeutic success was defined as improvement of 3 points on the VAS without requirement of rescue medication. A sample size calculation determined the need for at least 102 patients.

Results: 193 patients were approached for participation and 110 patients were randomized. 55 patients were assigned to each group of whom 75.5 % were women. Baseline pain scores were comparable between the groups. Therapeutic success after 60 minutes was achieved by 63.6 % of patients in the caffeine and 70.1% of patients in the ketorolac group (p=0.23). After 120 minutes, 87.3 % of the caffeine group and 83.6% of the ketorolac group achieved therapeutic success (p=0.49). Subgroup analysis did not reveal any association between age or sex and outcome.

Conclusion: In this multi-center, randomized double blind ED study, intravenous caffeine was as effective as intravenous ketorolac for first line abortive management of acute migraine.


Alireza BARATLOO (Tehran, Islamic Republic of Iran), Alaleh ROUHIPOUR, Mohammad Mehdi FOROUZANFAR, Saeed SAFARI, Benjamin WOLKIN FRIEDMAN, Ali ABDALVAND
16:20 - 16:30 #6480 - OP056 Predictive Performance of a Regression Model to evaluate clinical outcomes of Acute Low Back pain patients in emergency department.
Predictive Performance of a Regression Model to evaluate clinical outcomes of Acute Low Back pain patients in emergency department.

Background:

Low back pain (LBP) constitutes a challenging health problem which causes considerable socio-economic burden to healthcare system globally. Efforts have been focused on early prognostic assessment and stratification of LBP patients to matched interventions. Recently, the STarT Back Screening Tool (SBT) for back pain prognostic indicators has been developed to help initial decision making in primary care settings and has shown clinical and economic benefits. To our knowledge, SBT has not been used in the emergency department (ED) to assess LBP patients. In this study, we aim to create a regression model by integrating SBT, demographic and clinical variables and to evaluate its predictive performance for 6-month clinical outcomes of acute LBP patients presenting to the ED of a tertiary hospital in Singapore.

Methods:

A prospective observational cohort study was conducted. Eligible patients consulting ED doctors with acute LBP were invited to participate and administered the SBT at initial evaluation. Demographic information and LBP-related clinical characteristics were either gathered from patients’ case notes or self-reported by patients via telephone interview. The primary clinical outcome was pain score measured using the Visual Analogue Scale which was collected at baseline and at 6-week and 6-month follow-up. Treatment or referral of patients was at the discretion of ED doctors in line with current best practice. Prediction of pain score at 6-month was evaluated by using a multiple regression model which integrated independent variables including SBT score, demographics (age, gender, ethnicity, BMI, employment status) and LBP-related clinical characteristics (prior LBP onset, current LBP episode duration, pain score at ED, pain score at 6-week).

Results:

A total of 173 eligible patients were recruited, of which 19 patients were excluded from the analysis due to loss of contact in 6-month follow-up. Multicollinearity diagnostic analysis showed no correlation between independent variables of interest except for SBT overall and psychosocial scores (Pearson correlation=0.90). Therefore, SBT psychosocial score was not included in the model development in this study. The multiple regression model achieved R2 of 0.425 and adjusted R2 of 0.375, where pain score at 6-week (β=0.58), employment status (β=-0.12) and age (β=-0.10) were the three strong predictors among all the variables.

 Conclusion:

A regression model built by integrating SBT overall score, demographic and clinical variables has shown value in predicting 6-month pain score for acute LBP patients presenting to the ED. This study concludes that a predictive model is useful in determining the pain score at 6 months and early physiotherapy should be provided to high risk patients to avoid poor outcomes.


Sohil POTHIAWALA (Singapore, Singapore), Jiang BO, Jennifer LIAW, Mark LEONG, Celia TAN
16:30 - 16:40 #7628 - OP057 The quality of work life of young emergency physicians.
The quality of work life of young emergency physicians.

Introduction: Although the practice of emergency medicine can be meaningful and personally fulfilling, it can also be demanding and exhausting. Emergency departments (EDs) are a particularly stressful work environment. This can be explained by difficult work conditions including significant workload and psychological demand, a default of resources, and lack of support. It is probable that these characteristics impact young emergency physicians’ perceived quality of life and work life balance. Our aim, in this study, was to evaluate quality of life and work life balance of French young emergency physicians.

Methods: We conducted a cross-sectional, anonymous, online survey of quality of life satisfaction among young emergency medicine physicians in France. The survey, containing 32 items,  was distributed by email via the AJMU network (Association of young emergency medicine physicians). Burnout symptoms were measured using validated instruments. Because other burnout studies have focused on the presence of high levels of emotional exhaustion or depersonalization as the foundation of burnout in physicians, we considered physicians with a high score on the depersonalization or emotional exhaustion as having at least 1 manifestation of professional burnout. Satisfaction level with work-life balance was explored as well. Descriptive statistics of percentage, mean and standard deviation and odds ratio calculation were used to analyse the data.

Results: 475 physicians completed the questionnaire (response rate of 33,6%). The median age was 31.5 years old (SD=2.7), among those 55.4% were women. The median duration of practice in the ED was 3.2 years. On a scale of 1 to 10, the level of satisfaction with their work was 6.6 (SD=1.8). The level of satisfaction with their life outside the ED was 7.2 (SD=2), and with their work life balance was 5.7 (SD=2.1). Overcrowding was considered stressful for 72% of responders. The mean level of perceived consideration by others specialists was 4.1 (SD=1.74). Only 7% of the physicians considered working in the ED until their retirement.  52.6% considered transferring to general medicine if they stopped working in the ED. Working more than 48 hours per week and being a woman were associated with a higher risk of presenting symptoms of burnout with a respective OR of 1.8 [1.1; 2.9] and 1.9 [1.1; 3.2].

Discussion: Our study has several strengths. The large physician sample was drawn from a young emergency physician registry, and included physicians from across our country in all type of practices, settings, and environments. However, our study is subject to several limitations among which the response rate of 33,6% among physicians who received an invitation to participate in the study is lower than expected. It is however similar to those seen in this type of questionnaire studies.

Conclusion: These results show that the young ED physicians in our study have an overall good quality of life and a satisfying work life balance. The results of a larger study would yield a greater understanding of the factors associated with work-related quality of life and burnout in the ED.


Jennifer TRUCHOT (Paris), Anthony CHAUVIN, Alice HUTIN, Thomas LEREDU, Patrick PLAISANCE, Youri YORDANOV
16:40 - 16:50 #7647 - OP058 Prognostic value of SOFA score in a population of patients admitted in an Emergency-Department High-Dependency Unit.
Prognostic value of SOFA score in a population of patients admitted in an Emergency-Department High-Dependency Unit.

Aims: To evaluate the prognostic role of anamnestic variables and Sequential Organ Failure Assessment score (SOFA) in a population of patients admitted in an Emergency Department High Dependency Unit (ED-HDU).

Methods: ED-HDU is a clinical setting with a sub-intensive level of care, whose mission is to stabilize patients in order to prevent admission in Intensive Care Units (ICU); a maximum 48-hour ED-HDU length of stay is recommended. From June, 2014, we recorded all our patients in a standardized database; after 20 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-points were ED-HDU mortality and ICU admission.

Results: In the study period (June 2014-March 2016) we admitted 2300 patients, mean age 72±16 years (range 14-102; 5% aged ≤40 years, 22% aged 41-65 years, 38% aged 66-80 years, 34% aged >80 years), 53% male gender; Charlson index was 4±3 (range 2-15) and SOFA score was 2.4±2.6 (range 0-17). Final dispositions were: 733 patients were discharged to home, 1242 were admitted in an ordinary ward, 144 in a HDU, 138 in an ICU and 43 died.  Overall, we could stabilize and avoid a level of care increase in 86% of our patients. Compared with admitted patients, discharged patients were significantly younger  (69±16 vs 73±16 years, p<0.001) and had a lower Charlson index (3.9±2.3 vs 4.6±2.5) and SOFA score (1.0±1.3 vs 3.0±2.8 all p<0.001); 91% did not show any organ failure at admission, 89% did not have any infection (respectively vs 62% and 61% in admitted patients, p<0.001) and among the 82 patients with infection, 79 had not the criteria for sepsis or septic shock. Non-dischargeable patients were divided in three subgroups: patients admitted in ordinary ward or HDU (D1, n=1368), admitted in ICU (D2, n=138) and non-survivors (D3, n=43). D3 patients were significantly older than D1 and D2 patients (81±13 vs 73±12 and 73±16 years, both p≤0.01), had a higher Charlson index (D1: 4.5±2.5, D2 4.9±2.4, D3 6.4±2.9, p<0.001) and SOFA score (D1 2.7±2.4, D2 4.3±3.6, D3 9.8±3.8, p<0.001).  Presence of moderate to severe organ failure, involving up to two systems, increased significantly (D1 35%, D2 53% and D3 84%,  all p<0.001) in the aforementioned subgroups with increasingly worst prognosis, as well as proportion of patients with an infection at ED-HDU admission (D1 37%, D2 45%, D3 81%, p<0.001 D3 vs D1 and D2) and infection severity (sepsis/septic shock: D1 28%, D2 55%, D3 83%, all p<0.001). A multivariable regression analysis including age, Charlson index, SOFA score and presence of infection at ED-HDU admission  showed that only SOFA score showed an independent prognostic value  both for ICU admission (RR 1.21, 95%CI 1.13-1.29) and ED-HDU mortality (RR 1.76, 95%CI 1.57-1.96, all p<0.001).

Conclusions: ED-HDU carried out its own mission in the most proportion of admitted patients; a high SOFA score was the only independent predictor of a bad outcome. 


Federico MEO (Torino, Italy), Francesca CALDI, Rita AUDISIO, Caterina SAVINELLI, Valerio Teodoro STEFANONE, Lucia TAURINO, Francesca INNOCENTI, Riccardo PINI
16:50 - 17:00 #7771 - OP059 Emergency rooms in Germany: better than their reputation? Why do patients with lower treatment urgency visit emergency rooms (ER)? Results of a patient survey in central emergency department/unit at a specialized hospital.
Emergency rooms in Germany: better than their reputation? Why do patients with lower treatment urgency visit emergency rooms (ER)? Results of a patient survey in central emergency department/unit at a specialized hospital.

Every year, about 20 million patients in Germany visit emergency units or are transferred to emergency units by emergency services and general practitioners. The reasons why patients prefer ER as first touch point are diverse and have not been investigated systematically from the patient's perspective so far. As numerous studies have shown, a majority of patients visiting the emergency units required only outpatient emergency treatment. Moreover, the costs incurred in the ER are not covered. Apparently, the system of physician’s emergency care established in Germany is not accepted by patients as intended.

In a hospital focusing on specialized care with 36,300 emergency patients per year, a patient survey was carried out in the central emergency department to investigate the reasons why patients visit the ER and do not use the provided outpatient care structures.

Study Design:
In the Central Emergency Department, an initial assessment by MTS (Manchester Triage System) was carried out with all patients who did not have an immediate doctor contact.
The survey period lasted 4 months, the questionnaires were issued to each patient with MTS category green or blue. The survey was anonymous and participation was voluntary.


In addition to the reasons for the idea and sociodemographic data were collected on a voluntary basis. The return rate of questionnaires was 10.7%.


Results:
57.5% of respondents were older than 40 years. From all respondents of MTS categories green and blue, 40.6% rated themselves a minimum to average life-threatening emergency. 52.7% of respondents had not been previously treated by a doctor. 70.1% have presented themselves in the ER. The 3 main reasons which led the patient to visit the emergency department:
1. "I think I'm getting better care in the ER (get all necessary investigations)" - 39.4%;
2. "I think the first point is the hospital" - 19.1%;
3. "The period when domestic / Specialist by a deadline takes too long" - 17.1%.

The survey results clearly express the view of the patients and can lead to a better understanding of the reasons why ER are visited in hospitals. Despite long waiting times, particularly for patients with low treatment urgencies, patients place the hospital emergency first in 60% of the cases. The own feeling as an emergency is more pronounced in the patients, as it is expected by the triage level. The statements of the patient in the survey can be regarded a representative sample as usual sociodemographic factors of the survey (age distribution, presentation days / times / Education) reflect the usual clientele of patients in the ZNA.
Thus, the expectation of the patients should be taken care of, and the in-hospital emergency care in Germany should be strengthened. It remains open to what extent, for example, information campaigns on the supply system in Germany can lead to a reduction of the treatments of patients in emergency rooms.

For the patient, a timely and customized emergency care appears to be important. Professional societies and politics in Germany will need to take care of this.


Bernadett ERDMANN (Wolfsburg, Germany)
17:00 - 17:10 #7816 - OP060 Intranasal Sufentanil versus Intravenous Morphine Sulfate in Pain Management of Patients with Extremity Trauma.
Intranasal Sufentanil versus Intravenous Morphine Sulfate in Pain Management of Patients with Extremity Trauma.

Introduction: Pain is one of the most common complaints of patients referred to emergency department (ED) and its control is one of the most important responsibilities of the physicians. The present study was designed, aiming to compare the efficiency of intranasal sufentanil and intravenous (IV) morphine sulfate in controlling extremity trauma patients' pain in ED. Methods: In the present clinical trial, extremity trauma cases referred to the ED of Imam Hossein Hospital, Tehran, Iran, from October 2014 to March 2015 were randomly divided into 2 groups treated with intranasal sufentanil (0.3 μg/kg) and IV morphine sulfate (0.1 mg/kg) single-doses. Demographic data and information regarding the quality of pain control such as pain severity before intervention and 15, 30, and 60 minutes after intervention, and probable side effects were gathered using a checklist and compared between the 2 groups. Results: 88 patients with the mean age of 35.5 ± 14.8 years were included in the study (81.8% male). 44 patients received IV morphine sulfate and 44 got intranasal sufentanil. No significant difference was detected between the 2 groups regarding baseline characteristics. In addition, there was no significant difference in the groups regarding pain relief at different studied times (p = 0.12; F = 2.46; df: 1, 86). Success rate of the drugs also did not differ significantly at different studied times (p = 0.52). No significant difference was seen between the groups regarding side effects (p = 0.24). Conclusion: Based on the results of this study, it seems that intranasal sufentanil has a similar effect to IV morphine sulfate in rapid, efficient, and non-invasive pain control in patients with traumatic extremity injuries.


Ali ARHAMI DOLATABADI (Tehran, Islamic Republic of Iran), Memary ELHAM, Hamid KARIMAN, Majid SHOJAEE
17:10 - 17:20 #8128 - OP061 Sedation with nitrous oxide (N2O) in children, a clinical guide to implementation and use in everyday practice.
Sedation with nitrous oxide (N2O) in children, a clinical guide to implementation and use in everyday practice.

Introduction – In the emergency department (ED) and pediatric department (PD), minor procedures in children are often challenging due to anxiety and lack of cooperation by the child. Nitrous oxide (N2O) seems a suitable agent for procedural sedation (PSA). It has a rapid onset and offset, no fasting period is required and self-administration is possible. Although safety and efficacy were proven in international literature, PSA with inhaled N2O is only minimally used in Dutch hospitals. In this study we describe the implementation of procedural sedation with nitrous oxide in our hospital in a two year cohort.

 Methods –  All patients that underwent procedural sedation (PSA) with N2O (50%) in the emergency and pediatric department were retrospectively identified. Data on patient characteristics, type of procedure, depth of sedation and adverse events were recorded. PSA was performed using standardized pre-sedation assessment, monitoring during procedure and post-sedation discharge criteria. Concomitant use of systemic analgesia was contra-indicated. All medical staff was trained according to protocol, this included theoretical background training and supervision during the first five procedures. Knowledge of advanced life support was required. PSA could be executed by a well-trained nurse without supervision of a doctor. 

Results – During 2014 and 2015, 202 patients received PSA with inhaled N20, 48 patients were excluded due to missing data. 154 patients were included in this study. These were 86 boys and 68 girls with a mean age of 6,6 years (SD 3.9 years). Sedation was successful in children from the age of two years old. Procedures in which sedation was used; wound care (N=106), venous access (N=25), reduction of fracture (N=15), lumbar puncture (N=4), the administration of a plaster cast (N=2) and placement of a urine catheter (N=2).

97,4 percent of children had an ASA classification score of one. Mean duration of procedure was 17 minutes (SD 9,8 minutes).

Most reported side effect was laughing (N=57).There were no reported major adverse events. There were 16 reported cases in which comfort and suppression of anxiety during PSA were inadequate and the patient was uncomfortable during the procedure. There were seven reported cases in which the procedure could not be successfully completed. One procedure had to be aborted due to malfunction of  equipment. The other six procedures included; stitching of wounds to the face (N=3), placement of a urine catheter (N=2) and reduction of an incarcerated inguinal hernia (N=1). These procedures are known to be unpleasant and painful, especially in young children.

Conclusion– Sedation with nitrous oxide is safe, feasible and effective for both patient and medical staff in minor procedures in the emergency and pediatric department. In the vast majority (96.1%), sedation was successful. In more painful procedures, sedation without concomitant analgesia proved to be inadequate (N=6) and procedures could not be completed. For this reason the use of concomitant systemic analgesia with opiates was included in our protocol in 2016. Implementation of procedural sedation with N2O requires adequate training of medical staff and a close collaboration between the emergency and pediatric department.


Naomi PETERSEN (Amsterdam, The Netherlands), Femke GRESNIGT
17:20 - 17:30 #8201 - OP062 Factors associated with the development of chronic pain in trauma patients.
Factors associated with the development of chronic pain in trauma patients.

Introduction: In Canada, trauma injuries represent almost 200,000 hospital admissions per year. Depending on the type of trauma and other risk factors, a good proportion of patients will eventually develop mild to severe chronic pain. Fortunately, the early use of some treatments appears promising to prevent chronicity of post-traumatic acute pain. However, the research allowing the early identification of the subpopulation of trauma patients that may develop chronic pain is scarce and limits our capacity to test these preventive approaches.

Objective: To identify factors available at hospital admission associated with the development of chronic pain in a population of trauma patients.

Methods: In a cohort study performed on a registry of prospectively acquired data, we have included all patients 18 years and older admitted for injury in any of the 57 adult trauma centers in the province of Quebec (Canada) between 2004 and 2014. Patients who were either evaluated in specialized chronic pain clinics, diagnosed with chronic pain, and/or received at least 2 prescriptions of chronic pain medication 3 to 12 months post trauma were compared to patients who did not meet those criteria. Patients with a follow-up period lesser than 1-year and those with multiple trauma episodes were excluded.

Results: A total of 90 479 patients were retained. Mean age was 59.3 (±21.7), 53% were men, and the mean follow-up was 4.8 years (±2.4). The major causes of trauma were: falls (63%), motor vehicle accident (22%), as well as penetrating and blunt injuries (9%). We have identified 6172 patients (6.8%; 95CI:6.6%-7.0%) who were either evaluated in specialized chronic pain clinics, diagnosed with chronic pain, and/or received at least 2 prescriptions of chronic pain medication 3 to 12 months post trauma. After controlling for confounding factors, the variables that were associated with the development of chronic pain were: spine injury (OR=2.3; 95CI: 2.1-2.4), loss of consciousness (OR=1.7; 95CI: 1.5-2.0), nerves damage (OR=1.7; 95CI: 1.5-2.0), history of depression (OR=1.5; 95CI: 1.3-1.6), history of alcoholism (OR=1.4; 95CI: 1.2-1.7),  head injury (OR=0.62; 95CI: 0.56-0.68), multiple trauma (OR=1.4; 95CI: 1.3-1.5), and being a female (OR=1.2; 95CI: 1.1-1.3). Receiving operating characteristic curves derives from the model was evaluated at 0.70.

Conclusions: Despite low incidence of chronic pain development found in our trauma cohort registry, several significant risk factors were identified. Hospital admission screening of the trauma population at risk of developing chronic pain will allow the early testing of preventive approaches.


Raoul DAOUST (Montréal, Canada), Jean PAQUET, Lynne MOORE, Jean-Marc CHAUNY, Sophie GOSSELIN, Jean-Marc MAC-THIONG, Marcel EMOND, Manon CHOINIÈRE, Gilles LAVIGNE
17:30 - 17:40 #8236 - OP063 Profesional practices concerning care limitations and end-of-life situation in an emergency department.
Profesional practices concerning care limitations and end-of-life situation in an emergency department.

Introduction: Emergency Departments (ED) are the front line of public health care system and are often confronted to end-of-life care. These situations are difficult and uncomfortable for patients, families as for medical staff. Leonetti law (2005) strengthened by Clayes Leonetti law (2016) forbids “unreasonable obstinacy” and frames decisions concerning means limitation or ending active therapeutic means. In this recent context, we wanted to assess professional practices concerning the decision making and medical management of end-of-life situations.

Material: We conducted a retrospective monocentric study from october 2015 to april 2016 in an ED of an academic hospital. Through medical charts, we included all patients that died in the ED or in the emergency hospitalization unit through the period and for whom a means' limitation decision had been taken.

Results: n=53 patients presented the inclusion criteria (0,1% of all visits). For 57% of these patients, the limitation decision wasn’t clearly written in the chart. 30% of these decisions were taken by a sole practitioner. In the first moments of their arrival in the ED, 28% of these patients had invasive yet inappropriate care. 55% of these patients were visiting the ED for the first time. 21% died in the first 4 hours after being admitted to the ED. We noticed wide heterogeneous pratices while managing dyspnea, pain, consciousness and sedation.

Conclusion: End-of-life situations are part of ED care. However care limitations are difficult decisions and are not easily and efficiently managed. Education is necessary for medical and paramedical staff in order to help those patients through these moments.


Guillaume FONS (Paris), Marie BALLESTER, Florence ATGER, Richard CHOCRON, Anne-Laure FERAL-PIERSSENS, Philippe JUVIN

09:10-17:40
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SIMWARS
SimWars 2016

SimWars 2016

Animators: Alessandro COSTA (Intensive Care Physician) (Animator, Novara, Italy), Lukas DRABAUER (Animator, Austria), Dr Abdo KHOURY (PROFESSEUR ASSOCIE) (Animator, Besançon, France), François LECOMTE (PH) (Animator, Paris, France), Felix LORANG (Consultant) (Animator, Erfurt, Germany), Thomas PLAPPERT (Medical Director EMS) (Animator, Fulda, Germany)

17:40
17:40-18:40
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AWC
Award Ceremony

Award Ceremony

Moderators: Dr Thomas BEATTIE (Senior lecturer) (Edinburgh, United Kingdom), Pr Lisa KURLAND (speaker) (Örebro, Sweden), Youri YORDANOV (Médecin) (Paris, France)
Top Abstracts / Falck Prize / EBEEM Diploma Ceremony / EYSA / EuSEM Fellowships / EMDM / SimWars
17:40 - 18:40 #7244 - OP118 Efficacy and safety of methoxyflurane analgesia in adult patients in the emergency department: a randomised, double-blind, placebo-controlled study (STOP!).
OP118 Efficacy and safety of methoxyflurane analgesia in adult patients in the emergency department: a randomised, double-blind, placebo-controlled study (STOP!).

Background/Introduction

Acute pain remains highly prevalent in the Emergency Department (ED) setting1,2, with many patients undertreated3. Low-dose methoxyflurane, self-administered by the patient via a handheld inhaler (Penthrox®, 3mL dose) is a fast-acting, non-narcotic analgesic agent that has been used in Australia for 20 years. Data outside of Australia are limited, therefore this double-blind, randomised, placebo-controlled UK study investigated the efficacy and safety of low-dose methoxyflurane analgesia for the treatment of acute pain in the ED setting.

 

Participants and Methods

Patients presenting to the ED with a pain score of 4-7 on the Numerical Rating Scale due to minor trauma (contusions, fractures, lacerations, etc) were randomised in a 1:1 ratio to receive methoxyflurane (up to 6mL) or placebo (normal saline), both via a Penthrox® inhaler. Study medication was self-administered by the patient as required by inhaling from the device. Rescue medication (paracetamol/opioids) was available immediately upon request of the patient.

 

The primary efficacy endpoint was visual analogue scale (VAS) pain intensity. Changes from baseline were analysed using repeated-measures ANCOVA. Treatment effects were estimated as least squares mean differences between the treatment groups overall (primary analysis) and at each timepoint. Key secondary endpoints were time to first pain relief and time to request for rescue medication (compared using Cox proportional hazards model) and rescue medication use (yes/no) within 20 minutes of the start of treatment (compared using logistic regression). All analyses adjusted for baseline VAS score.  Patients had a 14-day post-treatment safety follow-up.

 

Results

300 adult and adolescent patients were enrolled; data are presented for the adult subgroup (N=203). Mean baseline VAS pain score was ~66mm in both groups. Mean change in VAS pain from baseline to 5, 10, 15 and 20 minutes was greater for methoxyflurane (-20.7, -27.4, -33.3 and -34.8mm, respectively) than placebo (-8.0, -11.1, -12.3 and -15.2mm, respectively). Overall, there was a highly significant treatment difference (estimated treatment effect: -17.4mm; 95% CI: -22.3 to ‑12.5mm; p<0.0001). Median time to first pain relief was significantly shorter with methoxyflurane (5 minutes) compared with placebo (20 minutes) (hazard ratio: 2.32; 95% CI: 1.63, 3.30; p<0.0001). The proportion of patients who used rescue medication in the first 20 minutes was 2.0% for methoxyflurane and 22.8% for placebo (odds ratio: 0.07; 95% CI: 0.02, 0.29; p=0.0003). The proportion of patients requesting rescue medication at any time (prior to censoring) was lower for methoxyflurane (11.8%) than placebo (38.6%) (hazard ratio: 0.23; 95% CI: 0.12, 0.44; p<0.0001); median time to request could not be estimated. Treatment-related adverse events (mostly dizziness/headache) were reported by 42% of patients receiving methoxyflurane and 15% of patients receiving placebo; none caused withdrawal and the majority were mild and transient.

 

Conclusions

The results of this study support the evidence from previous trials that low-dose methoxyflurane administered via the Penthrox® inhaler is a safe, efficacious and rapid-acting analgesic.

 

References

  1. Cordell et al. Am J Emerg Med 2002;20:165–169.
  2. Berben et al. Injury 2008;39:578–585.
  3. Pierik JGJ et al. Pain Med 2015;16:970-84.

®: PENTHROX is a registered trademark of MDI Limited.


Frank COFFEY (Nottigham, United Kingdom), Patrick DISSMANN, Kazim MIRZA, Mark LOMAX
17:40 - 18:40 #7460 - OP119 Short-time variation in available beds predicts admission rate among chest-pain patients independently of high-sensitivity troponin t, seasonal and daily variation.
OP119 Short-time variation in available beds predicts admission rate among chest-pain patients independently of high-sensitivity troponin t, seasonal and daily variation.

Introduction: Chest pain is a common symptom at the emergency department (ED) which often leads to admission for further investigation. Assessment algorithms aim to safely reduce the rate of admission but it is unknown if the number of available beds at the time of admission decision affect admission rate or the risk of major adverse cardiac events (MACE) after discharge. Purpose: To investigate whether number of available beds was associated to admission rate or 30-day MACE among chest pain patients in the ED. Methods: This was an observational study at two EDs between 1st of January 2013 to 14th of September 2015. All patients >18 years with chief complaint chest pain and at least one high sensitivity cardiac troponin T (hs-cTnT) measurment were included. Information on number of available beds at the short-time emergency wards and coronary care units was extracted every five minutes and the average during a 30-minute period was calculated for each patient, two thirds into their stay at the ED, when the admission decision usually occurs. Association between number of available beds (one standars deviation increase) and admission rate, acute myocardial infarction (AMI) among admitted and 30-day MACE among discharged were studied with logistic regression together with sex, age, hs-cTnT>14 ng/L, ED site, season (winter as reference), visit-year (2013 as reference) and 24-hour variation (day, evening and night with day as reference). Results: Out of 24,730 patient visits, 6,873 were admitted out of which 1,134 were diagnosed with AMI. Among discharged, 70 patients had a 30-day MACE. The number of available beds varied in relation to the 24-hour period (p<0.001), season (p<0.001) and decreased yearly (p<0.001) during the study. Admission was independently associated to the number of beds (OR 1.11 CI95% 1.07-1.15), male sex (OR 1.52 CI95% 1.42-1.62), initial hs-cTnT>14 ng/L (OR 6.41 CI95% 5.93-6.94), age (OR 1.76 CI95% 1.69-1.83), year (OR 0.87 CI95% 0.81-0.94 for 2014 and 2015 respectively) and seeking the ED during spring or night (OR 1.15 CI95% 1.05-1.25 and OR 1.29 CI95% 1.17-1.43 respectively). AMI among admitted was more common among those with male sex (OR 1.48 CI95% 1.27-1.72), initial hs-cTnT>14 ng/L (OR 6.42 CI95% 5.38-7.65), seeking the ED during the evening (OR 0.82 CI95% 0.70-0.96) and 2015 as year of ED admission (OR 1.27 CI95% 1.06-1.51). Furthermore, initial hs-cTnT>14 ng/L (OR 7.01 CI95% 3.76-13.06), age (OR 2.45 CI95% 1.71-3.50) and male sex (OR 1.92 CI95% 1.15-3.21) were all associated to 30-day MACE. No relation between 30-day MACE and number of available beds was seen (p=n.s). Conclusions: The number of available beds was associated to admission rate idependent of other clinical information, including hs-cTnT, and may have affected the admission decision. No relation between available beds and 30-day MACE was seen. Further studies are needed on the causal relationship and optimal number of available beds for chest pain patients. 


Caroline JOHANSSON (Stockholm, Sweden), Anna PETTERSSON, Umut HEILBORN, Per SVENSSON
17:40 - 18:40 #8169 - OP120 Can the incorporation of co-morbidity information improve risk estimation in older people with major trauma?
OP120 Can the incorporation of co-morbidity information improve risk estimation in older people with major trauma?

Can the incorporation of co-morbidity information improve risk estimation in older people with major trauma?

Background: Large datasets from registries such as the Trauma Audit and Research Network (TARN) facilitates the development of risk estimation systems for these patient populations. An initial analysis of the probability of survival (PS12) risk estimation system in trauma patients enrolled in TARN at our institution demonstrated excellent discrimination in younger individuals with an area under the receiver operating characteristic curve (AUROC) of 0.94 (95% CI: 0.83 to 1.00). However, the ability of the system to estimate risk of short term mortality in older trauma patients was considerably lower with an AUROC of 0.64 (95% CI: 0.39 to 0.88).

Hypothesis: Risk estimation in older people could be improved through the incorporation of co-morbidity information.

Objective: To assess the improvement in performance of the system with the addition of co-morbidity information.

Study population: 869 major trauma patients enrolled in TARN at Saint Vincent’s University Hospital (SVUH), a tertiary referral urban university hospital, between Sept 2013 and Aug 2015.

Methods: PS12 estimates the risk of inpatient or 30-day survival in trauma patients based on Injury Severity Score (ISS), age, gender and Glasgow Coma Scale (GCS). The newer PS14 additionally includes co-morbidities, as a categorical variable defined by the number of co-morbidities present. PS12 and PS14 were calculated for each individual. Discrimination of each system was compared using AUROC. This was done separately for those aged under 65 years and those aged 65 years and over.

Results: In the 419 individuals aged under 65 years, both systems showed excellent discrimination with AUROC of 0.97 (95%CI: 0.94 to 1.00) for PS14 versus 0.96 (95%CI: 0.93 to 1.00) for PS12, p for difference = 0.23. In the 450 individuals aged 65 years and over, discrimination was significantly better in PS14 (AUROC 0.79 (95% CI: 0.70 to 0.88)) compared to PS12 (AUROC 0.71 (95%CI: 0.61 to 0.82)), p for difference <0.001. These findings were consistent when examining older age groups including those aged 75 to 84 years and those aged over 85. However, due to lack of power in some age groups, the differences did not reach statistical significance.

Conclusions: These results suggest that the current PS systems discriminate extremely well in younger people. It is unlikely that further refinements will result in meaningful improvements in risk estimation but may add complexity. For older individuals the addition of comorbidity has resulted in significant improvements. Further refinements including the addition of specific comorbidities, alcohol use and initial vital signs may yield further improvements in discrimination in this age group.  Simulated external validation, for example using 10-fold cross validation, may add further strength to these observations. 


Marie Therese COONEY, Dr John CRONIN (Dublin, Ireland), Justine JORDAN, Rachael DOYLE, David MENZIES

17:45-19:45
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E25
DGINA - General Assembly
Ordentliche Mitgliederversammlung der DGINA e.V. (Teilnahme nur für DGINA-Mitglieder)

DGINA - General Assembly
Ordentliche Mitgliederversammlung der DGINA e.V. (Teilnahme nur für DGINA-Mitglieder)