Background

NICE CG 89 ‘Child maltreatment: when to suspect child maltreatment in under 16s’ ⁽¹⁾ suggests that health professionals should consider safeguarding issues in all encounters with children, gives guidance on when to suspect abuse, and stresses the importance of documentation. The Emergency Department is a place where this is of particular importance as children often present with injuries that could be indicative of maltreatment, such as burns or head injuries. Therefore, all attendances should have a record of a safeguarding assessment stating whether the possibility of child abuse has been considered or suspected. Previous audits ⁽²⁾ have shown that the level of documentation of safeguarding assessments in the ED was very high, with an excess of 90% of children having safeguarding considerations documented. This level was achieved following the implementation of a written prompt in the paper based patient record. Since the last audit in 2013 the hospital has introduced a new electronic system of patient records, Epic. This re-audit aims to assess whether the high levels of documentation have been maintained after the implementation of this new system the safeguarding section of which will be briefly presented.

Methods

Electronic patient records of all Paediatric ED attendances during the week 01/02/16 to 08/02/16 were reviewed and checked as to whether clinical staff completed the required documentation of safeguarding assessments and to gather information about those with absent safeguarding assessments. Sample size: 414. Results wre compared to the previous audit performed in 2013.

Results

385 (92.1%) had a safeguarding assessment completed, in 29 (7.9%) cases the assessment was missing. Re-attenders (n=14) had no safeguarding assessment documented on the second attendance in 6 cases. Split into age groups, the percentage of assessments not completed ranged from 8.33% in the 6 - 10 year olds to 5% in the 1 - 5 year olds. 15 patients (3.6%) in whom safeguarding assessments were missing presented with diagnoses like burns, head or other injury.

Conclusion

Following the implementation of a new electronic system of patient record keeping and thus the removal of the previous ED paper based system with its well established prompts, documentation of presence (or absence) of safeguarding concerns in the Paediatric Emergency Department remains in excess of 90%. This is despite the fact that safeguarding assessments on Epic are not a compulsory documentation item, reflecting a positive culture of safeguarding awareness. Children who re-attended the ED were amongst those who were lacking safeguarding assessments when attending the second time but one coud argue that this may be appropriate in the vast majority of patients that re-attend within such a short time.  The current system is effective but still does not capture a proportion of patients that present with significant injuries.

Introduction:

German immigration laws require refugees to undergo medical screening as part of the asylum application process. This consists of a self-reporting questionnaire, a physical examination and a tuberculosis screening. There appears to be some anxiety whether refugees pose a public health threat to the German population through higher than usual rates of communicable diseases. This study aims to assess the incidence of communicable diseases, i.e. head lice, scabies, hepatitis, HIV or tuberculosis amongst refugees.

Methods:

We collected data on communicable diseases of refugees living in holding camps in the County of Lippe, Germany. All refugees not having undergone a medical screening examination or parts thereof underwent a medical screening examination as part of the weekly refugee medicine clinics run by the emergency department. Demographical data including age, gender and country/region of origin as well as any notable findings during the self-reporting questionnaire, physical examination and tuberculosis screening were recorded. Tuberculosis screening consisted of either chest radiographs, interferon-gamma immuno-assay or a Mendel-Mantoux skin prick-test, or a combination of these, depending on age and/or pregnancy status.

Results:

The County of Lippe operates 6 refugee camps with a capacity of 70-700 refugees each. From October 2014 until March 2016 altogether 9,992 refugees were registered for medical examination with 8,678 actually attending (86.8%). Of these, 69.3% were male and 30.7% female. The mean age was 24 years. Most refugees originated from Western Asia (41.8%), followed by those coming from Balkan states (21.7%), Africa (8.3%) and former Soviet states (6.9%).

As part of tuberculosis screening 3,327 refugees underwent chest x-ray in our clinic, whereas 3,096 were x-rayed elsewhere. 1,192 refugees received interferon-gamma immuno-assay and 769 children under the age of 6 years received a Mendel-Mantoux skin prick-test. Due to a lack of supply of Mendel-Mantoux serum from December 2015 onwards in whole Europe, 123 children did not receive any tuberculosis screening at all.

Overall, only 66 refugees were found to have scabies (0.76%) and 49 (0.56%) were tested positive for head-lice (0.56%). In contrast, 676 refugees had a non-communicable yet relevant medical condition (7.78%) requiring follow-up. We found 50 of 8,524 screened refugees to have an abnormal tuberculosis screening result (0.59%). Of these, only 7 were confirmed to have active tuberculosis requiring standard combination therapy (0.08%) and 3 refugees required isolation due to open tuberculosis (0.04%). Interestingly 27 refugees were known to suffer from viral hepatitis (0.31%) and 7 reported to be HIV-positive (0.08%).

Discussion:

This study is the first to describe the incidence of notifiable/communicable diseases and tuberculosis amongst a representative sample of refugees coming to Germany. Although only 0.8% of the total refugees entering Germany were included, the results appear to be fairly comparable to the overall refugee population. The incidence of tuberculosis amongst refugees appears to be 11 times higher than for the resident German population. Nevertheless, the projected overall number of approximately 500 new tuberculosis cases amongst refugees compared to an overall national incidence of 5,895 new cases in 2015 does not seem to pose any serious public health threat.

Importance: Fever is one of the most common symptoms in children. It is not clear if children with high fever are at increased risk for serious bacterial infection (SBI). 

Objectives: To systematically review and to perform a meta-analysis, in order to determine whether children suffering from high fever are at high risk for SBI.

Data sources: The following databases were searched from their inception until the last week of December 2014: Embase (via Embase.com), Medline (via OvidSP) and Pubmed.

Study selection: Cohort and case control studies comparing the incidence of SBI in children with a temperature higher than 41⁰C,  with children with fever of 41⁰C or less, and children with a temperature higher than 40⁰C, with children with fever of 40⁰C or less.

Data extraction and synthesis: Based on a preliminary review, two reviewers independently pooled studies for detailed review using a structured data-collection form. We calculated the odds ratio and 95% confidence intervals (CI) for SBI, assuming a random-effects model. A sub-group analysis was conducted based on age.

Main outcome and measures: SBI

Results: Ten studies met the inclusion criteria.  Only two studies compared children with temperature over 41⁰C with children with lesser degree of fever. Children with temperature over 41⁰C had higher risk for SBI (OR 1.96 95%CI 1.3-1.97). Nine studies reported on children with temperature over 40⁰C. The summary end-point suggests an increased risk for SBI in children with high fever (OR 3.21 95% CI 1.67;6.22). When analyzing the studies reporting on young infants, the odds ratio for SBI in children with temperature over 40⁰C was higher compared to infants with lower degree of fever (OR 6.3 95% CI 4.44;8.95). Four studies reported on older children; the odds ratio for SBI in children with high fever was only slightly higher than in children with lower degree of fever (OR 1.36 95% CI 1.16;1.61).

Conclusions and relevance: Young infants with temperature higher than 40⁰C are at increased risk for SBI. Compared with children who have lower degree of fever, the risk of SBI in older children with temperature >40⁰C is minimal.

Introduction
The influence of gender on health and disease is increasingly being recognized. In emergency medicine, sex-specific differences are well described in adults, including the acute presentation of certain conditions, the epidemiology of illnesses and injuries, and the effects and side-effects of medications. Beside physiologic and biologic factors, gender-specific biases are found to influence physician’s treatment decisions. So far, little is known about how gender affects emergency care for children. The aim of this study was to assess the role of gender in presenting problem, disease management and outcome in children attending the emergency department(ED).

Methods
This study is part of the TrIAGE project, a prospective observational study in five ED’s in four European countries (the Netherlands, United Kingdom, Austria, Portugal). Data collection consists of routinely recorded patient data, automatically extracted from electronic medical records. Study sites are instructed in data collection and a minimum set of required variables. Data harmonization and quality checks were performed.  We included all consecutive children aged

Results
In total, 84,747 children under the age of 16 were included in the study, and 54.2% were male. In all 5 hospitals, the proportion of boys visiting the ED was higher than girls, ranging from 52.0 to 58.4%. The proportion of boys decreased with age, from 56.5% (range 52.3-61.4%) in children 12 years. Boys presented more often with trauma and limb problems (22.0% versus 19.7%), presented more often with high-urgent problems according to the Manchester Triage System (12.9% versus 10.6%) and were more often admitted (11.9% versus 10.6%). When adjusted for clinical parameters, diagnostics and therapy, and patient disposition, some differences between boys and girls remained. Girls were triaged less often with a high urgent triage category (OR 0.85, 95%CI 0.81-0.89). Moreover, in girls significantly more lab tests were performed in case of medical problems (OR 1.09, 95%CI 1.04-1.14) and more radiologic tests in case of trauma (OR 1.16, 95%CI 1.09-1.24). Girls were less likely to receive inhalation medication (OR 0.72, 95%CI 0.68-0.77), while overall there was no difference in oral or intravenous medications administered.

Conclusion
In childhood, boys attend the ED more often than girls, and this trend decreases with age. When adjusted for potential confounders, girls were triaged less often to a high urgency category. Moreover, some gender-based differences were found in diagnostics and management. Further research is needed to explore whether these findings are caused by differences in disease type, disease presentation, symptom severity or whether gender subconsciously plays a role in management decisions in children. 

Background

Vertigo and unbalance are frequent complaints in emergency department (ED), often due to a benign disease. However, the possibility of an acute brain disease is not remote and vertigo assessment is usually time and resource consuming. We aimed to investigate the diagnostic accuracy of an ED driven diagnostic algorithm.

Methods

Consecutive adult patients presenting with vertigo/unbalance to a third level university hospital in Florence, from October 2015 to March 2016, were considered for the study. The STANDING is a four steps algorithm, which includes the discrimination between SponTAneous and positional Nystagmus, the evaluation of the Direction of the nystagmus, of the head Impulse test (HIT) and of the standinG position. Reliability of each step was analysed in a subset of patients by Cohen’s k calculation. The reference standard (central vertigo) was a composite of acute brain injury at initial head imaging or a diagnosis of stroke, demyelinating disease, neoplasm or other new-onset brain disease during 3 months follow-up, adjudicated by an independent panel of experts in vestibular disease and neuroimaging.

Results

Three hundred and fifty one patients were included with a mean age of 57.6±18 years, with a slight prevalence (59.5%) of females. We found an incidence of acute brain disease of 11.7% (95% CI 8.5%-15.5%). The leading cause was ischemic stroke (68.3%) followed by neoplastic disease (24.4%). Each step of the STANDING algorithm showed e good reliability; the second step, the analysis of the direction of nystagmus, showing the highest (0.95) and the HIT test the lowest (0.83) agreement. The overall accuracy of the test was good (87%, 95% CI 84-88%) showing good specificity (86%, 95% CI 84-86%), high sensitivity (95%, 95% CI 83-99%) and very high negative predictive value (99%, 95% CI 97-100%) for acute brain disease.

Conclusion

The STANDING diagnostic algorithm showed good reliability and high accuracy in excluding acute brain disease in the emergency setting. 

Background Availability of venous access for administering drugs and fluids in critically ill patients is a cornerstone of modern Emergency Medicine. In patients with difficult peripheral venous access, alternative techniques, such as the placement of a central venous catheter, require expertise and are invasive, expensive, time-consuming and prone to serious adverse events. The attempt to obtain vascular access placing a peripheral venous catheter under ultrasonographic guide has been sometimes performed in clinical practice, but only a few case reports are presented in literature. Despite an easy placement and absence of complications, insufficient length of the classical PVC (45mm) led to frequent early displacement. For these reasons, we plotted a new venous catheter (JLB®, Deltamed Inc.) to cannulate large bore veins and lead an observational convenience sampling study to test the security of device and eco-guided bedside technique of insertion, the cheapness of the catheter, the handiness of learning and use of it.

Study  We led a multi-center observational convenience sampling study to evaluate safety and effectiveness of JLB®. Patients were enrolled in 3 EM units, 2 ICU, 1 Internal Medicine ward. Data were collected from July 1st 2015 to April 15th 2016. Inclusion criteria were: age≥18, impossibility to obtain peripheral access, need for inotropes/TPN or patient's preference. The procedure was performed by attending physicians or EM residents under US guidance. We enrolled 250 patients; at present data were analyzed in 158 patient: 91 women, mean age 74,5 years ± 16,2 SD. 130 patients (82,3 %) had not any other peripheral access, 33 (20,9 %) need inotropes/TPN infusion, 6 (3,8 %) express preference. Mean procedure time (from disinfection to securing) was 207,7 s ± 12,4 SD. Early complications (<24h) occurred in 2 (1,3 %) patients, consisting in 1 soft-tissue hematoma and 1 atrial tachyarrhythmia. No major complications (such as PNX, major arrhythmia, infection) were reported. Mean duration time was 132,1 h ± 67,6 SD, occlusion/dislocation occurred in 11 cases (6,9 %).

Conclusion Our bedside device revealed to be fast to place. This new catheter is also safe since no major complication or clinical device-associated infection occured. Moreover, placement of this device doesn't need CXR to confirm placement and exclude PNX because is unlikely, but this task can be easily performed using US. Our device can represent an ideal technique for DIVA not needing advanced vital monitoring and in emergency settings.

Our results indicate that in those patients with a higher D-Dimer, there appeared to be a correlation between D-Dimer level and clot burden.  A very high result should give a clinician a higher index of suspicion to consider larger VTEs and possibly a more serious underlying diagnosis. 

Background:

The prevalence of children with complex chronic conditions in pediatrics is increasing and their management is an important part of hospitalizations, emergency room visits and pediatric healthcare costs. Some of them are suffering from genetically determined diseases. Both group of diseases share part of their problems. In the literature, the impact of genetically determined diseases on pediatric emergency services is unclear.

Objectives:

The objective of this study was to determine the prevalence of genetically determined diseases in a pediatric emergency department and describe the features of their management.

Methods:

This was a prospective observational study performed in the pediatric emergency department of a French university Hospital receiving over 60,000 children annually. All children under 18 years old, visiting our pediatric emergency department for a medical complaint were included during five consecutive days in September 2014. Chronic diseases or malformations were classified according to the classification proposed by McCandless et al. Am J Hum Genet. 2004;74:121‑7. The study was reviewed and approved by the Ethics Committee of Necker-Enfants Malades Hospital. One family refuses to participate to the study.

Results:

Of the 454 children included, 39,5% of them had a disease or malformation genetically determined (categories I to IV, n = 179), of which 4.4% had a chromosomal or single-gene disorders such as sickle cell disease, hemophilia (IA), 6.4% had a multifactorial/polygenic disorder such as spina bifida, autism (IB), 7.1% had a disease or abnormality of heterogeneous cause, often genetic such as mastocytosis, migraine (IC) and 20.7% had an acquired chronic disease with genetic predisposition such as diabetes, asthma (III). Of these 179 patients, 83 (46%) visited the pediatric emergency department with a chief complaint related to their chronic condition. We observed more biology tests (40% versus 18%), more imaging test (32% versus 20%), longer length of stay (mediane 123 minutes versus 88 minutes), and higher hospitalization rate (32% versus 9%) in children with underlying conditions with strong genetic basis (IA + IB + IC). Similarly, the hospitalization rate was higher (37% versus 9%) in children with an acquired chronic disease with genetic predisposition.

Conclusions:

These results highlight the high frequency of patients suffering from complex chronic conditions, especially genetically determined diseases, in a pediatric emergencies department and the impact of such conditions on the care provided. These patients had particular characteristics that should lead to specifics treatments, and then a comprehensive and global approach of children with genetically determined diseases in pediatric emergencies is needed. This should be based on several axes of improving: training of professionals, scientific research, pharmacogenetics, support of families, the quality of care, and patient identification.

Background: Ischemic stroke is the leading cause of long term morbidity and mortality, which affects several hundred thousand people per year. Various biomarkers indicating neurologic damage have been developed. The biomarkers indicating neurologic damage will reduce the need for neurologist or radiologist consultation in emergencies, enabling to follow a more reliable way  in order to set the true diagnosis and determine treatment options in patients at risk. In addition, neurologic examination is not objective and may differ depending on a person's experience. With determination of an objective marker, a more accurate and reliable way will be followed in the diagnosis and treatment of stroke. It is believed that, a fast, simple and low-cost biomarker which provides information about brain tissue damage would be extremely beneficial. For this purpose; S100 calcium-binding protein B (S-100β), d-dimer (DDIM), matrix metallopeptidase 9 (MMP-9) and brain natriuretic peptide (BNP) that show cerebral damage have been studied in early period stroke patients. The primary objective of this study is to measure the correlation between clinical severity and serum/plasma concentration of neuronal injury biomarkers in stroke patients.

Material & Methods: This prospective study was initiated with 63 patients having pre-diagnosis of stroke, but then 15 patients were excluded due to various reasons. All patients were undergone the necessary  laboratory and radiological examinations and treated in accordance with guidelines. Blood samples were collected at the first admission and after 48 hours, and S-100β, DDIM, MMP-9 and BNP values were measured.

Results: Of patients, 45.8 (n=22) were female with median age 70 (min=25, max=85). There were previous SVO in 25% (n=12), DM in 12.5% (n=6) DM, atherosclerosis in 31.3% (n=15), hyperlipidemia in 25% (n=12), COPD in 16.7% (n=8), renal failure in 2.1% (n=1), smoking in 37.5% (n=18) and alcohol abuse in 8.3% (n=4). On ECG ordered, 30 (62.5%) patients have sinus rhythm and 18 (37.5%) atrial fibrillation. Patients were hospitalized in the neurology clinic between 1-60 days (median: 9 days). From the patients followed-up, 11 (22.9%) died and  37 were (77.1%) discharged from the neurology clinic. Impairment of consciousness was more common in the patients who died (72.7%; n=8 vs. 35.1%;n=13, p=0.04). GCS was significantly lower in patients who died (n=11; mean=11.2±2.7) compared to those discharged (n=37; mean=13.3±2.8) (p=0.01). BNP (died:783.3±778 vs. discharged:268.7±377; p=0.002) and DDIM (died:2565.4±1512 vs. discharged:1547.2±1341.7; p=0.036) studied at the hour 0 were found to be significant in determination in-hospital mortality. Whereas, no significant difference was found in the parameters studied at the hour 48. MMP-9 values at the hour 0 were positively correlated with the days of hospitalization (pearson correlation:0.291; p=0.045).

Conclusion:In this study, we demonstrate that BNP and DDIM as markers of prognosis at the time of first admission in patients with ischemic stroke. MMP-9 level was significantly correlated with hospitalization time, although no significant difference was found in terms of mortality. 

Ketamine is avoided in rapid sequence intubation (RSI) of trauma patients because of an assumption it causes increase intracranial pressure (ICP). However two recent studies showed  that there was no increase in intraocular pressure (IOP), and it was therefore assumed there was no increase in ICP either. An IOP change has never been shown to change cerebral physiology.  Cerebral oximetry studies have established it can correlate with acute alter cerebral physiology and ICP changes. The effect of ketamine on cerebral physiology in pediatric patients who have had respiratory failure or sepsis has not been studied.  Cerebral oximetry studies have shown normal hemispheric cerebral physiology rSO2  is 60-80% with a 10% mean variance. Abnormal cerebral physiology has been  demonstrated to be as  rSO2  < 60 or > 80 and/or side differences > 10.

Objective:

To analyze ketamine’s effect on cerebral physiology during RSI of patients with sepsis or respiratory failure by utilizing cerebral oximetry in the Pediatric ED (PED).

Methods:

An observational convenience study of patients intubated in the PED with sepsis or respiratory failure who had: bilateral cerebral oximetry (q 5 sec) placed and ketamine was used as an induction agent.  We analyzed rSO2 10 min before & then 10 and 20 min after ketamine along with cerebral blood volume index (CBVI) and compared to < 10% & 20% variance.  rSO2 side differences  > 10 and patients with rSO2 80 were analyzed as this is considered abnormal cerebral physiology. 

Results:

The maximum change on the left was 8.9%(SD+11.6%) and right was 8.7%(SD+9.7%).  Overall, the Left, Right rSO2, CBVI and heart rate changesat all points during data collection were less than 10% (p=0.99). Figure 1 

Conclusions:

Patients with sepsis or respiratory failure who underwent RSI with ketamine showed no alteration in their cerebral physiology based on cerebral oximetry.  The normal and abnormal cerebral oximetry (rSO2 & CBVI) for 10 and 20-minute changes were significantly < 10% variance. Since ketamine is used in adult trauma investigating ketamine’s effect on pediatric trauma cerebral physiology by cerebral oximetry is warranted. 

Background

Topical local anaesthetic creams are proven to reduce the pain and distress associated with intravenous cannulation in children. A major disadvantage of their use is the relatively long application time. A minimum of 30 minutes is required for LMX4^TM (4% Lidocaine w/w cream) [Ferndale Pharmaceuticals Ltd], the most rapidly acting agent. Coolsense^TM [Coolsense Medical Ltd] is a relatively new, reusable device designed to produce immediate, transient local analgesia through rapid cooling of the skin surface. No study has yet assessed the effectiveness of Coolsense^TM use in the paediatric emergency department (PED).

Aims

To determine any difference in age-appropriate paediatric pain score, at the time of intravenous cannulation, following use of the Coolsense^TM device or LMX4^TM cream. To describe the effect of each intervention on additional outcomes, such as time from decision to cannulate to performing the procedure, which may influence the decision to select a particular method for use in the PED.

Methods

Prospective, quasi-randomised study in a tertiary PED over 6 weeks (February – March 2016).

Results

175 patients were included (mean age 7.4 years). 80 were allocated to receive Coolsense^TM and 95 LMX4^TM, on a week-by-week basis. When analysed by allocated intervention, the mean pain score at time of cannulation was significantly lower with Coolsense^TM than LMX4^TM (2.5 vs. 3.8; p=0.006). Mean time from decision to cannulate to performing the procedure was significantly shorter with Coolsense^TM than LMX4^TM (25.6 mins vs. 48.4 mins; p<0.0001). There was no significant difference in the number of successful first cannulation attempts (67% vs. 73%; p=0.23), or intervention-associated adverse effects (1.2% vs. 3.2%; p=0.39), between the two groups. Redness, vasoconstriction and increased anxiety were associated with LMX4^TM application in a minority of cases.

Conclusions

The Coolsense^TM device performed better than LMX4^TM cream at reducing the pain associated with intravenous cannulation in children. The immediate nature of its local analgesic effect means it significantly reduces the waiting time to cannulation. Both interventions produce similar first cannulation success rates and frequency of reported adverse effects. Coolsense^TM should be considered a viable alternative to topical anaesthetic cream for providing local analgesia in children requiring intravenous cannulation in the PED.

Title: Web-based tools for educating caregivers about childhood fever: a randomized controlled trial. 

Introduction: Fever is a common reason for an emergency department (ED) visits and misconceptions abound. To date, educational strategies targeting caregivers have made little impact. Multimedia approaches to educate caregivers have proven effective in many childhood conditions. However, the utility of web-based interventions in caregivers has not been explored for childhood fever. In this study, we assessed the effectiveness of an interactive web-based module (WBM), read-only website (ROW), and written and verbal information (SOC) to educate caregivers about fever in their children.

Methods: This was a parallel group, randomized, superiority trial at a pediatric ED in London, Ontario, Canada from December 2013 to January 2015. The caregivers of children 0-17 years presenting to the ED with either a chief complaint of fever or had a temperature greater than 38 C were included. Caregivers were randomized to a WBM, ROW, or SOC. Primary outcome was the gain score on a novel questionnaire testing the caregiver’s knowledge on the measurement and management of fever. Secondary outcome was the caregiver satisfaction with the interventions. Primary outcome was analyzed using ANOVA and contrast analysis using the Student’s t-test was performed if overall differences were found. Caregiver satisfaction scores were compared using the Student’s t-test.

Results: There were 77, 79, and 77 participants in the WBM, ROW, and SOC groups, respectively. Web-based interventions were associated with a significant mean (SD) pre-test to immediate post-test gain score of 3.5 (4.2) [95% CI: 2.5, 4.4] for WBM (p < 0.001) and 3.5 (4.1) [95% CI: 2.6, 4.4] for ROW (p < 0.001) in contrast to a non-significant gain score of 0.1 (2.7) [95% CI: -0.5, 0.7] for SOC. Mean (SD) caregiver satisfaction scores (out of 33) for the WBM, ROW, and SOC groups were 22.6 (3.2), 20.7 (4.3), and 17 (6.2). All groups were significantly different from one another in the following rank: WBM > ROW > SOC (95% CI WBM: 21.9, 23.4; ROW: 19.8, 21.7; SOC: 15.5, 18.5, p < 0.001).

Conclusions: In contrast to verbal and written information, web-based interventions are associated with significant improvements in caregiver knowledge about fever. A web-based module is associated with the greatest caregiver satisfaction and should be routinely used in the ED.

References:

Wallenstein MB, Schroeder AR, Hole MK, Ryan C, Fijalkowski N, Alvarez E, Carmichael SL. Fever literacy and fever phobia. Clinical Pediatrics. 2012; 52(3): 254-259.

Walsh A, Edwards H. Management of childhood fever by parents: Literature review. Journal of Advanced Nursing. 2006; 54(2): 217-227

Kobak KA, Stone WL, Wallace E, Warren Z, Swanson A, Robson K. A web- based tutorial for parents of young children with autism: Results from a pilot study. Telemedicine Journal & E-Health. 2011; 17(10): 804-808

Acknowledgements: The authors have no conflicts of interest relevant to this article

A prospective cohort study of manipulation and closed reduction of paediatric distal radius and forearm fractures - emergency department (ED) procedural sedation versus general anaesthesia in emergency theatre. Single centre study based at the Royal Hospital for Sick Children (RHSC), Edinburgh UK.

Background

Distal radius and forearm fractures are common injuries in the paediatric population.  In the subset of these injuries that demonstrate an unacceptable degree of angulation or displacement, closed reduction is the standard practice of care where instrumentation is not indicated. This may be performed under procedural sedation within the ED or under general anaesthesia (GA) in theatre. It is postulated that procedural sedation within the ED may reduce cost and time to treatment when compared to reduction under GA. However concerns currently exist that reduction under procedural sedation within the ED may be associated with increased anxiety and pain, poorer treatment outcomes and complications arising from sedation when compared with inpatient GA. This study aims to compare the outcomes for the closed reduction of forearm and distal radius paediatric fractures under procedural sedation in the ED to those reduced under GA in emergency theatre.

Methods

All patients presenting to RHSC ED from August 2015 with distal radius or forearm fractures appropriate for closed reduction were included. Tertiary referrals and any fractures requiring instrumentation were excluded. Allocation to ED procedural sedation was based on anticipated safety and was assessed by the supervising ED consultant using a departmental standard operating procedure. Sedation agents used varied according to sedationist preference but most commonly were a combination of propofol and opioid. Our measurable outcomes were time to reduction, complications secondary to general anaesthesia or procedural sedation, need for treatment revision, incidence of re-fracture or mal-union/non-union postoperatively.

Results

Over the initial 6-month period, 56 patients aged between 2 and 14 years were included; 43 forearm and 13 distal radius fractures. 34 fractures (61%) were reduced under procedural sedation in the ED, 22 (39%) under GA in theatre. There was a significant difference in mean time to procedure of 15 hours (procedural sedation mean time 3 hours, GA 18 hours; p<0.05). There was no difference in complication rate between ED sedation and inpatient GA (n=0) and ED reduction was not associated with an increased rate of reoperation (n=0). Re-fracture rates were comparable in both groups (n=1) and all fractures were united in an acceptable position at follow-up. We will increase the power of this study through a further 6 months of data collection. We are also assessing service user satisfaction and quantifying the financial savings associated with the procedural sedation treatment limb.

Conclusion

Our preliminary data indicates that ED procedural sedation is as effective as inpatient GA for the closed reduction of paediatric distal radius and forearm fractures in those deemed safe for sedation. It appears to provide a more rapid, efficient and cost-effective alternative to inpatient GA reduction. It has shown to significantly decrease time to reduction and avoids hospital admission and the use of emergency theatre slots.  

On behalf of the SHIVER group (Studies in cHIldren with feVER) from Research in European Pediatric Emergency Medicine (REPEM) network.

Background

Fever is the most frequent reason for a child to attend pediatric emergency care (ED). We have a high antibiotic prescription rate in febrile children; often broad-spectrum.
The majority of febrile children, however, suffer from self-limiting illness; bacterial infections comprise pneumonia and urinary tract infections mostly. Aim: evaluating antibiotic prescription in febrile children at EDs focusing on variability among countries and clinical symptoms.

Methods

Design: Prospective observational multicenter study between October 2014-February 2016.
Population: Febrile children aged 1 month-16 years visiting the pediatric ED.
Outcomes: antibiotic prescription rate (primary); antibiotic type, geographical background, clinical symptoms (secondary). Data collection: each center registered clinical data and treatment (one randomly selected day per month, during 12 consecutive months).

Results

Preliminary results are based on 4544 children from 28 hospitals, 11 European countries. Median age was 2.4 years (25^th–75^th percentile 1.1–4.9); 2488 (55%) male. Working diagnosis was definite bacterial in 204 children (5%) and probable bacterial in 1181 (26%). Infections were located in upper airway most frequently (n=2777, 61%); followed by lower aiway (n=561, 12%) and enteric (n=506, 11%). The majority was managed ambulatory (n=3979, 88%). Antibiotics were prescribed in 1440 (32%), with (amino)penicillin (36%) and amoxicillin-clavulanic acid (39%) most frequent; cephalosporins in 15%. Two countries could be classified into low MRSA prevalence of <5% (223 ED visits), 7 countries into MRSA prevalence 5-25% (3267 ED visits), and 2 countries into high MRSA prevalence of >25%  (1054 ED visits). Antibiotic use was 23% and 25% for low and intermediate MRSA prevalence countries, and 58% in countries with high MRSA prevalence rates. Small spectrum antibiotics were applied in 45% and 49% in low and intermediate MRSA prevalence countries respectively, but in only 17% for high MRSA prevalence countries. Antibiotic use was also related to younger age, the presence of abnormal vital signs and ill appearance, but not related to the presence of meningeal signs or petechiae. Diagnostic tests (serum-CRP, blood leukocyte count, urine dipstick and chestradiographs) were more frequently performed in those who had antibiotics prescribed. Results of chestradiographs or urine tests were not related to antibiotic prescription. A combination of clinical variables explained 4% of antibiotic prescription variation.

Conclusions In a multicenter study among European EDs, a minority of febrile children is at risk for bacterial infections. Antibiotics were prescribed in 32%, with (amino)penicillin and amoxicillin-clavulanic acid most frequently. Antibiotic use in febrile children is most related to MRSA prevalence rates, but also to the clinical presentation. The performance of diagnostic tests, but not the result of chestradiographs or urinetests are related to higher antibiotic prescription rates. International best practices need to be identified for management of acute febrile children.

Introduction

The recognition of children with time-sensitive conditions amidst the large group of children with benign or self-limiting illnesses remains a challenge at the emergency department (ED). Because children present to the ED with a wide spectrum of problems, it is unlikely that a single clinical feature, vital sign or diagnostic test can accurately rule in or rule out a serious condition in a child. “Gut feeling”, the intuition that something is wrong despite a reassuring clinical assessment, may be a promising tool to identify children with serious illness. A previous study reported that primary care physicians’ gut feeling increased the risk of serious infection in children. Little is known, however about the gut feeling of ED nurses. The aim of this study was to define determinants of nurses’ gut feeling at the ED and to assess its diagnostic value for the recognition of children with a serious illness.

Methods

The study is based on a prospective observational cohort of all children aged

Results

During the study period, we included 6390 children who attended the ED with a medical problem and had information about gut feeling documented. A gut feeling was present in 20.0% of these visits. Gut feeling was associated with triage urgency (OR 10.2, 95%CI 8.0-12.9 for urgency category 1 and 2 and OR 4.2, 95%CI 3.4-5.3 for urgency category 3), fever (OR 2.7, 95%CI 2.3-3.1) and the presence of abnormal vital signs (OR 1.6, 95%CI 1.4-1.9 for 1 abnormal vital sign and OR 3.6, 95%CI 2.9-4.3 for 2 or more abnormal vital signs). Moreover, a gut feeling occurred less frequent in self-referred patients (OR 0.6, 95%CI 0.5-0.7) and patients presenting outside office hours (OR 0.8, 95%CI 0.7-0.9). When adjusted for age, gender, triage urgency and fever or abnormal vital signs, presence of a gut feeling was significantly associated with ICU (OR 4.4, 95%CI 3.0-6.3), and hospital admission (4.1, 95%CI 3.5-4.8). Sensitivity of nurses’ gut feeling for the recognition of patients requiring ICU admission was 0.71 (0.63-0.79), and specificity 0.81 (0.80-0.82). Sensitivity for hospital admission was 0.48 (95%CI 0.45-0.52), and specificity 0.85 (95%CI 0.84-0.86).

Conclusion

Nurses’ gut feeling at the emergency department is associated with clinical and non-clinical factors. The presence of a gut feeling increases the risk of ICU or hospital admission, but is in itself not an accurate predictor. It is important to combine gut feeling with other clinical parameters to determine the severity of illness of a child.

Urinary tract infections (UTI) are the most common serious bacterial infection in infants less than 90 days of age. Guidelines recommend inpatient treatment under 60-90 days old, due to risk of complications. In 2010, a predictive model was published by Schnadower et al. trying to find a subgroup of patients with low risk of adverse outcomes. That model shown high accuracy, but for predicting risk of bacteremia secondary to UTI. In 2014, a new approach was published by Velasco et al. This new model did not focus not in patients with a positive urine culture, but in patients with an altered urine dipstick, trying to select a group of low risk of having a invasive bacterial infection (IBI). Sensitivity and negative predictive value of this model were 100%.

Aim of this study was to test the performance of the predictive model in a new sample of febrile infants with altered urine dipstick. 

Study design

Retrospective multicenter study including 9 Spanish hospitals. Febrile infants ≤90 days old with altered urinalysis (presence of leukocyturia and/or nitrituria) were included. According to our predictive model, an infant is classified as low-risk for IBI when meeting all the following: being well appearing at arrival to the emergency department, being >21 days old, having a procalcitonin value <0.5 ng/mL and a C-reactive protein value <20 mg/L. Patients were excluded if any of the data evaluated by the predictive model was missed, a blood culture was not performed or if informed consent was not given by the parents. Invasive bacterial infection (IBI) was defined as the isolation of a single pathogen in a blood or cerebrospinal fluid (CSF) culture. IBI was considered as secondary to UTI if the same pathogen was isolated in the urine culture and in the blood or CSF culture

Results

Four hundred twenty-five febrile infants attended in the participant hospitals had an altered urine dipstick. After applying exclusion criteria, 391 (92%) patients were analysed. Mean age was 50.5 days old (SD 23.0), and 297 (69.9%) were male. Median hours of fever when attended in the PED was 4 (P₂₅-P₇₅: 2-12). Urine culture was positive in 346 (88.5%) patients, being Escherichia coli the most frequently isolated bacteria, in 302 (87.5) infants. Thirty (7.7%) patients were diagnosed as IBI. Among them, 28 had bacteremia, being 25 (89.3%) secondary to UTI. Two patients had meningitis, one due to E. coli and the other one growth Klebsiella oxytoca in both urine, blood and CSF culture.

According to the predictive model, 104 (26.6%) infants would have been classified as low-risk patients. Two low-risk patients (1.9%) presented an IBI vs 9.8% (p<0.05) of the infants classified as not low-risk patients, although 1 of them growth Moraxella catarrhalis, suspected of being a contaminant, even it was not defined as one in the study's protocol.

Conclusion

Outpatient management might be suitable for 1 of each 4 patients diagnosed as possible UTI, although limitations of the study make mandatory prospective validation prior its incorporation to clinical practice.

BACKGROUND: Head injury is an important cause of mortality and morbidity in children. Earlier studies have described significant practice variation in the use of imaging after pediatric head trauma, with  evidence to suggest that pediatric emergency departments (EDs) have lower rates of imaging than general EDs. Computed tomography (CT) is the imaging modality more commonly used in the ED evaluation of children with head trauma. The use of CT, however, is not uniform across all EDs, and variation between clinicians and pediatric EDs  exists.and appears unrelated to the frequency of clinically important Traumatic Brain Injuries (ciTBIs).

OBJECTIVE: To describe the variation in use of imaging, observation and admission rate for children with minor head trauma (MHT) in Europe.

DESIGN: A 3 years retrospective chart review involving 17 pediatric EDs of 9 European countries was conducted. A structured data collection method was used. Inclusion criteria included children 18 years or less, history of trivial or MHT in the previous 24 hours from the evaluation in the ED. Data collected included demographic information, type of injury, mechanism of injury, type of imaging  used and rate of admission to the observation unit or ward.

RESULTS: We report the preliminary results of  9 centers. Of 6535 charts reviewed, 6493 (99.4%) were analyzed. The mean age was 55.5 months (SD 49.4). 60.2% of the patients were male, without significant differences between hospitals. CT and observation rates varied across hospitals respectively from 0.8% to 19.6% and 12.3%  to 41%. Main data about the management are shown in Table 1.

Hospital

                                             1          2           3          4           5            6            7           8                9

n                                      517      895        430       141       438       459       1190        515         1950

Minor HT                       91.5%   86.1%   70.2%   32.6%    82.0%   84.8%   82.6%    85.4%      63.6%

Craneal X-Ray                8.1%     1.9%    11.4%   18.3%    21.7%   18.6%     3.6%      0.4%       4.8%

Head CT                        2.2%     5.5%     2.1%     0.8%      4.6%   14.7%     3.0%    19.6%       2.9%

Observation Unit          24.1%    41.0%   17.9%   14.3%    30.1%   39.8%   23.5%    23.1%      12.3% 

Admitted (Ward/PICU)    0.5%     1.8%     1.2%     0.8%     0.2%     1.2%     2.9%     18.3%      7.5%

CiTBI                               0%     1.5%      0.7%     0.7%       0%      0.2%    0.4%          0%      0.5%

CONCLUSIONS: Preliminary results demonstrate a significant variation in the   management of MHT in Pediatric ED across Europe when considering the rate of imaging, observation and ward admission. The reason for this variability may be based on differing criteria used by clinicians to order imaging, differences in the patient populations presenting to the various departments or training of physicians staffing EDs in the different hospitals.

BACKGROUND AND PURPOSE

Management of infants younger than three months old presenting to the Emergency Department (ED) with fever of unknown origin remains a difficult challenge for clinicians. Prenatal Group B Streptococcus screening and recently developed vaccinations changed the occurrence and epidemiology of serious bacterial infections (SBI) in this population. An evidence-based guideline was developed for use in the Paediatric ED of a tertiary university hospital in Brussels.

The purpose of this study is to examine the accuracy of this guideline to detect SBI, to search for the infectious agents in this population, and to analyse physicians' compliance to the guideline.

PATIENTS AND METHODS

All infants younger than three months old who presented to the ED with fever without clinical source, between January 1, 2012 and November 15, 2013 were eligible to include. All anamnestic and clinical data, laboratory test and culture results, chest X-ray findings, treatments and clinical outcomes were obtained from digital medical records, and retrospectively analysed.

RESULTS

From 31713 paediatric patients who presented to the Paediatric ED over 23 months' time, 1592 (5%) were under three months old, of whom 287 (18%) had fever of unknown origin. Median age was 42 days (range 6–90 days), 159 were boys (55%), and 16 (5.5%) had a history of prematurity.

Diagnostic screening categorised 143 infants (49.8%) as high-risk for SBI, of whom 26 (18%) had confirmed SBI. In 144 infants (50.2%) categorised as low-risk, no SBI was detected.

In 122/287 infants (42%), a microbiological source was found: 96/287 (33%) had a viral infection, 16/287 (5.5%) had a urinary tract infection (UTI), and 10/287 (3.5%) had a bacterial pneumonia. In the majority of infants (n=165/287; 58%), no pathogen was detected. The most frequently detected pathogens were Escherichia coli (mostly in urine) and Enterovirus (mostly in cerebrospinal fluid).

Most infants (n=279/287; 97%) were admitted to the hospital, of 8 patients (3%) parents refused admittance. In 62% (n=178/287), empiric antibiotherapy was initiated. In the high-risk group, all infants were treated; in the low-risk group 35/144 (24%) infants received intravenous antibiotics. In 11 cases (3.8%) acyclovir was added.

One infant died following septic shock after peritonitis due to bowel perforation.

Many non-adherences to the guideline were detected: in 14 infants (5%) no blood culture was obtained, only 35/287 urine samples (12%) were obtained in a sterile collection, 19% (n=56) did not undergo lumbar punction, and 3% (n=8) did not have a chest X-ray. Most infants (n=185/287 or 64%) were not screened for Bordetella pertussis. In the low-risk group, 20% (n=35/178) received antibiotics although the guideline recommended differently.

CONCLUSIONS

This study indicates that in 9% of infants presenting to the ED with fever without source an SBI was detected. Most common infections were of viral origin, most common SBI were UTI. Adding standard screening for Bordetella pertussis to the guideline is recommended. Given these results, the compliance of physicians to the evidence-based guideline should be improved, and attention is needed regarding sterile urine collection and antibiotic policy in the low-risk group.

Background: Adolescent girls presenting to emergency departments (ED) with abdominal pain are a common presentation. Pregnancy is one differential diagnosis amongst many but if missed can have serious consequences. The UK is one of the European countries with the highest rate of teenage pregnancies with large regional variations.  4.5% of all deliveries are to mothers aged 18 or younger (31,000 p.a.). There is limited guidance on when to screen for pregnancy in this age group. In our study we audited practice in a cohort of adolescent girls presenting to a tertiary teaching hospital ED with abdominal pain following a review of the literature.

Methods: Resource websites of RCPCH (UK), RCEM (UK), AAP (US), NHS Improving Quality (UK) and Pubmed were searched for protocols and guidelines. All female attendances aged between their 12^th and 18^th birthday with a presenting problem of abdominal pain between October 2015 and January 2016 were identified and the electronic records reviewed. Data was collected on whether a menstrual history was taken, sexual activity, pregnancy testing and final diagnosis and disposal.

Results: A total of 124 ED attendances by 98 patients were identified. One 16 year old girl was found to be pregnant on testing with suspected ectopic pregnancy. 27% of attendances did not have a pregnancy test, when excluding pre-menarchal patients this rate dropped to 25%. 14 and 15 year olds had a pregnancy test result documented in only 60% of cases. Of those patients not tested, 12% went to theatre and 14.7% were exposed to ionising radiation including CT scans. Sexual activity was asked about in only 25% of cases but did not impact on the rate of testing. Menstrual history was documented in 66% of attendances. 12% of attendances who were not tested had no definitive diagnosis on discharge from the ED.

Conclusion: Detection of teenage pregnancy is important. There are recommendations for testing in risk groups but this is not universally implemented. A number of factors account for substandard practice as highlighted in our cohort and we present current latest recommendations and propose a management algorithm.

Introduction: Pre-hospital severe trauma patients' (STP) clotting disorders are early and worsen their prognosis. The aim of this study was to describe the incidence of coagulopathy and to explore the existence of statistical associations between the presence of coagulopathy and other characteristics gathered from STPs cared for by prehospital medical teams in urban areas.

Material and method: This was a retrospective observational study.  The inclusion criterias were patients cared for hemorrhages by prehospital medical teams, transported to a hospital recovery room, and for whom the initial hospital hemostasis record sheet was available. The pre-hospital variables recorded were 1. Epidemiological (age, gender, circumstances) 2. Paraclinical and biological (shock-index, Glasgow scale score, blood lactate values) 3. Therapeutic (intubation, tranexamic acid and/or catecholamines administration) 4. Time from "prehospital medical team engagement to recovery room arrival. The hospital variables were the early biological results (prothrombin time (PT)). The analysis of results was gathered and then multivariated using STATA 14.0 ®.

Results: Over 11 months, including 1570 medical transports, 156 (10%) were STPs.   For 72 of these 156 STPs, initial hospital hemostasis record could be found. For these 72 (100%) included, the median age was 33 years, IQR [26-44], with 63 (88%) men. The trauma was linked to either a public highway accident (n=42 or 58%) or penetrative weapon wound (n=19) or defenestration (n=11). The initial shock-index was >1 in 9 (12.5%) cases. The patients were intubated in 10 (14%) cases, received catecholamine in 2 (3%) cases and received pre-hospital tranexamic in 22 (31%) cases. The median "prehospital medical team engagement-recovery arrival" time was 64 min (IQR [52-78]). On hospital arrival, 15 (21%) STPs had a PT<70%. .

In univariate analysis, the hospital PT tended to be correlated with pre-hospital lactate values (p=0.06). In multivariate analysis, we found an association between hospital PT <70% and respectively: pre-hospital shock index >1 (p=0.02), the elderly (p=0.02), and pelvis injury (p=0.04).

Discussion: Clotting disorders were found in one in five despite currently proper care.  The study continues on a larger cohort taking into account survival. It also constitutes the reference group of a pre-post study. The "after" period will be to administer lyophilized plasma at the pre-hospital phase. 

Background: Checklists improve the management of crises in simulated operating rooms and intensive care units. Crisis checklists have not been evaluated in the emergency department (ED) setting. Checklists may not necessarily have the same value when used in the actual working environment as opposed to a simulation center.

Aim: The aim of this pilot study was to evaluate crisis checklists using in-situ simulations in an actual ED.

Methods: Checklists of key emergency treatments were developed for eight crises:anaphylaxis, hemorrhagic chock, ST-segment elevation myocardial infarction, beta-blocker and/or calcium antagonist poisoning, poisoning with a membrane stabilizing agent, status epilepticus, severe sepsis, increased intracranial pressure.The content of the checklists was based on international guidelines and other authoritative sources.Emergency care teams working in the ED of Lund, Sweden, were randomized to manage simulated crises with or without access to these checklists, for a total of 16 simulations lasting 10-12 minutes. Time from scenario start to key treatment delivery was independently measured by two observers. Each crisis featured between 7 and 11 key treatments.Checklist user-friendliness was evaluated using a questionnaire.

Results: The median percentage of treatments carried out was 83% (range 38-100%) with checklist access versus 44% (range 15-86%) without (p = 0.03). One simulation needed to be prematurely terminated due to clinical care requirements and subsequently repeated. Of the 36 participants who had checklist access, 26 (72%) felt that the checklist helped them manage the case. Almost all participants, 67 of 71 (94%), would want the checklists used if they were the patient.

Interpretation: Studying crisis checklists in an actual ED is feasible. The pilot study results suggest that checklists may improve the care of critically ill patients in the ED.

Introduction Infections caused by microbial contamination in healthcare settings result in increased morbidity, mortality and economic burden. Hygiene in the emergency medical service is challenged due to the non-static environment with limited access to cleaning equipment etc.  The personnel are working in varying environments e.g. retirement homes, industrial farms or at roadsides after a car incident, often with little time to prepare the acute care and treatment. In addition, continually patient courses lead to limited time to clean and prepare the ambulance in-between patient courses, thus posing a risk of transferring infection. Knowledge of bacterial contamination in environment, on medical equipment and the personnel and related challenges is therefore substantial, thus future hygiene interventions can be organized and effectuated according to evidence (1, 2). The aim of this review is to create a systematic summary of the current evidence concerning hygiene in the emergency medical service focusing on 1) environmental contamination, 2) cleaning interventions and 3) personnel compliance. Methods A scoping review including English or Scandinavian literature, were performed in PubMed Central (PMC) from March to April 2016. At least two of the investigators decided the relevance of each report, and all inclusions/exclusions were unanimous, and the articles not blinded.  Results We found documentation of environmental contamination by several different pathogenic bacteria, on a wide variety of equipment and materials within the ambulance environment and limited effect of conventional cleaning, and risk of cross contamination. Furthermore, hygiene compliance appears challenged on a number of aspects e.g. hand- and uniform hygiene, cleaning and disinfection procedures etc. Conclusion Hygiene in the emergency medical service appear challenged on several aspects. This review reveal risk of infection due to environmental contamination by pathogens and lack of personnel compliance, thus underpinning a necessity of focus on prehospital hygiene and future research in order to secure evidence-based practice. 

BACKGROUND – YouTube, the third most popular website in the world, is a vast repository of user-uploaded video content and a potential source of freely accessible medical information. To our knowledge no study has identified or focused on parent uploaded videos which describe illness in their children.  

OBJECTIVE – to be able to describe the quantity, quality and use of videos featuring unwell children posted on YouTube by their parents, and the implications for and use of these videos in educating parents.

METHODS – Croup and dehydration were the two medical conditions used for comparison.  YouTube was searched for videos using the search terms ‘croup’ and ‘dehydration’ from servers based in the United Kingdom (UK) and the Netherlands on October 6, 2015. The first 400 videos were searched and videos which clearly had been uploaded by parents or caregivers selected for evaluation. Videos created by doctors or by educational institutions were excluded. 
The included videos were analysed independently by two research students and two paediatricians for different characteristics (duration, likes/dislikes, number of views) and technical quality (using the validated VRS system with a total maximum score of 5 to rate light, sound, angle, resolution and duration). 
Independently of this, each video was assessed for whether it represented a good clinical example of the condition or not.

RESULTS – for the condition croup there were 40 videos which met the criteria for inclusion after 400 videos had been screened. The 40 corresponding videos had a wide range number of views (142 – 121928). Out of 40 videos, 14 (35%) were judged to be a good clinical example. Only 7 of these 14 videos were also found to be of high technical quality, meaning that 7 of the videos judged by the study team to be a ‘good clinical example’ were of poor technical quality.

For the condition dehydration a total of 28 videos met the criteria for inclusion. 2 of 28 (7%) parent uploaded videos were judged to be a good clinical example. Both these videos had good technical quality (score 4-5). 

In most videos of both conditions, the reason for upload was unclear. 

CONCLUSION – Useful and high quality videos do exist for the condition croup (a clearly defined condition), but this was not the case for dehydration (a vaguer symptom). Some of the videos for croup could be used as educational material. However, these videos will not always be obvious to those searching and it can be hard to find these informative videos in the large amount of information available. 
Conversely, parents could be confused by apparently high technical quality videos (which have good light, sound and picture quality), which are not in fact good clinical examples. 
Further research into reason for uploading should be undertaken to understand why videos are uploaded which could be beneficial for understanding parents’ health seeking needs. YouTube could be a useful information source for parents if clearly guided.

Background

The study compares pathways for the same patient conditions of different Emergency Medical Services from 17 European Nations. These cases were designed as urgent but not life threatening emergencies: A simple laceration, an adult experiencing an asthma attack, a patient with lower back pain, a caller having cough and chest pain, an elderly after a fall, a patient with fever and a senior in need to have a urinary catheter change.

Participants and methods

Services in Austria, Belgium, Czech Republic, Denmark, Finland, France, Germany, Hungary, Italy, Luxembourg, Norway, Slovakia, Slovenia, Spain, Sweden, Switzerland and United Kingdom participated in the study. The seven case scenarios have been answered via questionnaire or personal interview during participation in field ambulance work.

•Results

There is a high degree of variation in steering the patient into different medical pathways via phone evaluation or on scene assessments between the different services that have been researched. Overall, in the observed institutions there is a tendency to treat and release patients if ambulance providers also have a nursing or community/advanced paramedic background, combined with standardized assessment protocols or if there are general practitioners systematically involved. Some services have a strict ‘transport to the hospital strategy’ whereas others have a ‘hear and refer or treat’ or ‘see, treat and release’ response.

Discussion/conclusion

Ambulance services fulfill primary care tasks in all nations. If there is no common strategy developed with traditional primary care providers such as general 

Background: Physician-staffed rescue helicopters are a high-end and very expensive resource of limited availability, therefore a deliberate dispatch system is of paramount importance. This retrospective observational study aims to evaluate how often the use of a helicopter was justified at a single rescue helicopter base in southern Austria.

Methods: Austria operates a dense network of ground-based physician-staffed prehospital response units and an additional coverage with rescue helicopters during daylight conditions. The protocol sheets and electronic records of the rescue helicopter base in Graz, Austria of a one-year time period were screened and entered into a database. The respective helicopter serves a population of about 900,000 people and 9,000 square kilometers covering both heavily populated urban areas, rural areas and poorly accessible mountain regions and can thus be viewed as representative for a large part of Austria´s territory. Three aspects of helicopter deployment were considered: rapid transport priority to a maximum care hospital according to the emergency physician´s diagnosis, use of the helicopter for extrication purposes and in inaccessible areas and the provision of invasive prehospital medical treatment provided by the specialized aeromedical crew. A scoring system incorporating these three aspects was generated to evaluate whether the utilization of the helicopter was justified or whether the call could have been attended to by a ground-based crew. Interhospital transfer missions and missions which were cancelled en-route were excluded from the analysis.

Results: From July 1^st, 2014 until June 30^th, 2015 1043 primary missions were the helicopter landed and attended to a call were registered. In 43,8% of those cases, there was no evidence of any benefit of the deployment of the helicopter versus a ground-based physician response unit (e.g. non-life threatening medical condition in close proximity to a ground-based crew). In the other 56,2%, we found at least some indication of an advantage of helicopter utilization. In 31,7% of all cases, there was a clearly comprehensible advantage of the helicopter as a rescue vehicle (e.g. severe multiple trauma in a poorly accessible mountainous area).

Conclusion: Despite the limitations of retrospective reviews, this study suggests that a large fraction of calls attended to by aeromedical crews could have been resolved employing ground-based emergency crews. Since rescue helicopters are a scarce and expensive resource, further studies to investigate the reasons for our findings are warranted and an audit system of feedback and quality control seems advisable.

Background: A large proportion of out-of-hospital cardiac arrests in Singapore (OHCA) occur in high-rise residential buildings.[1] This study aims to investigate the effect of the vertical location (floor level of apartment building) at which patients collapse from cardiac arrest, on survival outcomes and response times.

Participants and methods: A retrospective study was done based on data obtained from the Singapore cohort of the Pan Asia Resuscitation Outcome Study (PAROS). OHCA data from January 2012 to December 2014 were used. All OHCA patients conveyed by Emergency Medical Services (EMS) and confirmed by the absence of pulse, unresponsiveness and apnea were included. All OHCA cases occurred in Singapore. OHCA cases with incomplete data on vertical location were excluded. Primary outcome was survival to hospital discharge or to 30 days post cardiac arrest. Statistical analysis was performed using SAS V9.3 (SAS Inc., Cary NC, USA) and expressed in terms of counts and percentages, odd ratio (OR) and the corresponding 95% confidence interval, mean and the standard deviation (SD) as well as p-value.

Results: A total of 5114 OHCA cases met the inclusion criteria for this study. 76 cases (1.5%) had missing vertical location data and were excluded. Out of the 5038 OHCA cases analyzed, 1482 (29.4%) cases occurred at ground level, 41 (0.8%) cases occurred at basement levels and 3515 (69.8%) cases occurred at ≥ 2^nd floor level. 3653 out of 5038 cases (72.5%) occurred in home residences. The response time (in minutes) from time of ambulance arrival on scene to patient contact by EMS for cases that occurred at basement levels (mean 3.32 [SD 4.24]) and cases that occurred at ≥ 2^nd floor level (mean 2.53 [SD 1.66]) are both significantly higher (p<0.001) than those that occurred at ground level (mean 1.67 [SD 1.99]). Survival outcomes for OHCA patients were poorer as the vertical location increases away from ground. For every 1 floor increase in vertical distance from ground, OHCA was 4% less likely to result in survival (OR 0.96 [0.92 – 0.99]). OHCA was also 3% less likely to be witnessed (OR 0.97 [0.96 – 0.98]), 1% less likely to have bystander CPR performed (OR 0.99 [0.98 – 1.00]), and 16% less likely to have bystander AED applied (OR 0.84 [0.79 – 0.89]) for every level increment in vertical distance from ground. First arrest rhythm was also 7% less likely to be shockable at every floor increment (OR 0.93 [0.92 – 0.95]. Return of spontaneous circulation (ROSC) on scene or enroute was 3% less likely to happen (OR 0.97 [0.94 – 0.99] and 3.5% less likely to be maintained at the ED [OR 0.97 [0.94 – 1.00] for every increase in vertical floor distance from ground.

Conclusion: There is significant effect of vertical location on survival outcomes for OHCA in Singapore. Interventions aimed at improving access to OHCA patients in high vertical floors need to be investigated.

Background: New nurses in the prehospital emergency care service are a precious and valuable resource, however they enter a challenging environment and the risk of clinical errors is increased. The transition from novice to proficient has been described as a process of becoming. An evolutionary journey that, although not always linear or strictly progressive, is ultimately transformative. This transformational journey has been well described in students becoming professionals in intrahospital context. Little is known however about the experience of being new in the prehospital setting, where a novice prehospital care nurse work with the sole medical responsibility of the patients, with no doctor and often without an experienced nurse to ask for support when difficult situations emerge.

Aim: This study aimed to deepening the understanding of newly hired ambulance nurses experiences of the first year of employment in the Emergency Medical Service, EMS.

Method: Data were generated from 13 semi-structured interviews with newly hired prehospital emergency care nurses, PECN’s, from seven districts representing rural, urban and suburban areas in Sweden. Analysis was a latent inductive qualitative content analysis.

Result: The findings show that being new is experienced as Striving for balance in internal expectations and external conditions and can be described with the three generic categories; Reflecting on the own ability, Searching for identity and Strategies for learning.

This study adds to the knowledge about being new in the EMS and illuminates the need for further research in how to support novice PECN’s strive for balance in this context.

Introduction

Algorithim based dispatch codes are widely used amongst ambulance services to prioritise dispatch of ambulance resources. This prioritisation is based on perceived urgency at the time of dispatch. There is little described in the literature about how this perceived level of urgency at ambulance dispatch relates to long term outcome.

Aim

To determine whether the AMPDS dispatch code was a predictor of a composite outcome of mortality within 30 days and/or ICU admission within two days.

Methods

All adult patients attended to by ten Scottish Ambulance Service (SAS) paramedics working across 5 centres.over a 13-month period. Data for all patients in the study was obtained from the electronic records via the SAS Data Warehouse. This data was then matched with the receiving Intensive Care Units and hospital information systems to ascertain outcome.

Results

A total of 1900 patients were available for analysis. Complete data on AMPDS code and outcome was available for 1895/1900 (99.7%).

The mean age of subjects in the study was 61.6 years (95% CI 60.7 to 62.6) with 50.5% of subjects being male gender.

Regarding outcome, 0.3% of subjects were admitted to an Intensive Care Unit within 48 hours and 4.9% of subjects died within 30 days of the initial ambulance call. The combined outcome of ICU admission within 48 hours or death within 30 days contained 5.0% of all subjects. Some subjects were in both of these groups.

There were a total of 191 different AMPDS codes used to dispatch an ambulance resource to the subjects in our study.

24 of 191 codes had more than 20 subjects dispatched. In this group of 20 codes the combined outcome measure again varied between 0 and 17.9% with a median of 3.5%.

9 of the 24 codes, covering 270 subjects, had a 10% or greater rate of the combined outcome measure of ICU admission within 48 hours or death within 30 days.

10 of the 24 codes, covering 364 subjects, had no subjects associated with a combined outcome measure of ICU admission within 48 hours or death within 30 days.

Discussion

This data is the first to link initial AMPDS coding to medium term outcomes such as ICU admission or 30 day mortality. Firstly the data from our study shows that this is feasible.

We also show that there is a wide variation in outcomes according to AMPDS code, Some codes, such as cardiac arrest, are associated with a high incidence of adverse outcome,. Some other less specific codes such as sick person/unwell are also associated with a high incidence of adverse outcome.

Conversely, some codes have no adverse outcomes associated with them. Although these are based on low absolute numbers, this may support down grading or regarding of some dispatch codes.

These findings will require replication in a much bigger cohort to confirm its accuracy at an acceptable level, however they open the possibility of basing dispatch codes based on hard outcomes such as ICU admission or 30 day mortality, rather than just immediate outcomes.

Introduction: Nearly 50 years after its discovery, Gamma-OH (GOH) is used less and less in pre-hospital emergency medicine. Yet it offers good hemodynamic tolerance, is not much of a respiratory depressant and is easy to use in extra-hospital situations. In the absence of recent practice studies, we determined reporting its most frequent indications in the current pre-hospital setting as the main objective. Secondary objectives were to assess compliance with proper use, associated anesthetics and the occurrence of complications.

 Material and methods: Retrospective monocenteric practice study in a pre-hospital emergency medical service with 6 mobile intensive care units (MICU). Inclusion criteria: all patients who received GOH administration in a pre-hospital situation. Data collected from medical observation sheets were epidemiological, clinical, therapeutic (indication and dose of Gamma-OH administered, associated hypnotic and/or analgesic treatments) and safety (adverse events, complications from anesthetics).

 Results and Discussion: From 01/01/2015 to 12/31/2015, 111 patients were included, with a mean age of 51 years [3-91] and 81 (73%) men. Prescription of GOH was related to: in 61 (55%) cases, return of spontaneous circulation (ROSC) after cardiac arrest; in 19 (17%) cases, coma; in 17 (15.3%) cases, severe trauma, including 9 associated with severe head trauma (SHT); in 7 (6.3%) cases, an isolated SHT; in 6 (5.4%) cases, acute respiratory distress with reduced consciousness; and in one case, a burn patient. Note that among the severe trauma patients there were 4 victims of multiple ballistic wounds in the November 13 attacks that received maintenance dose of GOH after tracheal intubation using rapid sequence induction.

After tracheal intubation, maintenance of sedation was performed by GOH alone in 26 (23.4%) cases; by GOH associated with sufentanil in 27 (24%) cases and GOH+midazolam+sufentanil in 54 (48.6%) cases. In adults (n=109), the initial dose was 60 mg/kg in the majority of cases (85%) as recommended, and 30 mg/kg in 10% of cases. This administration was followed by a second half-dose injection in 16 (14%) cases. No anaphylactic complications were reported. Only 2 episodes of hypotension were observed in patients who received it with midazolam. 

Conclusion: Because of its ease of use and a low complication rate, Gamma-OH proves even today to be a relevant product in pre-hospital situations or in disaster medicine. Gamma-OH remains in favour with our MICU physicians, particularly in cases of ROSC after cardiac arrest or severe trauma. These preferences are explained by facilitating the management of anesthesia, especially during long and difficult transportation by stretcher. A prospective study should be started to compare it to other products.

Introduction. The referral of cerebrovascular accident patients (CVA) to neurovascular units (NVU) has improved the prognosis of said patients. Imaging (CT or MRI) must be systematically carried out on arrival at the hospital. The aim of this study was to evaluate in urban areas of high population density the time between stroke onset and the completion of the 1^st brain imaging, according to the transportation of patients to the hospital. 

Materials and methods: This was a prospective observational study including all patients hospitalized in NVUs of a large metropolis. Data collection involved patient characteristics (age, gender), their means of arrival in the service: personal vehicle (PV), private ambulance (PA), professional rescuers (PR), emergency physician (EP); time of CVA onset and, first arrival in care, 1^st brain imaging, at the beginning of early thrombolysis if carried out. The different times were reported by their median [interquartile range]. Comparison of times made use of a median test (STATA^® 14.0)

Results.  From the June 1^st to 30, 2015, 554 patients (with the average age of 69 + 15 years, 306 men) were admitted in 13 NVUs in the studied geographic area. The average "CVA-1^st imaging" times were 550 [128-559] minutes in case of personal transportation (n=141), 236 [144-510] min by private ambulance (n=99), 167 [105-325] min. by professional basic life support (BLS) teams (n=220), 180 [135-154] min by a medical team (n=41), 69 [45-70] minutes in case of intra-hospital transfer (n=23).

Transient Ischemic Attackpatients favored a personal mode of transport; hemorrhagic CVA, BLS teams transport; ischemic CVA, a medical team tied with the rescuers.

Discussion. The time between the 1st symptoms and carrying out the 1^st imaging doubled when patients used their personal transportation versus that of institutional care. Awareness campaigns for institutional care in case of onset of CVA signs should continue to be carried out.

Study Objectives The ACEP International Ambassador Program was developed as a venue for international experts to provide the current status and progress of Emergency Medicine (EM) in their assigned countries. An annual one-day conference was created to convene the ambassadors and allow for collaboration in order to reach the common interest of advancing emergency care. Our objective was to analyze the major perceived barriers for the evolution of the specialty.

Methods Open-ended interviews were conducted during the program’s annual conference and collated from 2013-2015. ACEP International Ambassadors (N=75), who represent over 60 countries, were divided into focus groups through break-out sessions. Interviews were centered on thematic topics, including barriers encountered by stage of EM development; local, regional, and international needs for EM development; and barriers and needs of International Emergency Medicine (IEM) education. Data collection took place in real-time using scribes and subsequently grouped into key themes and findings. An inductive approach to data analysis was used to identify barriers for the evolution of EM abroad.

Results Ambassadors represented 83 countries which accounted for almost 50% of the world’s nations. The definition of EM is very country specific. Identifying local stakeholders in each country that would advocate for EM can be difficult. Even though the motivations of local governments are difficult to recognize at times, the involvement of Ministers of Health, public officials, and local leaders are an essential part in advancing the specialty. Furthermore, international organizations could provide quality control that allows for the development of EM through a process of merit. A heterogeneous curriculum and lack of knowledge of EM as a specialty has been a major challenge for residency programs. Centralizing educational resources can reduce duplication of efforts and would benefit educational processes for EM residency programs and health personnel.

Conclusion International Emergency Medicine remains underdeveloped and there still is not a clear definition of EM as a specialty. The scope of practice of EM abroad is still not widely recognized, which further increases the difficulty of its evolution. The indispensable expansion of EM will be exponential with the support of regional leaders to form a unique identity of the specialty. These leaders play a vital role in standardization and communication, while serving as catalysts in resolving shared concerns. It is important to attempt to professionalize IEM education. With the support from ACEP and IFEM, initial steps to professionalize IEM education would include course maps with milestones and guide for a core curriculum.

Introduction: Currently, in the prehospital setting, the first line ambulance crew don’t have any objective tool for helping to define the usefulness of Mobile Intensive Care Unit (MICU - SMUR) intervention. Early Warning Scores (EWS), based on vital signs, are used to monitor inpatients and to trigger a timely medical response. EWS in the prehospital setting might provide an objective tool leading to a more rational use of Emergency Medical Services (EMS). This study compares the performance of ten EWS among which the new EAS (Emergency Alert Score).

Material and method: 2343 ambulance’s report forms recorded during two months (January and July 2014) were retrospectively reviewed. Patients not transferred into one of the six participating hospitals of the ambulance district, patients aged less than 16 years, patients known to be pregnant and incomplete forms were excluded. Seven criteria for a medical response, independent of vital signs, were taken into account before calculating EWS. The primary outcome was the usefulness of MICU intervention, who was assessed by reviewing hospital medical files (adverse event and/or severity level at admission).

Results: 1120 patients were analysed. Hospitalisation rate was 45 %, among which 8 % in intensive care unit. Areas Under the Curve (AUC’s) of the best EWS (i.e. the EAS) without or with criteria for a medical response, independent of vital signs, were 0.76 (95 % CI: 0.74 – 0.79) and 0.83 (95 % CI: 0.80 – 0.85) respectively. For an EAS > 3, sensitivity was 73 % (95 % CI: 67 – 79), specificity was 80 % (95 % CI: 77 – 83), predictive positive value was 48 % (95 % CI: 43 – 53) and predictive negative value was 92 % (95 % CI: 90 – 94).

Discussion and Conclusion: Criteria for a medical response, independent of vital signs, improve the performances of the EAS score. A negative score (EAS ≤ 3) may help ambulance crew to decide to stop or to not call the MICU, with the advantage of an improvement in EMS management. These results must be confirmed by a prospective study.

References: Fullerton JN. et al. Resuscitation 2012; 83: 557-62. Silcock DJ et al. Resuscitation 2015; 89: 31-35.

Background

Vascular access in out-of-hospital cardiac arrest (OHCA) patients is challenging. Locally, emergency ambulance paramedics have a 50% success rate of obtaining an intravenous (IV) access in order to administer epinephrine. The aim is to evaluate the use of intraosseous (IO) in addition to IV to determine if there is an improvement in return of spontaneous circulation (ROSC).

Methods

This is a prospective, parallel group, cluster-randomised, crossover study comparing ‘IV only’ against ‘IV+IO’ in medical and traumatic OHCA cases in Singapore. In the ‘IV+IO’ arm, if 2 IV attempts failed or took more than 90 seconds, paramedics may have 2 attempts of IO. Inclusion criteria for IO were OHCA adult (body weight ≥40kg) and paediatric (body weight between 3 to 39kg) patients. Exclusion criteria were contraindications to IO. The primary outcome was ROSC. Secondary outcomes were insertion success rate, epinephrine administration, time taken for 1st dose of epinephrine and survival outcome.

Results

Based on phase 1 results (prior to crossover) from 1 September to 31 December 2014, there were 251 cases in the ‘IV only’ group and 307 cases in the ‘IV+IO’ group. Baseline characteristics were similar in both groups. There were more successful vascular access and prehospital epinephrine administered in ‘IV+IO’ compared to ‘IV only’ (69.4% vs 53%, p<0.001, 62.5% vs 47.8%, p<0.001 respectively). There were 38 IO attempts in the ‘IV+IO’ group, of which 5 failed as the 1st attempt was unsuccessful but a 2nd attempt was not made. Median time to epinephrine was similar in both ‘IV+IO’ and ‘IV only’ groups (10 min [IQR 7-16 min] vs 11 min [IQR 7-18 min] respectively, p=0.104), also ROSC whether it was prehospital ROSC (8.5% vs 10% respectively, p=0.558) or hospital ROSC (25.7% vs 26.7% respectively, p=0.847), as well as survival to discharge or 30 days (3.9% vs 5.6% respectively, p=0.421) and good neurological outcome of cerebral performance category (CPC) ≤2 (2.6% vs 4.8% respectively, p=0.178).

Conclusions

The use of IO in addition to IV led to higher vascular success rate and prehospital epinephrine administration. However, it was not statistically significant for ROSC, survival to discharge or 30 day survival, or good neurological outcome.

Acknowledgments

We would like to thank the SCDF paramedics for their participation in this study. We have no conflicts of interest to declare. This study was funded by NMRC New Investigator Grant and AM-ETHOS Duke-NUS MSRF Grant. 

Background

Patient safety is an important issue in emergency medicine. However, patient safety management is mainly focused on the care within  the emergency department (ED), although safety risks are known to take place in the chain of emergency care. For instance problems in the handovers of emergency care occur in safety incident reports of the general practitioner (GP) practice, ambulance emergency medical services (EMS) and other departments in the hospital. However, these reports are retrospectively focused, and insight in underlying causes is usually lacking. In this pilot study we explored the feasibility of a prospective risk analysis (PRI) in the chain of emergency care from the perspective of professionals, managers and board members.  

Methods

The pilot was performed in two emergency regions (provinces) in the Netherlands. Professionals of the emergency GP practice, EMS, ED and neurological department were included. We developed a protocol for the PRI process in the chain of emergency care, based on the health failure mode and effect analysis (HFMEA-light) method. The HFMEA-light method provides insight in safety risks of a care process or a chain of care through a systematic  assessment. Furthermore, we developed criteria for the selection of a care process that needs a safety risk assessment. An independent health policy advisor, with ample experience in facilitating PRI within hospitals, guided the PRI process in the (pre)hospital working group. We defined evaluation criteria for professionals, managers and board members of the participating organizations, as patient safety is a responsibility for each of them in a different role.

Results

We performed a PRI focused on changes in the Dutch national guideline for the emergency treatment of patients with a cerebro vasculair accident (CVA), and a PRI focused on handover of medication (errors) in the chain of emergency care. Professionals of the GP, EMS, ED, radiology and neurology  identified 14 patient safety risks in the CVA emergency care chain and 15 risks around medication handover. Risks were related to: inadequate or different education of professionals (knowledge and expertise), lack of ICT facilities and hampering communication between ICT systems, lack of synchronization of protocols in different organizations, miscommunication in oral and written handovers, lack of qualified staff for adequate performance of emergency care. The participants formulated a mutual plan for the improvement of patient safety, as part of the method. Professionals, managers and board members reported that the PRI was a useful and practical method, that contributed to a constructive improvement of patient safety (management) in the chain of emergency care. The PRI method connected well with the professional knowledge and expertise (intrinsic motivation) of the participants and improved the patient safety culture, when preconditions on confidentiality and mutual trust were met .

Conclusion

The PRI method provides prospective insight in safety risks in the chain of emergency care. It is a feasible method to improve patient safety  (culture) in the chain of emergency care, and professionals, managers and board members reported additional value of the method, with regard to others (retrospective) methods in use.

Background:

Executives of emergency healthcare services (EMS), such as Helicopter EMS, ambulance EMS and the emergency department (ED), have a fundamental governance role in overseeing and managing safety risks, because they are accountable for the overall quality and safety of healthcare their services provide. In the last decade, attention for the responsibility of executives towards patient safety has rapidly increased. This attention is stimulated by the crucial role executives have in the implementation of quality and safety improvement programmes, and by multiple patient safety incidents with great societal impact and directly related to poor governance. However, insight into the governance of patient safety within high-risk emergency care settings and the chain of emergency care is scarce. This study explores the factors that hinder executives in overseeing and improving safety risks within their own EMS, and in the chain of pre-hospital emergency care.

Methods:

A mixed-methods study was performed in two Dutch regional emergency healthcare networks covering a large part of the southeast Netherlands (provinces Gelderland and Limburg). In the Netherlands, pre-hospital emergency care is provided by General Practitioners (GPs), GP Out of Hours Service, EDs, ground-based ambulance and helicopter EMS and Psychiatric EMS. The Dutch EMS system operates on a variation of the Anglo-American model of EMS care. We performed 28 in-depth interviews with executives from different EMS organisations. The interviews lasted between 40 and 70 minutes and followed a semi-structured format using an interview guide. The guide was based on patient safety and governance literature, the input from experts (n=10) in the field of emergency care, public administration and patient safety, and brainstorm sessions with the research team. A pilot interview with the director of a regional emergency healthcare network was conducted to pre-test and refine the interview guide. Interviews were digitally recorded and transcribed verbatim. Transcripts were analysed based on the Grounded Theory approach. Furthermore, we collected and analysed relevant documents, such as annual reports, board minutes, policy statements, protocols and work instructions, to identify governance activities.

Results: Executives are satisfied with the governance of patient safety within their service. However, the professional autonomy often seems to conflict with the need of executives to be accountable for patient safety. Risk oversight and management are hindered by: the provision of care out of the executives’ sight, inadequate tools to measure or assess safety risks and fear amongst staff for the negative consequences of incident reporting. Many services lack a reliable organisation of up-to-date and easy accessible safety protocols. Governance within the chain of emergency care is hindered by conflicting interests and safety norms between services, the absence of an administrative authority and lack of appropriate risk identification tools.

Conclusions: Important safety risks within pre-hospital emergency care may be unnoticed and unmanaged by executives due to: inadequate risk monitoring, absence of a reporting culture and the lack of a shared sense of responsibility among executives for patient safety in the chain. Improvements should focus on these aspects as primary conditions for improving the governance of patient safety within emergency care.