Background:  Hospital readmissions account for a significant portion of both US Medicare and overall healthcare spending.  Many experts believe that many of these readmissions are unnecessary and considered a failure of the healthcare delivery system.  Strategies to further reduce readmissions can decrease the overall cost and improve quality of care.  Our program looked to see if Community Paramedicine/ Mobile Integrated Health programs could safely decrease hospital readmission rates for CHF and COPD patients.  

Methods: This government and IRB approved demonstration project cohort study evaluated the effectiveness of paramedics to perform post-discharge visits with the intent to decrease hospital readmissions for CHF and COPD.  The study commenced September 15, 2015 and includes data through April 1, 2018.  The study includes patients discharged from a single community based hospital serving both an urban and semi-rural population.  178 enrolled in the study group versus 270 cohorts treated in the traditional manner. Participants were similar in both demographic insurance status and medical history. The selection process was volunteer sample. 

 

Primary outcome was readmission, secondary measures were satisfaction, perceived improvement in health, length of readmission, and mortality. Cost savings were calculated based on data reported to Medicare.   Standard statistical methodologies were employed.  

Results: National information demonstrates that 30-day readmission for any cause was 23.5% for CHF and 20.0% for COPD.  Prior to the study, the facility’s 30-day historical readmission rate for any reason for CHF and COPD-related hospitalization was 22.1% and 18.9% respectively. 448 patients were eligible for the study and 178 enrolled.  Of the 80 CHF patients enrolled, the enrolled re-admission rate for any cause was 6.2% and disease specific was 1.3% versus the eligible not enrolled cohorts was 13.8% for any cause and 7.7% for disease specific. Of the 98 COPD/bronchospasm patients enrolled, the re-admission rate was 8.2% for any cause and 4.1% for disease specific versus from 17.9% to 13.6%. Unplanned readmissions cost between $11,500 and $14000. When patients were readmitted, enrolled average readmission days were 4.2 days vs 7.7 days.  Based on the pre-study incidence of readmissions and average cost of readmission of per patient, this program could prevent over 1 million Medicare CHF  and COPD readmissions and save over $14 billion.  There might be additional savings from shorter readmissions. Patient satisfaction of the program was in excess of 97%.  There were no deaths or otherwise unanticipated known complications in the study cohort.   Steps to avoid preventable readmissions were multifactorial, identifiable, and actionable. These included: assistance with medication and disease understanding, follow-up appointments, weight assessment, and access and appropriate use of MDI spacer.

  Conclusions:  Strategies to further reduce CHF-related readmissions are needed to reduce the overall cost and morbidity associated with disease. Creative financial modeling creating sustainability and thoughtful integration with the hospitals are key components of a successful program. An appropriately implemented community paramedicine /mobile integrated health program demonstrated that it can decrease 30 day readmission rates, decrease overall costs, improve patient satisfaction, and improve patient outcomes.  

The IRB Board reviewed and discussed the recently submitted material for the above-referenced study. The following was approved on April 27, 2016: APPROVAL INCLUDES: • Protocol- V5.1 Solano County Community Paramedic Manual dated 4-18-2016 • Summary of Changes- Medic Ambulance Program Manual Update Notes for IRB third Addendum 4-18-2016 • Medic Ambulance Service CP Delegation Log 4-15-2016 • The Following is Acknowledged: • CITI Training (FDA Regulated Research) • CITI Training (Human Research- Biomedical Researchers-Staff) - NO SPECIAL FUNDING WAS RECEIVED

Background

Carbon monoxide (CO) poisoning can lead to a variety of clinical effects that resemble many neurological and cardiovascular conditions, leading to potential misdiagnosis.  Recent studies suggest that the incidence of CO poisoning is 100/100,000 of all emergency department (ED) admissions. Advances in pulse oximetry have enabled this traditional noninvasive technology to monitor dyshemoglobins including carboxyhemoglobin (COHb) and methemoglobin. The only pulse oximeter currently used in emergency medicine capable of measuring dyshemoglobinemias has been repeatedly found to provide suboptimal reliability for clinical monitoring of CO poisoning due to low correlations with co-oximetry.  Nonin Medical recently developed a new sensor and oximeter system capable of reliably and accurately (A_rms <3.0%) measuring dyshemoglobins with and without concurrent hypoxia, as demonstrated in two separate controlled environment studies with human subjects. The purpose of this study was to demonstrate the accuracy of the COHb measurement in a hospital ED environment on suspected CO-poisoned patients.  

Methods

The study was IRB-approved and conducted in compliance with the Declaration of Helsinki. Prior to participation, all subjects provided written informed consent after all procedures and study risks were fully explained.  This ongoing study is a prospective observational study at a European reference hospital for hyperbaric oxygen therapy. Preliminary data presented here includes twenty ED patients (7M:13F, Age: 48 ± 22 years old) that presented with suspected or known carbon monoxide poisoning.  Seven subjects were current smokers with a history of smoking ranging 5 to 50 years.

During the study, blood samples (arterial: n=3; venous: n=17) were taken concurrently with oximetry data.  Blood samples were analyzed promptly by available hospital co-oximeters.  Co-oximeter COHb values were compared to the CO-Met noninvasive oximetry system (Nonin Medical, Plymouth, Minnesota).  The mean and standard deviations for both measurements and bias for COHb measurements from the co-oximeter and the noninvasive sensor (Model 8330AA) are presented.  Lastly, the accuracy root mean square difference (A_rms) between the noninvasive oximetry system and co-oximeter is presented.

Results:

Preliminary results indicate that in clinical practice, measured COHb levels were similar between the invasive co-oximetry (14.1 ± 4.7%, range 4-21% COHb) and noninvasive oximetry (13.0 ± 6.2%, range 2-20% COHb) systems.  The overall bias of the pulse oximetry based COHb estimation was –1.4 ± 3.3% and A_rms was 3.5 compared to co-oximetry in ED patients.  These data indicates consistent results between invasive co-oximetry values and the noninvasive COHb measurement in ED populations.  Overall accuracy was similar to the previously reported accuracy of A_rms 3.0; the slightly degraded accuracy in the current study may be due to the less-controlled setting in this study compared to a controlled hypoxia lab.

Conclusion:

These preliminary results suggest the new Nonin CO-Met^TM Noninvasive Oximetry System delivers high quality performance in an ED environment.  The ongoing study seeks to expand on these results by demonstrating consistent and reliable COHb readings in pre-hospital and referring hospital settings. The addition of the new Nonin CO-Met^TM Noninvasive Oximetry System may significantly improve clinical decision-making by increasing confidence in the reliability of a quick, simple, pulse oximetry derived-COHb.  

Support for this study was provided by Nonin Medical Inc.

How often to patients desaturate during pre-hospital induction of anaesthesia? A retrospective review of rapid sequence intubation by a united kingdom based helicopter emergency medical service.

A. S. Al-Rais¹, S. Taylor², D. Bootland³ and M. Nelson³

1 Anaesthetic Registrar, London and HEMS Registrar, Kent, Surrey and Sussex Air Ambulance Trust, UK.
2 HEMS Paramedic, Kent, Surrey and Sussex Air Ambulance Trust, UK.
3 Consultant in Emergency Medicine, Brighton and Sussex University Hospitals Trust and HEMS Consultant, Kent, Surrey and Sussex Air Ambulance Trust, UK.

Introduction

Pre-hospital anaesthesia is well established throughout the UK and aligned to the same standards expected for in-hospital emergency anaesthesia. Yet rapid sequence intubation (RSI) outside of the operating theatre is associated with higher rates of complication; of which hypoxia is one . Hypoxia is a cause of increased morbidity amongst the critically ill, and even transient hypoxia has been shown to worsen morbidity and mortality, especially in head injured patients.

There have been several single centre publications from the UK and globally that place the incidence of an episode of desaturation during pre-hospital RSI in the region between 10.9% and 22.6%.

One of the risk factors likely to be associated with desaturation is inadequate pre-oxygenation prior to intubation. A recent survey of UK HEMS services found pre-oxygenation practices to be widely variable. Our service currently pre-oxygenates with 15 litres of oxygen via a reservoir mask.

We performed a retrospective review of RSI's within our UK HEMS service over a 12-month period. Our aims were to quantify our incidence of desaturation during pre-hospital RSI; to identify patient groups at greater risk of desaturation and to establish whether there is any remit to examine other methods of pre-oxygenation.

Methods

A retrospective single centre cohort review of Rapid Sequence Intubations from December 2016 to December 2017. Data was collected from our electronic patient record system (HEMSBase). An episode of desaturation was deemed to have taken place if the SpO2 fell below 92% or dropped by more than 10% in the 5 minutes after administration of Rocuronium.

There were 269 Rapid Sequence Intubations performed during the study period, of which 205 had records that contained sufficient data for analysis..

Results

30/205 (14.6%) of patients had an episode of desaturation during the peri-intubation period.

12/30 (40%) patients in the desaturation group had a chest injury versus 37/175 (21%) in the no desaturation group.

14/30 (46%) patients in the desaturation group were aged 60 or over versus 47/175 (26%) in the no desaturation group.

Conclusion

The incidence of peri-intubation desaturation in our service is in keeping with previously published data.

There is a remit for examining other methods of pre-oxygenation in order to reduce the incidence of desaturation.

Patients with chest injuries and the elderly are more likely to desaturate in the peri-intubation period.

Background
Healthcare-associated infections (HAI) have a severe impact on patient outcomes, and high-quality hand hygiene (HH) is a valid preventive measure, but HH compliance in the emergency medical services (EMS) is inadequate. Thus, improvement is highly necessary. Few studies have investigated HH perception among EMS providers and those that have, report on challenges related to practical measures. No study has investigated motivational factors; thus in this study, we aim to quantify components of EMS providers’ motivation to comply with HH.

Methods
A cross-sectional, anonymous, self-administered questionnaire consisting of 24 items (developed from WHOs Perception Survey for Health-Care Workers) provided information on demographics, practical measures and various behavioral-, normative-, and control beliefs that determine intentions to perform high-quality HH among 6305 providers from Finland, Sweden, Denmark and Australia. Written and/or verbal reminders were provided at least one time during the study period from November 2017 to February 2018.

Results
A total of 933 questionnaires were returned (response rate 15%). Demographics: of the respondents, 795 (86%) were advanced-care providers, 746 (81%) male and 686 (75%) had > 5 years of EMS experience. In total, 563 (61%) had received HH training within the last three years, 858 (93%) perceived HH a regular routine. Practical measures: access to HH supplies was perceived effective to improve HH by 740 (82%) respondents, training and education by 488 (54%).  Behavioral beliefs: 452 (69%) estimated the annual HAI rate > 15%, 890 (97%) perceived HAI severe to patient outcome, and 903 (98%) perceived HH highly preventive. Normative beliefs: 510 (55%) believed that HH had a high organizational priority, 232 (26%) that HH was important to their managers, 330 (36%) to their colleges, and 526 (58%) to the patients. Also, 326 (44%) perceived their colleges HH compliance high (> 80% compliance rate). Control believe: 646 (71%) perceived HH easy to perform.

Moreover, organizational priority, colleges’ HH compliance, HHs importance to patients, being “a good example” and perceiving HH easy to perform were separately associated with a high self-reported HH compliance.

Conclusion
These results underline the need for practical measures such as access to HH supplies, simple and clear instructions and training and education, and is thus comparable to prior findings. Moreover, they illustrate that organizational priority, role models, and self-efficacy are motivational components that have the potential to empower HH compliance within this cohort. However, future interventional studies are needed to investigate the effect of a multimodal improvement strategy including both practical and behavioral aspects. 

Background: Opioid misuse is a growing public health challenge, with more than 4% of the adult United States (U.S.) population misusing prescription opioids. As deaths due to opioid overdose have risen, there has been growing momentum to increase public access to naloxone. Poison Centers (PCs) are in a unique position to track the trends of naloxone and the related outcomes. The objective of this study is to evaluate the use of naloxone in patients prior to communication with U.S. poison centers (PCs).

Methods: A retrospective study was conducted utilizing the National Poison Data System (NPDS). All cases where naloxone as therapy was performed prior to recommendation from PCs, also known as not recommended but performed (NRP), from 2000 through 2016 were evaluated. Descriptive statistics were used to analyze the characteristics of naloxone reports made to the PCs. Poisson regression models were used to evaluate the trends in the number and rates of reports, with percent changes during the study period being reported with the 95% confidence intervals (95%CI). Incidence of naloxone reports at the state- and national-level were calculated.

Results: There were 218,861 calls to the PC where naloxone was used as therapy prior to PC recommendation and these calls demonstrated a 4-fold increase from 5,693 in 2000 to 21,864 in 2016, despite an overall drop in PC calls during the same time period. Exposures mainly occurred at the cases’ residence (87.7%). Cases that received naloxone were predominantly between ages 20 and 39 years (40.9%) or 40 and 59 years (36.3%), with teenagers constituting 8.9% of the sample. The proportion of females (52.5%) was higher among cases. Multiple substance exposures accounted for 59.3% of the cases, with the number of substances ranging from 2 to 30.  Multiple substance exposures were more commonly seen in older age groups receiving NRP naloxone. In regards to severity, major medical outcomes were seen in 22.7% cases, while the cases fatality rate was 1.5% with 3,300 deaths reported during the study period. One-fourth of the intentional abuse cases exhibited major clinical effects. Hydrocodone (14.6%) and oxycodone (13.6%) were the most frequently reported opioid exposures that resulted in NRP naloxone therapy, while benzodiazepines was the most common co-occurring substance. The national incidence of NRP naloxone was 264.3 per 100,000 persons, with West Virginia being the state with the highest reported incidence. During the study period, the frequency of NRP naloxone increased significantly by 284% (95% CI: 272.9%, 295.4%; p<0.001), while the rate per 100,000 NPDS exposures increased by 271.8% (95% CI: 225.1%, 324.1%; p<0.001).

Conclusions:  There was an increasing trend of naloxone being administered prior to any communication with the PC. Cases demonstrated significant clinical effects with opioids as the most frequently reported exposures and attempted suicide being the most common reason for exposure. Though a potentially important measure to address the current opioid crisis, several challenges exist in expanding access to naloxone, including the appropriateness of use. PCs could play a key role in this process.

N/A

Background

United States (U.S.) drug overdose deaths have increased significantly over the past decade, in large part due to opioid overdose. Increasing access to naloxone, an opioid antagonist that rapidly reverses the effects of opioids, has been a key initiative in response to this crisis. Naloxone is touted as safe and effective in opioid overdose. However, data is lacking as to the adverse consequences associated with naloxone administration.  The objective of this study is to evaluate potential adverse events associated with the administration of naloxone.

Methods

We conducted a retrospective chart review utilizing data from a regional Poison Center (PC) associated with a single tertiary university health system. Toxicall^TM, a comprehensive case management software system used by 75% of U.S PCs, was queried for cases where naloxone was used as therapy from 01/01/15 through 12/31/16. Detailed case information was obtained by linking the PC exposures to the hospital records by utilizing the electronic medical record numbers. Cases were independently reviewed by two medical reviewers. Discrepancies were identified and resolved by a third reviewer.

Results

There were 132 cases of naloxone administration reported to the PC in the study period, with the majority in males (56.1%) between ages 20 – 39 years (41.7%). Of total naloxone administrations, 35/132 (26%) doses were administered to non-opioid exposures on final diagnosis, most commonly ethanol and benzodiazepine ingestions.  Multiples substances were reported or determined by analytics as used in 59.1% of cases. Complications following naloxone administration included agitation (17.4%), agitation requiring the use medical sedation (10.6%), and vomiting (2.2%). Four patients (3.0%) experienced severe agitation after naloxone administration requiring both sedation and intubation with mechanical ventilation. One patient vomited following naloxone administration, developed an aspiration pneumonitis on chest radiography and was subsequently intubated for hypoxic respiratory failure. The median dose of naloxone given was 0.8 mg (mode - 2 mg; range - 0.04 mg – 4 mg). Of patients with agitation, the median dose of naloxone was 1 mg, with 78.1% of doses given intravenous (IV), 17.4% given intranasal (IN) and 1 dose given intramuscular (IM). For the four patients intubated and placed on mechanical ventilation, the doses and route of naloxone were 1 mg IV, 2 mg IV, 1 mg IV, and 2mg IN followed by 2 mg IV, respectively.  Patients were admitted to an intensive care unit (66%), admitted to a general medical floor (12.1%), or were treated and released (15.9%). A significant number of administrations (24.2%) were to patients with a documented respiratory rate > 12/min just prior to administration. A pre-administration GCS > 14 or an assessment noting the patient to be alert and oriented to person, place and time was noted in 4.0% of administrations.

Conclusions

Naloxone administration, when given at appropriate rate and at dose for appropriate indications, is hypothesized to be safe and effective. However, when given in doses that precipitate opioid withdrawal, administration can be complicated by vomiting, aspiration (especially if another coexisting sedative is present), or marked agitation. Agitation often requires sedation and intubation/mechanical ventilation.

n/a

Title: Preparing the ground for ACORNS.

 

Authors: Dr. Harry Apperley MBChBS, BSc; Melanie Dias BSc; Michelle Riska; Dr Catherine Bevan, MBBS, MRCPCH-UK, FRACP

 

Background: The Department of Health reported that 26.5 % of Emergency Department admissions during 2014/2015 were attributed to under 20s¹. Reducing children’s Emergency Department (CED) admissions, by employing integrated care closer to home (ICCH), could potentially have a significant impact on the funding of the National Health Service (NHS). We evaluate the scope and effectiveness of the newly implemented Acute Children’s Outreach Nursing Service (ACORNS) at the RACH (Royal Alexandra Children’s Hospital), Brighton.

 

Methods: This retrospective observational study evaluated CED admissions before and after the implementation of ACORNS. CED admissions data collected on the ‘Symphony’ information management system was collated for the period October 2016 to January 2017 and stratified using Excel, where each attendance and outcome was reviewed. The attendances were filtered, and a final number of potentially ‘ACORNS eligible’ patients were determined. In the same period the following year, 2017-18, the performance of the newly instated ACORNS service was evaluated using the same criteria.

 

Results: Scope and effectiveness of service provision were assessed in context of the Department of Health ‘NHS at Home Children’s Community Service’ 2011 paper². In the four-month period October 2016- January 2017 there were 2012 admissions from 9352 attendances. Of these, 973 patients spent less than 24 hours on the Children’s Assessment Unit (CASU). According to our current ACORNS service model and capabilities, 841 patients would have been appropriate ACORNS referrals, using diagnostic criteria alone. During the period October 2017- January 2018 there were 172 patients seen by the service, accounting for 15% of the anticipated uptake according to attendances the previous year. One aspect of this performance difference is constraint due to current service limitations, such as postcode and time of attendance to CED.

 

Feedback on the service has been collated using Google Forms, with a response rate of 25%. Upon analysis of the feedback, 96% of service users rated ACORNS positively, describing the service as “extremely reassuring” and “very supportive”.

 

Conclusions:

Models concerning ICCH are deemed to be able manage up to 14% of CED admissions, according to recent literature³. It is possible the ACORNS model is not performing as anticipated due to geographical and time restrictions, which were not taken into account during the original analysis of the 2016-2017 data. The abundance of positive feedback obtained from service users indicates the ACORNS model is successful in its goal of reassuring parents/carers and treating patients outside the hospital setting successfully.

 

1.Lewis, L. & Lenehan, C. Report of the Children and Young People's Health Outcomes Forum 2013/14 [internet]. 2014. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/307011/CYPHOF_Annual_Report_201314_FORMAT_V1.5.pdf (last accessed 20 April 2018).

 

2. Department of Health. NHS at home: Children’s Community Nursing Services. London: Department of Health; 2011

 

3. Viner RM, Blackburn F, White F, Mannie R, Parr T, Nelson S, et al. The impact of out-of-hospital models of care on paediatric emergency department presentations. Arch Dis Child [Internet]. 2017;archdischild-2017-313307. Available from: http://adc.bmj.com/lookup/doi/10.1136/archdischild-2017-313307

INTRODUCTION 

Studies describing emergency medical systems are lacking in our country and especially if it’s about patients under eighteen. This sub-group had specific characteristics and needs such as specialized physicians, algorithms or equipment. Young and adult patients are managed by medical mobile units called SMUR for “service mobile d’urgence et de reanimation”.

The aim of our study was to describe the activity of the SMUR units managing patients under eighteen..

METHODS

Prospective and descriptive study over one year (January 2017-december 2017). Inclusion of all SMUR interventions on patients aged 18 or less. Collection of demographic and clinical data, times and medical and paramedical procedures performed with SMUR intervention. The activity was evaluated with Codage Activité SMUR score or CAS.

RESULTS

Inclusion of 109 patients. Mean age=11±5 years. Sex ratio= 1,48. Type of interventions n(%): primary 27(25) and transfers 82 (75). Age distribution [interval] n(%):[12-18years] 40 (37); [2-12years]32 (30); [0-28days]20 (18) and [29 days-2 years]16 (15). Seven interventions (6%) were cancelled. Eighty interventions (73%) were needed in hospitals and only 13% (n=14) at the patient’s home. Reasons for interventions (%): respiratory (28), traumatology (24) and toxic (19). Median CAS= 5 [IQR 4-14]. Median delay between ambulance dispatch and arrival at patient location was 10 minutes [IQR 0.05-0.20]; between arrival at patient location to receiving hospital registration was 57 minutes [IQR 0.57-1.21], between arrival at and departure from patient location was 15 minutes [IQR 0.08-0.25]. Procedures within SMUR n(%): oxygen therapy 9(8), intubation 4(4), sticking 10(9), intravenous drug 49(45), bronchodilators 3(3), point-of-care blood level 22(20), monitoring of vital signs 89(82) and electrocardiogram 2(2).

CONCLUSION

The pre-hospital management of young patients is specific. We reported more secondary interventions and respiratory diseases. The CAS score was mild.

 

Objective(s): To evaluate the effectiveness of a Rapid Assessment and Discharge (RAD) protocol to improve patient flow in the Emergency Department. Overcrowding in emergency departments (ED) is associated with both poor outcomes and a negative patient experience. Our aim was to reduce patient numbers seen in majors that do not ultimately require admission and so improve flow through the department. We proposed that ambulatory and non-elderly patients were more likely to be discharged, and of these a proportion could be managed without a bed.

Methods: A Rapid Assessment and Discharge (RAD) protocol for ‘walk-in’ patients was introduced in November 2017 with the aim of reducing the number of patients that progressed to the majors area. Patients were deemed suitable for RAD if they were under 75 and did not arrive by ambulance. These patients were investigated by doctors in assessment rooms within the waiting room and only progressed to majors for treatment that required a trolley. Using an interrupted time-series analysis, the primary outcome was total daily majors occupancy. Secondary outcomes were the percentage of patients seen and discharged within 4 hours and the proportion of patients that arrived by ambulance that were able to turnaround within 30 minutes.

Results: During the 3 months study period after the protocol was introduced, 9319 patients were seen in the majors area as opposed to 11146 of the attendances in the three months prior to the RAD intervention. We observed an average daily reduction of 17 patients seen in majors: this was a total reduction of 1653 patients and a mean daily reduction from 121 to 104 patients or 14% (p <0.001).

Conclusions: ED overcrowding continues to be a challenge. Lack of space means ambulances cannot offload their patients and sick patients that require treatment often have to wait for long periods until a bed becomes available. Majors overcrowding can be reduced by actively stratifying patients based on their likelihood of requiring admission or treatment in a bed in keeping with lean thinking principles of flow.

Background: Risk aversion amongst junior doctors, that manifests as greater intervention (ordering of tests, diagnostic procedures etc.) has been proposed as one of the possible causes for increased pressure and corwding in Emergency Departments (EDs) (NHS, 2017). In this study we explored the extent to which tolerance of uncertainty mediates the relationship between experience and risk aversion.  We predicted that doctors with more experience would be more tolerant of uncertainty and therefore less risk averse in decision making.

Method: In this cross-sectional vignette based study, doctors working in three EDs were asked to complete a questionnaire measuring experience, reactions to uncertainty (Gerrity, DeVellis and Earp, 1995) and patient management decisions. To assess the latter, doctors read four vignettes describing different patient presentations before rating the extent to which they agreed with four management plans, ranging from highly risk averse (additional investigations and admission to hospital) to decisions to redirect to GP with safety netting advice. 

 

Results: 92 doctors completed at least 50% of the questionnaire, representing an 80% response rate. Doctors had worked in the ED for a minimum of 5 weeks and a maximum of 21 years. We found a strong and significant association between experience and risk aversion so that more experienced clinicians made less risk averse decisions about patient management. We also found that experience was strongly and significantly associated with reactions to uncertainty, with more experienced doctors being much more at ease with uncertainty and being more open to disclose this to patients and colleagues. However, tolerance of uncertainty did not fully explain the relationship between experience and lower risk aversion. 

Discussion: We present some initial explanations of these findings and consider how we can support staff to deal with uncertainty in the early part of their careers. This is important, not least because coping strategies, may currently lead junior doctors to slow down the decision making process, resulting in the ordering of more tests and investigations in an attempt to reduce the anxiety associated with uncertainty. This, in a climate of stretched NHS resources, may become increasingly untenable.

Funded by NIHR YH CLAHRC, UK

Purpose: The aim of this study was to evaluate biomarkers’ diagnostic accuracy in identifying LV and RV systolic dysfunction during sepsis.

Methods: We included patients diagnosed with severe sepsis/septic shock and admitted in our ED-High Dependency Unit between August 2012 and February 2018, in whom an echocardiogram was performed within 24 hours from admission. We evaluated LV systolic function using Global Longitudinal Strain (GLS, > -14% diagnostic for LV systolic dysfunction) and RV systolic function with Tricuspidal Annular Plane Systolic Excursion (TAPSE, 0.1 µg/L; NTproBNP: > or ≤ 7000 pg/mL). Day-28 mortality was our primary end-point.

Results: we included 238 patients (mean age 73±15 yeras, male sex 58%, T1 SOFA score 6.0±2.9), 41% with septic shock, 28-day mortality rate 27%. Troponine (T0: 0.59±2.19 vs 1.7±8.2 ug/L; T1: 0.68±2.04 vs 1.52±5.08 ug/L) and NTproBNP levels (T0: 12421±19511 vs 24346±44189 pg/L; T1: 16760±60038 vs 26666±33423 pg/L, all p<0.05) were similar in survivors and non-survivors. Conversely, Troponine level was significantly higher in patients with impaired GLS, both considering continuous values (T0: 1.21±5.67 vs 0.23±0.67, p=0.04; T1: 1.21±3.81 ug/L, p=0.002) and dichotomized values (T0: Troponine ≥0.1 in 31% of survivors and 56% of non-survivors; at T1, 42 vs 61%, all p ≤0.01). T0 NTproBNP was significantly higher in patients with reduced TAPSE (26341±44025 vs 17127±64910 pg/L), while T1 levels were comparable between the subgroups. An NTproBNP>7000 pg/L was more frequent among patients with RV dysfunction (T0: 64 vs 38%; T1 67 vs 41%, all p <0.01), in patients with LV dysfunction (T1: 55 vs 37%, p=0.018). By an analysis with ROC curves, Troponine (T0: Area under the curve, AUC, 0.64, 95%CI 0.56-0.71; T1: AUC 0.65, 95%CI 0.58-0.73, p≤0.001) and NTproBNP (T0: AUC, 0.68, 95%CI 0.60-0.77; T1: AUC 0.68, 95%CI 0.60-0.76, all p<0.001) showed a fair discriminative value, respectively for impaired GLS and TAPSE. We compared biomarkers level among subgroups with increasing cardiac dysfunction: T0 troponine levels were comparable while T1 levels were higher in G3 compared with other subgroups (G1: 0.30±1.28; G2: 0.68±2.28; G3: 2.32±9.81, p>0.05 between G1 vs G3 and G2 vs G3). A Troponine >0.1 prevalence increased in different subgroups (respectively 29%, 55% and 52% at T0, p=0.005; 41%, 58% and 61% at T1, p=0.06). T0 NTproBNP was higher in G1 than in G3 (9164±15134 vs 27448±29116, p<0.05), while T1 levels were comparable between subgroups; an NTproBNP>7000 prevalence significantly increased in different subgroups (33%, 45% and 72% at T0; 33%, 48% and 75% at T1, p≤0.001).

Conclusions: Biomarkers levels were significantly higher in patients with impaired LV and/or RV systolic function, with a fair to good diagnostic accuracy.

Objectives:

Antiplatelet and anticoagulant medications are known to increase the risk of intracranial hemorrhage in patients with mild head injuries.  We sought to determine the incidence of traumatic intracranial hemorrhage (tICH) in patients taking antiplatelet agents, heparins, coumarins, and novel oral anticoagulants who presented to the ED after a minor fall.

Methods:

Retrospective review of routinely gathered operational data at a single facility without a trauma designation.  Minor falls were identified from chief complaints.  The use of anticoagulant or antiplatelet medication was determined from the patient medication list.  We hand-reviewed all charts for patients who were admitted or transferred, as well as all patients who returned to the ED within a 9-day period.  We defined tICH by presence of intracranial hemorrhage or contusion on computed tomography. 

Results:

There were 64,605 ED visits records in the 2-year period (January 1, 2015-December 31, 2016).  2403 patients met inclusion criteria by chief complaint, and 283 met criteria for hand-review.  Of the 283 patients who met criteria for hand review, 184 (65%) had CT imaging of the brain performed.  9/2403 patients (0.4%) were diagnosed with tICH:  5 patients with subdural hematoma, 2 patients with traumatic subarachnoid hemorrhage and 2 patients with intraparenchymal hematoma. One patient (0.04%) with a subdural hematoma required craniotomy. The rate of tICH in patients taking antiplatelet agents was 3.26% (7/215), compared to anticoagulants, where the rate was 3.81% (4/105). The rate of tICH in patients taking aspirin alone was 3.89% (7/180). One patient on DOAC (apixaban) had tICH (subdural hematoma), resulting in an incidence rate of 5%. 

Conclusion:

Traumatic intracranial hemorrhage is an infrequent complication of antiplatelet and anticoagulant use in patients with history of minor head trauma. In our study, the rate of clinically significant tICH requiring neurosurgical intervention was rare.

BACKGROUND: Analyse the emergencies of patients who die in the emergency department during 2 periods of time, to compare and detect possible failures.

 METHODOLOGY: Study of patients deceased in the Emergency Department during 2008-2009 and 2016-2017.

 Variables analysed: age, sex, length of hospital stay, place, cause of death, diagnosis; type of death, treatment, background, tests requested. Inferences through Chi squared.

 RESULTS: Assistances in 2008-09: 79,083 earnings / year. Mortality rate: 1.34 / 10,000. In 2016-17: 75,083; income / year. Mortality rate: 1.25 / 10,000 Exitus 2008-09:54, in Observation Area (OBS): 46%; Emergency Area (EA): 52%. Exitus 2016-2017:30; OBS: 55%; E: 45%. Average age 2008-09: 49 years (10-90years). Men: 53%, women 47%. Average age 2016-17: 63 years (0-99). Men: 68%, women: 32%. Exitus 2008-09: traumatic: 85%; not traumatic: 15; 2016-17: Traumatic exitus: 89%; non-traumatic exitus: 11% average stay

Hospital: 2008-09: 2 hours (h) (1- 46h), 2016-17: 6h (1- 48h). Exitus 2008-09: in 1ºh: 33%; 2º-3ºh: 25%; > 24h: 10%. Exitus 2016-17: 1ºh: 20%; 2ºh: 12% .3ºh: 12%, & 24h: 16%.

 Injury Severity Score (ISS) in 2008-09: 29; 2016-17: 25.RTS: 2008-09:9; 2016-17: 6

Survival probability (ps), based on RST and average ISS: 2008-09:25% (15% - 75%); ps & lt; 50%: 84%; ps> 50%: 16% (4 deceased with serious previous diseases with diagnosis:

polytraumatized (ps: 70%), 2 TCE in anticoagulant treatment (ps: 69% and ps: 69%) and traumatic tetraplegia (77%).

 In 2016-17 average ps: 7% (0% -85%); ps & lt; 50%: 79%; ps> 50%: 21% (5 deceased with serious illnesses previous and without anticoagulant treatment: presenting 2 limb fractures (82% and 79%); 2 by polytrauma: (73%, 85%), 1 by TCE (69%).

 Pathological history 2008-09: 75%, 2016-17: 69% with anticoagulant therapy 2008-08: 10% and 20016-17: 38%, prehospital treatment: 2008-09: 73%, and 2016-17: 70%. Urgent supplementary tests: 2008-09: RX: 71%; TAC: 71%; RNM: 2%; fast scan: 61% .2016-17: X-ray: 36%; TC: 52%, FAST SCAN: 44%.

 Reasons for income 2008-09: fall:24%, precipitation:12%, traffic accident:40%, illness previous:14%, burned:8%, aggression:2%. 2016-17: fall:42%, precipitation:11%, accident of traffic:22%, decompensated previous illness:10%, aggression:7% firearm wound attempt Autolysis:4% stab wound:4%

 Diagnostics 2008-09: dead on admission: 24%, polytraumatized: 32%; TCE: 26%; polytraumatized with TCE: 4%; traumatic tetraplegia: 2% neoplasia: 8% Weapon wound: 2% Cerebral vascular pathology: 2% and in 2016-17: dead on admission: 11%; polytraumatized: 7%; TCE: 39%; polytraumatized with TCE: 18%; stab wound: 7% Brain pathology: 7%, limb fracture: 7%, cardiac pathology: 4%

 There are no significant differences between ISS / hospital stay 2008-09: (p = 0.7677 chi-square: 235.29), 2016-17: p = 0.2031, chi-square: 24,000; anticoagulant tto / ps 2008-09: p = 0.9080, chi-square: 410.519, 2016-17: p = 0.6640 chi-square: 54.8462,

 

DISCUSSION AND CONCLUSIONS:

-Decrease in the number of annual deaths and the number of dead on admission, possibly due to more early and accurate diagnoses and treatments

-Reduction of the number of patients due to traffic accidents from 44% to 22%, probably due to the prevention campaigns.

-Increased anticoagulated patients but no death due to trauma, demonstration of the effectiveness of our traumatized coagulation control protocols

 

BACKGROUND Thromboprophylaxis for patients with nonsurgical isolated lower limb trauma requiring immobilization is matter of debate. Indeed, a randomized controlled study failed to prove the benefit of low-molecular-weight-heparin in unselected patients: the 3-month rate of symptomatic VTE was 1.4% in the treatment group and 1.8% in the control group.  Therefore, the conclusion of the recent Cochrane meta-analysis for VTE prevention in patients with lower-limb immobilization was that future research might provide more directives on specific advice for different patient types or patient groups. The risk of symptomatic VTE is probably not high enough to justify thromboprophylaxis for all of them. Current guidelines for thromboprophylaxis and practices vary widely among countries and centers, ranging from the absence of preventive anticoagulation in the United States to thromboprophylaxis for all patients for whom the plantar support is not possible in France.

Our aim was to develop and validate a clinical risk stratification model taking based on characteristics of Trauma, Immobilization and Patients (the TIPscore). 

METHODS Firstly, after a literature review, all identified thromboembolic risk factors have been submitted to expert opinion. The TIP score criteria and the cut-off were selected and ranged by consensus of international experts (n=27) using the Delphi method. Secondarily, Retrospective validation was performed in a population-based case-control study named MEGAstudy in Leiden. Thirdly, the usefulness of the score was assessed in a prospective monocentric observational cohort study. The primary endpoint was the thromboprophylaxis prescription rate in current practice compared to the theoretical prescription rate with TIP score. The secondary endpoint was the 3-month rate of symptomatic venous thromboembolism (VTE).

RESULTS After 4 successive rounds, 30 items constituting the TIP score were selected, with an absolute (> 90%) or strong consensus (> 75%). Thirteen items for trauma, three for immobilization and 14 for patient characteristics were selected, each ranging from a scale of 1 to 3.  In the validation case-control database, the TIP score had an AUC of 0·77 (95% CI 0·69-0·84). Using the cut-off proposed by the experts (≤4) and assuming a prevalence of 1.8%, the TIP score had 89.9%, 30.4% and 99.4% for sensitivity, specificity and negative predictive value respectively. In the prospective cohort, 84.2% (165/196) of concerned patients consulting emergency department patients had a low VTE risk not requiring thromboprophylaxis. One patient with a TIP score positive and who has not received thromboprophylaxis in current practice developed a proximal deep vein thrombosis. The 3 month-rate of symptomatic VTE was 0% [95%CI 0-2,3] in the subgroup of patients with a TIP score ≤ 4 and 3.2% [95% CI 0,2- 14.9] in the subgroup of patients with a TIP score ≥ 5.

INTERPRETATION For patients with non-surgical lower limb trauma and orthopedic immobilization, the TIP score allows an individual VTE risk assessment and exhibits promising results in terms of safety and usefulness for guiding thromboprophylaxis. It may lead to a significant reduction in the prescription rate of preventive anticoagulation by targeting safely the high risk patients; validating its major impact in medico-economic terms. A multicentric validation study is forthcoming.

Approval for the retrospective study on MEGA was obtained from the Medical Ethics Committee of the Leiden University Medical Centre, and all participants provided written informed consent. The pilot study was approved by the Ethics Committee (ID-RCB : 2017-A00291-52) and declared on clinicaltrials.gov before the inclusion of the first patient (NCT03089255). No author or their institutions have received: grants, consulting fees or fees, fees for participation in review activities such as data monitoring committees or statistical analyzes payments for writing or writing manuscript review, and / or providing editorial assistance, medication, equipment or administrative support.

[Background]

There is no strong evidence of protocolized mechanical ventilation weaning especially for septic patients. The aim of this study was to investigate the effectiveness of the spontaneous breathing trial (SBT) for mechanical ventilation weaning compared with mechanical ventilation weaning without SBT for septic patients.

[Methods]

Between 2016 and 2018, 38 consecutive septic patients who satisfied the awareness of  spontaneous awakening trial (SAT) protocol for over 24 hours and thought to be a candidate of mechanical ventilation weaning were divided into two groups: the SBT group (n = 23) and the non-SBT group (n = 15). Exclusion criteria were patients without sedatives and patients requiring daily wound management. A propensity score matching that incorporated age, sex and APACHE II score on admission day was performed. Clinical outcomes included the rate of extubation failure, ventilator days, lengths of ICU stay and in-hospital mortality. Statistical analysis was performed using Mann-Whitney analysis for numerical data, and Fisher’s exact analysis for categorical data.

[Results]

Thirteen patients in each group were selected after the propensity score matching. The SBT group had significantly shorter length of ICU stay (median, 3 d vs. 6 d, P = 0.04; SBT group vs. non-SBT group) and showed a tendency toward decreased ventilator days (median, 2 d vs. 5 d, P = 0.09). There were no significant between-group differences in the rate of extubation failure and in-hospital mortality.

[Conclusion]

The mechanical ventilation weaning protocol using SBT and SAT may reduce the duration of mechanical ventilation and the length of ICU stay in septic patients.

Tetanus is a potentially lethal disease that occurs after contamination of a wound with spores of Clostridium Tetani. At the beginning of the 20st century, the number of affected cases in Western countries, washigher than 50 per million of inhabitants. Now, thanks to the introduction of vaccination, the number of cases dramatically decreased to less than one case per million inhabitants. Tetanus prevention is currently performed according to the WHO regulations. If the patient doesn’t recall having undergone complete prevention or recent booster, the vaccine must be administered. If the wound is dirty, tetanus immunoglobulin needs to be administered as well.

Among the patients attending EDs, less than 10% bring with them a vaccination card. The accuracy of the clinical history collected from the remaining percentage of patients, is poor. Different studies showed that sensibility and specificity of clinical history are respectively 41% and 85%. As a consequence, many patients are unnecessarily vaccinated, whilst others don’t receive the necessary prevention. Tetanus prevention based solely on clinical history is expensive.

A Point-of-Care test (POCT)  that evaluates whether the patient has a protective level of tetanus antibodies, has been available at our centre for the past few years. The accuracy of this POCT is excellent. The sensibility and specificity are respectively of 93% and 94%. Given this level of accuracy, we decided to use POCT in our ED for tetanus prevention. The first cost benefit study realized before 2015, using Td vaccine as booster, demonstrated that tetanus prevention with POCT was cheaper than prevention performed following WHO regulations: $11.8 versus $13.1.

Since 2015, the rules of tetanus prevention recommend using TdaP vaccine as booster for patients that are not immunized. The TdaP booster is even more expensive than the Td vaccine ($19.2 versus $6).

We therefore carried out another cost benefit study on a large cohort of 6670 patients from 01/01/2015 to 30/06/2017. Using the POCT, the cost of prevention amounted to $13.8. The cost of tetanus prevention using WHO regulations was instead of $26.3.

 

Conclusion

Using POCT tetanus prophylaxis avoids unnecessary vaccinations and allows better and cheaper tetanus prevention.

 

 

Background: In the emergency department (ED), early identification and appropriate management of patients that require admission to a pediatric intensive care (PICU) unit is essential. Predictive scoring systems are measures of disease severity that are used to predict outcomes, typically mortality, of patients in the PICU. However, the scoring systems have not been validated in other hospitalized patients.  

Objective: To identify ED predictors related to an increased risk of death in patients admitted to a PICU.

Methods: Prospective registry based on observational cohort study including all patients admitted to the PICU from the ED between 2010 and 2017. Epidemiological and clinical data (including triage level with the Pediatric Canadian Triage and Acuity Scale, pediatric assessment triangle [PAT] and vital signs upon arrival, final diagnosis, treatments administered in PICU and evolution of these patients) were analyzed. To assess the independent association of previous variables with PICU mortality, we performed a multivariable logistic regression analysis. The significance level was set at P < .05 for all analyses.

Results: We included 718 children less than 14 years old, 402 male (56%), being the median age 27 months old (interquartile range 10-84 months). Around 50% of them were not previously healthy, 138 (19.3%) had previous admission to the PICU, 96 (13.4%) had previously visited an ED in the last 72 hours, and 345 (48%) were assisted previously being transferred by the family vehicle to the ED 102 (29.5%).

Upon the arrival to the ED, 330 (55.9%) were classified as I-II triage level and in 167 (23.3%) PAT findings were considered abnormal (respiratory distress 224, 31.2%, respiratory failure 103, 14.3%, and cardiopulmonary failure 61, 8.5%).

Respiratory infection/insufficiency (309, 43%) and non-infectious neurologic disease (105, 14.6%) accounted for more than half of the group of diagnosis of admitted patients; being the the asthma and bronchiolitis the most common diagnosis (148 [20.3%] y 92 [12.4%], respectively).

Seventy patients (9.7%) received inotropic support and 126 (17.5%) required mechanic ventilation.  Twenty-three patients died (3.2%, IC 95% 2.1-4.7). Multivariable logistic regression identified two independent risk factor for death: cardiopulmonary failure when evaluating the PAT (OR: 5.3, CI 95%: 2.1-13.4) and triage level= I-II (OR: 2.7, IC 95%: 1.1-7.2).

Conclusions: Tiage level and PAT upon arrival to the ED are related to the death of patients admitted to the PICU from the ED.

Introduction :

Acute poisoning with Cyproheptadine (CPT) has become frequent and potentially serious through neurological complications.

Despite the increase in the incidence of intoxication and the severity of this intoxication in Tunisia or the world, few studies have been interested in this molecule.

The purpose of this study was to identify epidemiologic characteristics and clinical outcomes in patients who were through CPT and to investigate any association between ingested dose and reported adverse events.

Methods

- We conducted a retrospective study at CAMU's intensive care unit over a period from February 2006 to March 2017.For each patient we collected the anamnestic data (age, sex, antecedents, the ISD and the delay between ingestion and management), clinical (mainly neurological and hemodynamic), biological (transaminases , arterial blood gases), therapeutic and progressive

RESULTS

We collected 47 patients (4 men / 43 women). The median age was 22 years [18; 33]. Pathological antecedents were psychiatric in 12% of cases (n = 6). All intoxications were voluntary. The median CPT ISD was 100 [40; 750] mg. The median consultation time was 3 h [1; 14].The IGS II score ranged from 6 to 38 with a median of 6.Metabolic acidosis was observed in 8.5% of cases (n = 4).The main clinical manifestations were impaired state of consciousness with Glasgow score (GCS) ≤ 11 in 4.3% of cases (n = 2), anti-cholinergic syndrome in 47% of cases (n = 22) and one sedative syndrome in 21% of cases (n = 10).For GCS comatose patients <= 8 there is a correlation between coma and the supposedly ingested dose of (CPT) with p = 0.03 .ASC = 0.91 and p = 0.01. The corresponding dose is 140 mg.There is a correlation between the dose of ingested antihistamine and obnubilation with p = 0.005 with AUC 0.83.There is a correlation between the dose assumed to be ingested and the tremor with a p = 0.008 AUC = 0.84.For a dose equal to 117 mg p = 0.003.

CONCLUSION :

Cyproheptadine is a widely available drug. Medical staff and parents should take special care in the management of cyproheptadine because it can be used in suicide attempts, especially by adolescents