Background and Objective

Neonates attending the paediatric emergency department (ED) pose challenges. The presenting problems differ from older children and are unique to this age group, prescribing requires attention to detail and consideration of physiological quirks and even resuscitation algorithms are irritatingly idiosyncratic. So who are these babies that are brought to the ED by their parents, what serious illness needs consideration and why are they attending the ED in the first place? We present a large data set with a view of identifying attendance patterns, population characteristics and potential pathway issues.

Methods

Retrospective review of all neonatal attendances (age less than 28 days) to the paediatric ED of a UK tertiary hospital during a two year period (01/04/2017 to 31/03/2019) from the electronic patient record database for age at presentation, presenting complaint, source of referral, length of stay in ED and disposal. Where necessary, individual records were accessed and any missing information added. Acuity of visits was determined by the need for admission, duration of in-patient stay and follow-up arrangements. 

Results 

1,699 attendances involving 1,467 neonates were identified, constituting 3.81% of all paediatric ED attendances (n=44,571) and 16.2% of all births in the hospital (n=10,515). The peak of attendance occurred at age 2-3 days, with over 60% presenting with jaundice. Monthly attendance mirrored the birth rate, there was no seasonal variation. The most common presenting problems were jaundice, respiratory symptoms, weight-loss and vomiting. Only 23.7% of all visits were self-referred. Most referrals came from midwifes (37.3%), other primary healthcare professionals (24.1%) and after contacting the UK’s 111 helpline (9.83%). 5.1% of babies came by emergency ambulance. As expected, the ratio of acute to non-acute visits was higher in referrals by ambulance (r=1.00) and primary healthcare professionals (r=0.808) compared to self-referrals (r=0.728) but not significantly so. On average, these infants spent 165 minutes in the ED. There were 111 breaches of the 4-hour target (6.42%). The admission rate was 42.1%, and the top reasons for hospital admissions were jaundice (44.3%), feeding problems (18.2%), respiratory (11.3%) and infection including suspected sepsis (7.97%). 32.9% of neonates admitted were discharged within 48 hours of admission. 4 deaths including two neonatal sepsis deaths were identified, both of which had disseminated Herpes-Simplex Virus (HSV) infection. 

Discussion

ED attendance is common during the neonatal period, notably over half of the visits are for non-acute complaints and do not require immediate medical intervention except parental reassurance.

The large number of jaundice-related attendances calls for a review of the jaundice care pathway. We will be discussing possible interventions that may help reduce unnecessary attendances in the ED like feeding support following postnatal discharge and improved awareness of neonatal normal variants by primary care professionals.

We suggest that the current referral algorithms for the UK's national telephone advice service 111 may significantly increase inappropriate ED attendances.

The neonatal deaths due to sepsis were both caused by HSV infection, our local incidence matching published evidence and we postulate Aciclovir to be first-line treatment in neonates presenting with sepsis to ED.

Background and Objectives

Complications related to ventriculoperitoneal shunt (VPS) are common, and multiple revisions are almost expected throughout a patient's lifetime. Standard noncontrast head computed tomography (CT) that is currently the gold standard for diagnosis of VPS dysfunction, consists of an average of 35 to 40 sequences and causes severe radiation exposure. However, it is stated that the evaluation of four sequences which show 4 ventricles, 3 ventricles, lateral ventricles and basal ganglia may be sufficient for the diagnosis of VPS malfunction. This may significantly reduce the radiation exposure. The aim of this study was to determine the feasibility of the four-sequence limited head CT for predicting VPS malfunction.

Methods

We performed a retrospective analysis of the PED medical records (MRs) between January 2013 and December 2017 that involved all patients who received a head CT for suspected VPS malfunction. MRs were reviewed to describe demographic, clinical characteristics surgical interventions and full head CT reports. For all enrolled patients, a limited series was generated from the last CT scan by selecting four representative axial slices based on the sagittal scout image. Four slices selected at the level of the fourth, third ventricle, basal ganglia level, and lateral ventricles, respectively. A blinded neuroradiologist evaluated the limited 4- slice CT to determine the VPS malfunction. After this review, we compared the standard full head CT reports with the limited 4- slice CT, and analyzed the sensitivity and specificity of the 4- slice CT to predict VPS malfunction. We also calculated the real 4 –slice CT sensitivity and specificity for children  who received surgical shunt revision.

Results

A total of 164 patients were enrolled in the study. The mean age was 54 ± 24 months and 85 (52%) were males. The most common presentation complaints were vomiting (27%) and seizure (17%). V-P shunt revision was performed in 60 patients (37%) as a result of clinical and radiological evaluation. When we compared the standard complete head CT reports with the limited modality, the limited 4-slice CT had sensitivity, specificity 83% and 97% respectively, for the evaluation of the changes in ventricular size. However, when the analyze performed based on surgical V-P shunt revision, only one case would have been missed with the limited 4-slice CT. The  sensitivity was 98% and specificity 78%. The effective dose (ED₅₀) of limited 4-slice head CT was 0.32 mSv, while the ED₅₀ of the standard head CT was 2.7 mSv. In this way, the prefer of a limited head CT instead of a complete head CT may provide about 88% reduction in radiation dose.

Conclusion

The present study demonstrates that utilization of limited head CT scan in the evaluation of children with suspected VPS malfunction is a feasible strategy for the evaluation of the ventricular size as well as prediction of surgical intervention. Further prospective, well designed studies are needed to evaluate the reliability of limited head CT for the clinical evaluation of VPS malfunction.

Background and Objectives: Mobile intensive care units frequently manage unplanned out-of-hospital births (UOHB). Rewarming methods during pre-hospital management of UOHB have not yet been compared. The aim was to compare rewarming methods used during pre-hospital management in a large prospective cohort of UOHB in France.

Methods: We analyzed UOHB from the prospective AIE cohort from 25 prehospital emergency medical services in France. The primary outcome was the change in body temperature from arrival at scene to arrival at hospital. Our database was approved by the French Data Protection Authority and by a French research ethics committee. Maternal consent was systematically requested before or during birth management (left at the physician’s discretion).

Results: From 2011 to 2018, 1,854 UOHB were recorded, of whom 520 were analyzed. We found that using incubator care was the most effective rewarming method (+0.8°C during transport; P < 0.001), followed by the combination of plastic bag, skin-to-skin and cap (+0.2°C). The associations plastic bag + cap and skin-to-skin + cap did not allow the newborn to be warmed up but rather to maintain initial temperature (+0.0°C). The results of the multivariate model were consistent with these observations, with better rewarming with the use of an incubator (Adjusted temperature difference = +0.33 95CI(0.13; 0.52)). According to the classification and regression tree (CART) method, we also identified circumstances of increased risk of hypothermia according to classification and regression tree, like premature birth (< 37 weeks of gestation) and/or low outside temperature (< 8.4°C).

Conclusions: Using an incubator was the most effective rewarming method during pre-hospital management of UOHB in our French prospective cohort. Based on our model, in cases of term less than 37 weeks of gestation or between 37 and 40 weeks with a low outside temperature, using such a method would be preferred.

Background:

Paediatric cervical spine injury (CSI) is rare but can have devastating consequences. In an attempt to identify all children with CSI, many children are assessed for possible injury and may either be “clinically cleared” or receive imaging to exclude radiologically apparent injury. Clinical decision rules (CDRs), or proposed rules, are commonly used to guide imaging decisions despite limited evidence for their use in paediatric populations.

Objectives:

To determine the frequency of previously identified risk factors for CSI in children presenting to a single Australian centre and to assess the performance of commonly used CDRs or proposed rules when strictly applied to our population, including the projected impact on imaging rates if these CDRs were strictly applied.

Method:

Prospective observational study across one year of all children under 16 years presenting to Emergency Department (ED) with possible CSI as defined either immobilization for possible CSI, neck pain the context of trauma or otherwise considered at risk by the ED team. Those with imaging prior to arrival were examined as separate cohort. CDR variables for the National Emergency X-ray Utilization Study (NEXUS) rule, Canadian Cervical Spine Rule and proposed Paediatric Emergency Care Applied Research Network (PECARN) rule were collected prospectively and applied post hoc.

Results:

1010 children were enrolled; 973 had not received prior imaging. Of these 973, two thirds were male, median age was 10.9 years and 16% were aged under 5. 40.7% received imaging of their cervical spine with 32.4% receiving X- Rays, 13.4% Computed Tomography and 3% Magnetic resonance imaging. 5 children had CSI.  Nine children of the 37 with prior imaging had CSI.

 All 3 CDRs identified the 5 children with CSI who had not received prior imaging (Sens 100%, 95%CI 56-100). The NEXUS rule did not identify 2 out of the 9 children with prior imaging. 

If strictly applied as a rule for imaging, all 3 CDRs or proposed CDRs would increase imaging rates in our setting, with individual CDR guided rates ranging between 44 and 68%. Despite these higher projected imaging rates, and while all but 2 imaged children were positive for at least one of the three rules (i.e. imaging indicated according to the CDR), no single rule suggested that all children  imaged in current practice should actually be imaged; individual NEXUS and PECARN CDRs were  positive in 82 and 91% of those imaged respectively.

 Conclusion:

Paediatric CSI is rare, and while many children are clinically cleared without imaging, a considerable percentage receive imaging for relatively few injuries detected. CDRs have been proposed to guide imaging decisions, however the use of those currently available to the paediatric practitioner, could, if strictly applied, result in more children receiving imaging than occurs in current practice. Research with a larger cohort is required to assess whether a more refined CDR can be designed to limit discomfort, cost and radiation exposure, and to formally determine the performance of current rules (including sensitivity in injury detection) in the paediatric setting.

Background: Due to existence of nuclear power plant sites in various parts of the world, as well as political threats in disaster-prone areas throughout the world, there is a probability of nuclear and radiation incidents. The present study was carried out with the purpose to extract effective criteria in emergency department preparedness of hospitals in radiation, nuclear incidents and nuclear terrorism in different countries around the world.

Methods: A systematic search was carried out in Cochrane Library, PubMed, Scopus, Science Direct, Web of Science, ProQuest and EmBase databases between January 1970 to July 2018. The systematic search was carried out according to the PRISMA standard. The required information was extracted from the papers based on the abstract and collection form.

Results: After searching the databases, 1091 papers were finally extracted. The initial search included research papers. After reviewing the papers’ titles, abstracts and full texts, 15 papers were selected for final analysis. Next, 32 criteria were extracted. The criteria were divided into 3 categories. The categories included staff, stuff and systems (structure). The most frequent criteria included training criteria, personal protective equipment, decontamination and practice.

Discussion and Conclusion: The results of the systematic review provided an overview of the effective factors in improving the emergency department preparedness during radiation and nuclear incidents. In addition to the mentioned criteria in different studies, there are other hidden factors that affect the emergency department preparedness in radiation and nuclear incidents, thus, the highest level of preparedness should be considered.

Introduction: In case of mass casualty incident (MCI) abroad, medical assistance companies are entrusted to provide a rapid and appropriate response. In addition to a standardized and regularly updated operating process, exercises are key component to ensure performance. The purpose of the present report was to evaluate the effectiveness of our primary casualty plan on our different platforms around the world.

Methods and Setting: Our medical assistance company is present in 28 countries but only 5 large regional platforms are accredited to deal with MCIs. A primary casualty plan, common to all entities, governs all aspects of MCI management (activation, coordination, forwarded team on the spot, relation with Foreign Affairs, communication with media…) under the responsibility of the Group Medical Direction. The present simulation was a tabletop exercise (no field deployment). The scenario was a terrorist attack (fire arms, no bomb) in a touristic place in Senegal with 10 killed and 20 severely injured people from 6 different countries. Coordination of the exercise was performed by the Group Medical Direction with the help of an external team of facilitators located in the country of occurrence, following a detailed chronogram and giving inputs/responding to the different platforms involved. There were also observers on each platform. The exercise was kept secret toward platforms. The main evaluative criterion was the concordance between the response each platform provided and the primary casualty plan (considered as the standard). 

Results: Alert was sent to 6 platforms with victims involved at 8:00 GMT on Sept 19, 2018. After 60 min, 1 regional platform had implemented a specific desk with dedicated staff, activated the local medical correspondent, contacted the other platforms within its region and the other regional platforms, and been in touch with Foreign Affairs Ministry. This platform was designated as leading platform for the entire group. After 90 min, this leading platform had collected a brief description of injuries for all victims and initiated local evacuations for those who required urgent/invasive procedures. One of the doctors of the team was ready to fly over there for local coordination of repatriation, agents having flight options ready. Secrecy was disclosed at this point and exercise ended.

Discussion: This simulation clearly identified platforms in which our primary casualty planis mature and those that need further attention or training. Since most managers and head of platforms were not present at the time of the exercise, it was also interesting to challenge on how not to rely on them. Also the email server of the company was down that morning, which invited to further think on communication tools. Formal debriefing was conducted with heads of platform and chief medical officers 10 days after the exercise and improvement measures were discussed and decided. The program of simulation will be continued.

Background

Somatic complaints (i.e., somatization symptoms and pain) in survivors of natural disaster are frequent symptoms and a complicating factor in the treatment of these patients.

The main objective of this study is to analyze the prevalence of possible somatic complaints in survivors during phase 3 post Typhoon Haiyan 2013 in the Philippines.

Methods

One month after-disaster, between 23th of November  and 22th of December  2013, ARES Emergency Medical Team Type 1 Fixed have managed health care of survivors in Esteban – Burauen (Leyte - Eastern Visayas) and collected data: anagraphic data, prevalent symptoms and final diagnosis of these survivors. We defined pssible psychosomatic complaints those cases in which the prevalent symptom was either chest pain or abdominal pain or headache or malaise or hypertension and it was not possible to obtain an organic diagnosis after the diagnostic pathway. We analyzed the prevalence of psychosomatic complaints in our population and by using simple logistic regression we looked for predictive factors for or against the diagnosis of psychosomatic symptoms.

Results

1890 patients were visited: median age 31 (standard deviation 24), 54% female. 407 patients (21%) had possible somatic symptoms (40% abdominal pain, 25% chest discomfort/pain and palpitations, 19% headache, 11% malaise and 5% hypertension). 225 of these 407 patients (55%) were diagnosed as psychosomatic complaints (12% of the entire study population). The predictive factors for diagnosis of psychosomatic symptom were: malaise with OR of 1.40 (95% CI 1.15-1.71, p<0.01), headache with RR of 1.34 (95% CI 1.11-1.62, p<0.01), abdominal pain with RR of 1.06 (95% CI 0.89-1.26, p=0.5) and hypertension with RR of 1.25 (95% CI 0.91-1.72, p=0.2). The predictive factor against diagnosis of psychosomatic symptom was chest discomfort/pain and palpitations (RR 0.54, 95% CI 0.41-0.73, p<0.01).

Discussion and conclusions

The importance of diagnosing a psycosomatic complaint in patient who experinced natural disaster is the possibility of special treatment options. In the literature the prevalence rates of psycosomatic complaints, such as patients presenting persistent pain symptoms, after natural disaster range from 10 to 50%. Our data confirmed this moderately high prevalence,  in particular in a selected subgroup of patients with pain and/or malaise.

Introduction:

While an emphasis has been placed on the importance of personal protective equipment (PPE), there are no standardized PPE training guidelines for EM physicians, though many hospitals require brief in-person annual trainings.  Physicians’ response to hazardous material events require PPE utilization to ensure the safety of victims, facilities, and providers; therefore, providing effective and accessible training is crucial. In the event of a real event, circumstances may not allow for an in-person presentation and an accessible video training may provide a useful alternative.

Methods:

A randomized trial was performed with sixteen EM residents divided into two sets of groups, with Groups 1 and 2 viewing a demonstration video and Groups 3 and 4 receiving a separate in-person training. The groups then donned and doffed while blinded evaluators assessed critical tasks utilizing a prepared evaluation tool.

Results:

Donning

During donning, the four groups were evaluated on fourteen individual critical tasks.  These tasks were meant to happen in sequence and were specifically included in both the video and in-person trainings.

Groups 1 and 2 (video trained) had a total of nine failures out of fifty-five evaluated possibilities - an error rate of 16.0% (95% CI 11.2% to 32.0%).  Frequently failed tasks involved checking the PAPR for functionality, and not performing a final Buddy check prior to entering the decontamination showers.

Groups 3 and 4 (in-person trained) had a total of eleven failures out of fifty-six evaluated possibilities - an error rate of 19.6% (95% CI 8.6%-28.5%).  Most frequently failed tasks also involved PAPR inspection and final Buddy check but had additional common failures in checking vital signs and providing hydration during the process.

Using a Fisher’s exact test to compare the number of failed demonstrated a two-tailed P value of 0.81, demonstrating no statistically significant difference between donning errors in the two sets of groups.

Doffing

During doffing, each of the four groups were evaluated on eleven individual critical tasks, also meant to happen in sequence.

Groups 1 and 2 had a total of fifteen failures out of forty-four evaluated possibilities with an error rate of 34.1% (95% CI 21.8% to 48.9%).  The failed tasks were largely evenly distributed.

Groups 3 and 4 had a total of twelve failures out of forty-four evaluated possibilities - an error rate of 27.3% (95% CI 16.2% to 42.0%).  Frequently failed tasks involved the removal of the PAPR hood and rechecking vital signs.

A Fisher’s exact test demonstrated a two-tailed P value of 0.64, showing no statistically significant difference in doffing errors between the two sets of groups.

Discussion:

In this pilot study, video and in-person training were equally effective in preparing residents for donning and doffing Level C PPE, with no statistically significant difference between the error rates in each modality.  Further research into this subject with an appropriately powered study is warranted to determine if this equivalence persists.

Background:

Intern doctors are required to complete a term of at least eight weeks in emergency medical care in Australia to gain general registration.  This requirement along with a significant increase in medical graduates in recent years has created challenges in delivering a quality educational experience for intern doctors rotating through busy emergency departments.  This study attempts to assess the effectiveness of a blended emergency medicine intern education program that incorporates web-based learning into traditional classroom-based didactic sessions.

Methods:

This prospective study involved a convenience sample of intern doctors doing their emergency medicine term at two urban Australian emergency departments between April 2015 and January 2017.  Participation in the study was voluntary.  The Emergency Department General Education (EDGE) program is an emergency medicine intern education program that utilises a blended curriculum which incorporates web-based modules into weekly didactic and skills sessions.  All intern doctors rotating through the emergency departments of each study site hospital are given protected off the floor time each week to attend the program's educational sessions.  The program runs throughout the ten-week emergency medicine term and is run five times each academic year.  All interns are given access to the program's corresponding web-based learning modules (www.moodle.learnem.com.au) with completion of the web-based material being voluntary.

To assess change in medical knowledge base during the program, participants were administered two multiple choice examinations covering a variety of emergency medicine topics at the beginning (Week 1) and during the final week (Week 10) of the term.  To determine the study's primary endpoint, the impact of the program's web-based resources on improving participants' emergency medicine knowledge base, the median % of online modules completed by participants (75%) was used as a cut off to create two groups; those that completed < 75% and those that completed >75% of the web-based modules.  Student T-test was used to compare the improvement between Week 1 and 10 scores for all interns as well as the improvement between the two groups.  Mean Week 1 and Week 10 examination scores, Standard Deviation, and 95% confidence intervals (CI), were carried out for the two groups.  Intern satisfaction with the program was also assessed using a satisfaction survey.

Results:

The Average examination score obtained in Week 10 (80%) for all participating interns (N=85) was significantly greater than that achieved in Week 1 (68%; P<0.001).  The % improvement between the Week 1 and Week 10 scores of those that completed <75% (N=42) of web-based modules (16% mean; 95% CI 12-20%) and those that completed >75% (N=43) of web-based modules (27% mean; 95% CI 20-34%) showed a statistically significant difference (p=0.03).  Interns when surveyed were also highly satisfied with all aspects of the EDGE program. 

Discussion & Conclusions:

Educational programs that incorporate web-based learning into didactics have several advantages over traditional lecture-based education and have shown promise in the literature.  This study of a blended curriculum that utilizes web-based learning material shows promise in enhancing intern emergency medicine education.

Background: Clinical supervision (CS) is an important foundational requirement to maximize education and assure patient safety. The resident supervision index (RSI) has been proposed as a validated tool in GME programs in the United States to measure the quality of CS. CS in a busy emergency department (ED) setting can be challenging due to the demands of clinical service.

Aim/Objectives: The Impact of Clinical Supervision Shifts on the RSI in the ED

 Method: We implemented special four hours shifts to commit faculty time for CS and measured its impact on the RSI. The study was done in a busy academic ED in Qatar with an annual patient attendance of around 450,000 and staffed by around 240 emergency medicine (EM) physicians including 48 residents and 58 fellows.

Results: A total of 336 responses of individual CS encounters were collected over a period of 8 months of CS shifts. The CS encounters were a mix of case discussion, review of test results, supervision of clinical procedures, WBAs and Ultrasound. The faculty was fully involved in patient care in 20.8% of encounters, partially involved in 46.4% and offered advice in 25.6%. The CS contributed to the understanding of the case by the supervisee in 94.0%. The CS resulted in significant impact on all aspects of the RSI – changes were noted in history in 12.2%, examination findings in 14.4%, interpretation of diagnostic data in 23.1%, diagnosis in 13.6%, overall assessment in 21.6% and in the management plan in 35.1%.

Discussion:  Unlike other instruments to assess the quality of supervision, RSI provides quantitative measures of resident supervision. Better supervision will help residents to become skilled physicians and will also help the importantly in patient care.

Conclusion:  

CS shifts in a busy ED resulted in a significant overall impact on the RSI and have the potential to offer major benefits to the educational experience of learners and to patient safety.

 Further studies are recommended to assess the use of RSI to assess outcomes of educational programs on patient’s outcomes

Backgrounds and Aims: Adrenaline is administered to patients with out-of-hospital cardiac arrest (OHCA) after basic life support and/or advanced airway management. Time interval between start of CPR by emergency medical service (EMS) and adrenaline administration varied depending on regions, levels of EMS and circumstances of OHCA. It is not rare that ECG rhythm conversion from the initial rhythm to other rhythms are recorded during the BLS period. The first goal of basic and advanced life supports in OHCA cases is sustained return of spontaneous circulation (SROSC) although benefit of each resuscitation procedure should be determined by neurologically favourable outcome. This study aimed to identify the factors associated with SROSC in OHCA groups with adrenaline administration before and after hospital arrival (prehospital and in-hospital first adrenaline groups), with consideration of ECG rhythm changes before adrenaline administration.

Methods: In this retrospective analysis of prospective data collection, we extracted the data for 3,729 adult (≥ 8 y) OHCA cases with adrenaline administration before hospital arrival and 4,070 cases with adrenaline from the population-based OHCA data that were prospectively collected during the period of 2011‒218. Univariate and stepwise multivariable logistic regression analysis were applied to disclose the factors associated with SROSC.

Results: The rates of ECG rhythm conversion in prehospital and in-hospital first adrenaline groups correlated with the initial rhythm (P <0.01): 59.5% and 72.9%, respectively in cases with ventricular fibrillation/tachycardia (VF/VT) as initial ECG rhythm , 24.3% and 43.0% in pulseless electric activity (PEA), 7.0% and 5.6% in asystole. In univariate analyses, both initial rhythms and the last rhythms recorded before first adrenaline administrations were associated with SROSC (P <0.01). However, the rate of SROSC was highest when the initial ECG rhythm was VF/VT (43.1% and 35.9%, in prehospital and in-hospital first adrenaline groups respectively) and when the last rhythm recorded before adrenaline administration was PEA (46.1% and 35.9%.respectively). Stepwise multiple logistic regression analyses revealed that PEA as the last rhythm recorded before adrenaline administration was better predictor of SROSC than VF/VT as initial ECG rhythm and that an interaction for SROSC exists between the initial and last ECG rhythms. Any prehospital defibrillation attempt before the first adrenaline administrations was not a major factor associated with SROSC: P = 0.23 and P = 0.69, in prehospital and in-hospital adrenaline groups, respectively. The overall rate of SROSC in the prehospital first adrenaline group (24.9%, 928/3729) was higher than that in the in-hospital first adrenaline group (15.8%, 644/4070).

Conclusions: Rhythm conversions to PEA before first adrenaline administration are likely to be associated with SROSC. PEA as the last rhythm recorded before adrenaline administration is a good predictor of SROSC.

Background: According to current literature a limited compression ultrasound (LCUS) protocol is safe to diagnose or exclude lower extremity deep venous thrombosis (DVT). It is a good option to a whole leg ultrasound performed by a radiologist especially in remote health care units where the availability of radiological services is limited and also in emergency department performed by emergency physician (EP).

Objective: To determine whether teaching LCUS to general practitioners (GP) reduces the number of patients with a suspected lower extremity DVT referred to a hospital for US examination safely.

Methods: During 2015-2016, a physician with 5 years of experience in diagnostic US (author Hannula) trained the GPs (n=13 working in Saarikka Primary Care Public Utility (catchment area 18.000 inhabitants) to use LCUS. The number of annual referrals due to a suspected DVT from Saarikka to the closest hospital were evaluated before and after training. The incidence of DVT was considered to be constant, thus the reduction of referrals was interpreted to happen because these patients were diagnosed and treated in primary health care without referring them to hospital. Safety was evaluated by examining all patients from Saarikka area who were diagnosed pulmonary embolism (PE) in nearest hospital during study years and following 3-month periods. Also patients referred to consultant radiologist were examined to find any possible false negative DVTs in LCUS.

Results: In 2014, the number of annual referrals due to a suspected DVT was 60. In 2017 the amount had reduced to 16 with a decrease of 73,3%. The incidence of referrals per 1000 person-years decreased from 3.21 to 0.89. (IRR 3.58, 95% CI 2.04 – 6.66, p<0.001). The annual numbers of PEs were 12 and 23 respectively. None of PE patients had a LCUS performed prior to diagnosis.  There were 13 and 16 referrals to consulting radiologist respectively with no false negative DVTs found.

Conclusions: Teaching a LCUS protocol to GPs seems to effectively and safely reduce the number of referrals to hospital due to a suspected DVT.

Background:

Apoptosis of CD4⁺T cells plays a central role in the progression of sepsis because it is associated with subsequent immunosuppression and the lack of specific treatment. Thus, developing therapeutic strategies to attenuate apoptosis of CD4⁺T cells in sepsis is critical. Several studies have demonstrated that Mdivi-1, which is a selective inhibitor of the mitochondrial fission protein dynamin-related protein 1 (Drp1), attenuates apoptosis of myocardial cells and neurons during various pathologic states. The present study revealed the impact of Mdivi-1 on apoptosis of CD4⁺T cells in sepsis and the potential underlying mechanisms. We hypothesized that Mdivi-1 ameliorated apoptosis in CD4⁺T cells by re-establishing mitochondrial fusion-fission balance and preventing the induction of endoplasmic reticulum stress in experimental sepsis.

Methods:

It is an original study. We used lipopolysaccharide (LPS) stimulation and cecal ligation and puncture (CLP) surgery as sepsis models in vitro and in vivo, respectively. Apoptosis and cell viability of CD4⁺T cells were assessed by TUNEL assay and CCK8 assay. Protein levels were measured by western blotting. And mitochondrial morphology was observed by electron miscrosope.

The data were represented as the mean ± standard deviation (SD) using PSS (version 20.0). A one-way ANOVA was used to analyze significant differences between three or more groups and an unpaired Student’s t-test was used to analyze significant differences between two groups and significance was defined as P<0.05. GraphPad Prism 6 (San Diego, CA, USA) were used for the figure design.

Results:

Firstly, Mdivi-1 increased the cell viability of CD4⁺T cells and attenuated apoptosis of CD4⁺T cells both in vitro and in vivo. Secondly, the potential mechanism underlying the protective effect of Mdivi-1 involved Mdivi-1 re-establishing mitochondrial fusion-fission balance in sepsis, as reflected by the expression of the mitochondrial fusion proteins MFN2 and OPA1, Drp1 translocation, and mitochondrial morphology, as observed by electron microscopy. Moreover, Mdivi-1 treatment reduced reactive oxygen species (ROS) production and prevented the induction of endoplasmic reticulum stress (ERS) and associated apoptosis. After using tunicamycin to activate ER stress, the protective effect of Mdivi-1 on CD4⁺T cells was reversed. Together, Mdivi-1 attenuated apoptosis of CD4⁺T cells is probably through re-establishing mitochondrial fusion-fission balance and prevented the induction of ER stress.

Discussion and Conclusion:

Recent studies and clinical findings have demonstrated that apoptosis of T lymphocytes has a considerable involvement in immunosuppression and is critically related to the outcome of sepsis. Here, our study showed that apoptosis in CD4+ T cells was increased after LPS administration and CLP surgery. Consequently, it is urgent to develop novel therapeutic strategies to attenuate apoptosis in CD4+ T cells during sepsis to affect the outcome. Our results demonstrated that Mdivi-1 protected against apoptosis of CD4⁺T cells and balancing mitochondrial fusion-fission and preventing the induction of endoplasmic reticulum stress in experimental sepsis are probable mechanisms involved in it. Mdivi-1 is a probable novel therapeutic strategy that targeted apoptosis in CD4⁺ T cells to affect the outcome of septic patients.

Background

Intravenous drug users (IVDUs) commonly present to the emergency department (ED) complaining of pain and/or swelling in the groin after recent injection. Clinicians concerns include necrotising fasciitis, psuedoaneurysms, abscess and DVT. There is little data available on how common these diagnosis are or what antibiotics to give. Therefore, decisions regarding imaging, antibiotics and specialty involvement are challenging. This study aimed to address this by answering the following questions: what is the best antibiotic to give, do they need imaged in the ED and how do we identify the particularly sick patient?

Methods

This was an observational study of patients presenting to the ED at a large tertiary hospital in Aberdeen, Scotland. Those patients that were included attended the ED between 1^st January 2015 and 31^st December 2016 and had a diagnosis of ‘local infection of skin and cutaneous’, ‘cellulitis’, ‘other bacterial infections’, ‘cutaneous abscess’, ‘necrotising fasciitis’, ‘septic shock’ or ‘septicaemia’ or had a CT or USS in the ED.

Patients who did not present with pain and/or swelling of the groin and a history of recent intravenous drug injection were excluded, as were those with no microbiology samples.

The remaining group consisted of 30 patients. Documentation, radiology and laboratory results were analysed for these patients.

Results

Within the 30 patients, 13 different combinations of antibiotics were administered. 11 patients were bacteraemic. Samples obtained from blood cultures, deep tissue samples, pus/fluid samples and superficial samples all grew similar organisms, with a significant presence of anaerobes, as well as Staphylococcus, Streptococcus and gram negative bacteria.  

3 patients had a pseudoaneurysm (one of which was not identified on CT as an abscess was compressing the vessel), 5 had features of necrotising fasciitis on CT and required multiple debridements, 1 had necrotising myositis, 12 had an abscess and 11 had a DVT. 6 required HDU or ICU care.

Patients with significant pathology were difficult to recognise. Most were given a low triage category, had relatively normal observations and only mildly raised lactates even if they ultimately required theatre from the ED and then ICU. A LRINEC score of ≥ 6 or 8 was not a good discriminator of need for urgent theatre but none of those who had a score of <6 had time critical findings on CT or at theatre. In 4 out of the 5 cases of requiring urgent repeated debridments in theatre, the CT in the ED did change management because it had not been clinically apparent how significnant the pathology was.

17% of these patients have subsequently died (as of January 2019).

Conclusions

Based on the organisms that were grown and the resulting sensitivities, if the patient does not warrant necrotising fasciitis specific antibiotics, Flucloxacillin 2g IV and Metronidazole 500mg IV are advised, with Vancomycin to be used in cases of penicillin allergy.

A substantial proportion of these patients will have significant time-critical pathology and it is challenging to clinically identify this. We therefore propose that all these patients should have CT angiography in the ED.

INTRODUCTION

The bacteriemia is an important cause of morbidity and mortality in spite of the availability of a powerful antimicrobial therapy and the advances in the support attention. In the Hospitable first aid services, after the clinical evaluation of the feverish syndromes there is habitual the achievement of complementary tests, between which they emphasize the capture of hemocultivos.

TARGETS 

Main: To evaluate the patient's profile with bacteriemia in our health area 

Secondary: To determine the most frequent comorbidities that these present.

METHODOLOGY 

Observacional has designed an epidemiologic study to himself with retrospective character, in our hospital that is classified as of the second level and a population of 250000 inhabitants attends. The firs aid service receives approximately 9000 urgencies a month. There were selected patients who consulted for feverish syndrome in the year 2017 and it extracted them to itself hemocultivos. There were checked the case histories of the chosen episodes, variables being gathered as: age and sex, microorganism that isolated itself in the hemocultivo, pathologies previous to the patients, established treatment, I number of returns and mortality.

 RESULTS 

131 patients included with hemocultivos positives. The entire distribution of the sample for sex belonged to 73 males (55,7 %) and 58 women (44,3 %), being the median of age of 76 years, the minimal age 11 and the maxim 97. Of the obtained sample, 14 patients re-entered after being discharged and the mortality in whole was 10,7 %.

As for previous pathologies that they were presenting, it was obtained that 80 (61,06 %) was diagnosed of HTA, their 25 (19,08 %) of DM. As for the cardiovascular diseases, their 28 (21,37 %) had arrhythmias precedents, 6 (4,58 %) had suffered previous IAM, 7 (5,34 %) was presenting cardiovascular disease and 9 (6,87 %) heart failure. If we speak about respiratory illnesses, we are that their 19 (14,50 %) had been diagnosed previously of EPOC and 3 (2,29 %) of bronquiectasias. As for the renal illnesses, 28 of them were presenting ERC (21,37 %), receiving 4 of them hemodiálisis. If we speak about present digestive illnesses in our patients' sample, their 5 (3,81 %) was presenting hepatopatía established and 2 (1,52 %) ulcus. Finally as for the illnesses of neurological origin, their 23 (17,55 %) was presenting cerebrovascular illness and 20 (15,26 %) dementia.

CONCLUSIONS 

The bacteriemias collaborate to a high morbimortalidad incidence. In our series we obtained that the patient's profile is usually a 76-year-old male, with some associate comorbidity, being the pathology more often associated the HTA. On having analyzed the most frequent pathologies for systems, we obtain that the most frequent pathology associated with our patient's profile is that of cardiovascular origin, followed by the neurological one, in the third place the renal one, being the least frequent the digestive one

Background: A three-level subjective triage was used to sort patients at the Emergency Department of University Hospital Motol, Prague, until 2018. P1 priority was defined as an emergency (a life- and/or health-threatening condition) to be seen by a physician immediately, P2 as an urgent case to be seen within an hour and P3 as conditions where the care can be delayed according to the current capacity. This was replaced by an objective triage using Emergency Severity Index v. 4 in 2018. Results of both approaches were compared during a one-month period.

Methods: Triage nurses were instructed to triage all the patients using both conventional subjective triage (P1-P3) and ESI v. 4 (P1-P5) and record both the priorities during December 2017. Former subjective P1 priority was replaced by P1 and P2 priorities, P2 by P3 and former P3 by new categories P4 and P5. Their decision making was supported by a paper ESI flow-chart and a computer application.

Results: Both priorities were recorded in 1,010 out of total 1,782 patients (56.7 %), 376 out of them were admitted to the hospital (37.2 %). The average priority using a subjective triage was 2.37 (median 2) and 3.11 using ESI (median 3). The correlation between both priorities was 0.71 (p < .00001). The new ESI priority was, in comparison to the previous subjective triage, lower in 62.9 %, the same in 35.0 % and higher in 2.1 %. A priority obtained by a subjective triage corresponded to ESI as stated above in only 62.2 % cases, in 33.7 % cases (340 cases, 139 out of them were admitted to the hospital, i.e. 40.9 %) it can be evaluated as a possible undertriage and in 4.1 % cases as an overtriage.

Background: The aim of this study was to assess the benefit of direct ICU admission from the emergency department (ED) compared to admission from wards, in patients with hematological malignancies requiring critical care.

Methods:Post hoc analysis derived from a prospective, multicenter cohort study of 1,011 critically ill adult patients with hematologic malignancies admitted to 17 ICU in Belgium and France from January 2010 to May 2011.The variable of interest was a direct ICU admission from the ED and the outcome was in-hospital mortality. The association between the variable of interest and the outcome was assessed by multivariable logistic regression after multiple imputation of missing data. Several sensitivity analyses were performed: complete case analysis, propensity score matching and multivariable Cox proportional-hazards analysis of 90 day-survival.

Results: Direct ICU admission from the ED occurred in 266 (26.4%) cases, 84 of whom (31.6%) died in the hospital versus 311/742 (41.9%) in those who did not. After adjustment, direct ICU admission from the ED was associated with a decreased in-hospital mortality (adjusted OR: 0.63; 95%CI: 0.45-0.88). This was confirmed in the complete cases analysis (adjusted OR: 0.64; 95%CI: 0.45-0.92) as well as in terms of hazard of death within the 90 days after admission (adjusted HR: 0.77; 95%CI 0.60-0.99). By contrast, in the propensity score matched sample of 402 patients, direct admission was not associated to in-hospital mortality (adjusted OR: 0.92; 95%CI: 0.84-1.01).

Conclusions: In this study, patients with hematological malignancies admitted to the ICU were more likely to be alive at hospital discharge if they were directly admitted from the ED rather than from the wards. Assessment early predictors of poor outcome in cancer patients admitted to the ED is crucial so as to allow early referral to the ICU and avoid delays in treatment initiation and mis-orientation.

Background

Patients in the emergency department (ED) need a diagnostic work-up from complaints upon presentation to a correct treatment. The intent is to recognize frequently occurring diagnoses and to not miss serious, potentially life-threatening disorders. Emergency physicians continuously refine information to rearrange the probabilities of seriousness and likelihood of potential diagnoses. They consider the patient characteristics and results of technical investigations and implement clinical decision rules. However, the environment of the ED (e.g., the availability of resources) and the personal characteristics of the physician (e.g., experience, memory, interpersonal skills) also contribute to the decision-making.  Therefore, a secondary source of knowledge proposing the next activity to perform (e.g. take an X-ray) and reflecting all preceding experiences with similar patients in the setting of the specific ED would be an improvement.

Methods

Design Science methodology was applied to develop techniques that generate recommendations for the next activity to be executed for patients in an ED, using a combination of historic data, process management and machine learning. In this project, historic data were used from the ED of the Maria Middelares hospital in Ghent, Belgium consisting of 41657 patients. For each patient, the timeline of all registered events in diagnosis and treatment was reconstructed, starting from the registration at the entrance and ending with either a discharge or hospital admission. Additionally, keywords (e.g., “anemia” in the medical history) and other data values (lab and X-ray) were identified.

Forty strategies that each prioritize different similarities between the current and historic patients based on either activities, data or both, were prototyped to generate probabilities that serve as next-activity recommendations. They were trained on a subset of the patients and evaluated by comparing the predicted with the actual next activities of the other patients. The evaluation criteria were the calculation time and five performance measures:  rank, accuracy, brier score, log loss and rank score.

Results

The Design Science methodology identified 1350465 data events with 625758 activities and 117 unique activities in patient timelines with a maximum of 128 subsequent activities. The best performing strategy achieved an average top ranked recommendation accuracy of 60% and the correct next activity was ranked in the top 3 on average, with an average calculation time of less than 0.4 seconds.

Conclusions and future directions

The proposed strategies were fast and sufficiently accurate to help remind emergency physicians of alternatives or forgotten activities, without impacting their decision freedom. These experiments are to be seen as operational process support, i.e. not to try to impose a specific diagnosis or therapy but merely suggesting suitable next activities. It could prevent medical errors and promote a more uniform diagnostic approach. Future research is aiming to further improve the accuracy of the first recommendation and to allow the introduction of clinical pathways. The ultimate goal is to provide real-time recommendations for the possible next-step activities of all patients present at the same time in the ED and for the prioritization of patients, based on their characteristics and results of their preceding processes.

Background

In line with global trends, European countries have witnessed increase usage of Emergency Departments (ED) services for low acuity complaints. Research on ED utilization in Europe has shown that AS comprise a greater proportion of non-urgent ED visits. Although a variety of factors associated with the use of ED services for low acuity complaints, studies have yet to examine the reasoning underlying hospital-based ED usage for low acuity complaints among patients with asylum seeker (AS) status.

Methods

We conducted a prospective cross-sectional, single center study. Data was collected during 01/12/2016 and 31/07/2017 among AS and Swiss residents attending the ED of the University Hospital, Bern (Switzerland). The survey included questions about motives to present in the ED for low acuity complaints, patients and the treating physicians were asked to answer a questionnaire.

Study participation was voluntary, free of any compensation and individual verbal and written patient consent was obtained before answering the survey. The study was presented to and approved by the regional ethics committee of the Canton of Bern, Switzerland.

Results

AS and Swiss residents differed in several reasons for seeking care in the ED. 30.2% of the AS patients reported to have no knowledge about the Swiss healthcare system (HCS). The perception of medical urgency as reported by the AS and the treating physician showed a significant mismatch, e.g. only 14.2% of the AS-patients perceived their problem as non-urgent in contrast to 43.3% given by the treating ED physician.

With more than half of the AS, direct communication was impossible and in 70.2% of this cases family and friends were used as translators.

Outcomes, like length of stay (LOS), discharge type, and time of visit did not differ between the two groups.

Conclusion

Lacking knowledge about the healthcare setting in the reception country, language barriers, and the perceived urgency of medical care are the main reasons for AS to seek care in ED for primarily low-acuity medical issues. In both groups, convenience and the perceived level of urgency played a role in the decision-making to present themselves in the ED.

Measures to increase health literacy and provision of easily accessible primary care could improve quality of care and reduce the usage of ED as primary care providers in AS. Implementation and usage of professional translator service will relieve family and friends from this role and might provide better and equal care.

Background: In European countries, an increasing number of patients consult the emergency department (ED) instead of a general practitioner for non-urgent primary medical care. These patients may benefit from ED-based preventive care but overloaded ED physicians are reluctant to be involved. The primary objective of this study was to evaluate the proportion of patients accepting a preventive care intervention using a digital tablet (DT) during their ED visits; the secondary objective was to evaluate the proportion of patients benefitting from counselling.

Methods: Single-center observational study conducted in the minor section of a tertiary-care ED in August and September 2018. Inclusion of consecutive patients ≥18 years with decision-making capacity, admitted during the investigator's presence (rotating 8-hour shifts within a 24h/7d schedule). The DT presented a menu of nine validated health questionnaires with, after completion, a personalized report with health recommendations based on individual scores, and links to support material or details of specialized services. The report could be printed or emailed to the patient.

Results presented as proportions, mean and standard deviation (SD) or median and interquartile range (IQR). The ethics committee approved this study.

Results: 500 eligible patients were approached and 317 (63%) included. Median ED length of stay: 5.2h (3.7; 7.6). Mean age: 44 ± 17 years, women: 45%; 98% Swiss residents; 54% professionals and 20% retired; 27% with a postgraduate degree, 83% registered with a GP, of whom 84% had visited at least once in the preceding year. Patients filled a median of 4 (2;9) questionnaires. Questionnaires presented by frequency of choice: 1) physical activity 71%: 55% below the recommendation of ≥2x30 minutes/week of moderate activity; 2) alcohol consumption 62%: 55% at-risk drinkers; 3) 62% tobacco: 53% active smokers and 58% contemplating smoking cessation; 4) diabetes 62%: 14% at high risk of developing diabetes, with 62% accepting a bedside capillary glucose check with one new diabetes diagnosis; 5) vaccination status 60%: 24% not up to date; 6) colon cancer 56%: 26% of those aged 50-69 years never screened by colonoscopy or fecal occult blood testing, and 14% having failed to keep up with screening schedules; 7) HIV 50%: 40% accepting a rapid non-targeted opt-in capillary test; no reactive test;7) interpersonal violence 46%: 21% victims of verbal and/or physical violence, of whom 10% wished to discuss this issue with the ED physician; 9) drug misuse 48%: 35% reporting recent misuse.

Discussion & Conclusions: A majority of patients accepted a digital screening and health-counseling offer, and 50% chose at least four domains. The questionnaires revealed that a significant proportion of this mostly young and active ED population could benefit from advice to improve their health. Although we did not measure the long-term impacts of our intervention, a significant proportion accepted immediate bedside tests for diabetes and HIV. Our results suggest that a DT screening offer would allow the ED to play a complementary role in promoting health in Switzerland. However, further research on its clinical impact is needed before widespread dissemination of this intervention is attempted in Swiss EDs.

Background:

Six years ago a mass casualty incident digitalization project began under the acronym SICAD. The aim of the project was to completely transform the mass casualty incident management on the field and remotely by using current communication technology. This implies using a mobile and server solution as well as electronic patient tags. After a long period of extensive testing of all modules and given several technical drawbacks due to the complexity of the overall solution, a completely redesigned project emerges to carry on the future version of the initial project. The new solution is renamed EMERSYS and it is designed primarily for the use of Romanian emergency agencies.

Methods:

The technical backbone of the previous solution was redesigned in terms of modularity and interconnectivity. Initial requirements for the software solutions are set, allowing for each module to receive and output data independently. The previous Parse.com database integration is completely replaced by an SQL database. Trafficked data is managed by a store-and-forward algorithm in order to maintain a steady flow of operation despite probable moments of lack of data signal. Data logging is significantly augmented. The solution also expands in terms of purpose to several individual applications – mobile and web-based – to address both professionals and bystanders. Improvements are also integrated in terms of power efficiency, graphics, software solution size and operation optimization and security.

Results:

Three distinct packages are set. EMERSYS ONE is an entry level pack designed to digitize the mass casualty incident paper chart and integrate several electronic patient tags. It comprises of a dedicated mobile app for prehospital physicians and paramedics and a web-based app for data output. EMERSYS TWO is a professional pack designed to integrate the majority of functions of the project. It addresses all professionals involved as well as bystanders and it comprises of a dedicated extensive mobile app and six distinct web-based apps: 112 Dispatch, Hospitals, Analysis, Press, Simulator and Backoffice. EMERSYS THREE is based on the same structure as the previous pack but it allows for more advanced algorithms and functions for a more detailed integration of the event digitalization.

Discussion & Conclusions:

The current EMERSYS project carries on the purpose of the previous project to take full advantage of the current technology, especially mobile communications technology. Current work is under way to allow for full offline operation. Further tests are also necessary in order to assess a reliable operation of all packs. Moreover, there is a strong need of simulation by professionals and tech team alike, as well as integrating their feedback. This report refers to the current progress in terms of the overall structure and design and modules operability.

Background: Smartphone applications (apps) have been increasingly utilized by physicians as a tool to supplement and support clinical practice. Barriers to utilization include cost of purchasing the app, user friendliness, lack of specific content, and timeliness of software / content updates. Pediatric Emergency Medicine (PEM) is a specialty that could benefit from a customized mobile app, given nuances in clinical management such as medication dosing or unique age-specific pathology. The purpose of this study was to understand the needs of post-graduate learners as it relates to PEM resources to aid in clinical practice.

Methods: This was a prospective study, and institutional Research Ethics Board approval was obtained. The survey was sent out to all current Emergency Medicine and Pediatrics residents at McMaster University, Canada. Survey questions were related to type of residency, year of training, smartphone and app utilization, and desired content for a new app. For the desired content, participants were requested to list their top 5 items and the responses were then grouped using a theme analysis.  

Results: A total of 35 responses were received (33.7% response rate). 31.4% were from Pediatrics residents, with the remainder from Emergency Medicine. Eighty percent of respondents used Apple’s iOS as their mobile operating system with the remainder using Google’s Android. The top three most commonly used apps were UpToDate (51.4%), MDCalc (42.9%), and Spectrum (22.9%). Spectrum and MDCalc are both free applications available on both platforms, while UpToDate is only offered by paid subscription (whether individually or through an institution).  From the desired topics, the top five themes were related to medication dosing (71.4%), appropriate antibiotic choices (65.7%), treatment algorithms (25.7 %), electrocardiogram (ECG) references (22.9%) and vital sign reference ranges (22.9%).

Conclusion: While there is an abundance of clinical resources available to trainees, mobile apps are a great resource for just-in-time reference. This study provides a starting point to identify what trainees are looking for in an app that is specific to PEM, and can be used to either build a new app or add to an existing one. Further studies would be helpful in understanding the actual utilization of such a resource.

BACKGROUD

Improving patients flow throughout the Emergency Department(ED) is a desirable goal to reduce overcrowding, morbidity and mortality, and to improve patients and operators satisfaction. Several interventions can be made to reduce the throughput patient flow. Our ED is provided with a rapid assessment area (RAA) after standard first level nurse-led triage. Since November 2018 a senior doctor, so called facilitator, was placed in the RAA. The aim of this study was to compare the waiting-to-be-seen time and ED length of stay (LOS) before and after this intervention.   

METHODS

This is a retrospective cohort study conducted in the ED of the San Martino University Hospital, a tertiary referral centre located in Genoa, Italy, accounting of 90.000 annual visit rates. We analysed data of all ED presentations during 5 months before (from November 2017 to March 2018) and 5 months after (from November 2018 to March 2019) the facilitator implementation. Using our local software, waiting-to-be-seen time (from triage registration to first medical contact) and LOS (from triage to ED discharge) of all patients were analysed. The intervention consisted of the presence of the facilitator in the RAA from Monday to Friday for 6 hours/day meeting the peak demand periods since 1^st November 2018. Before this date RAA was nurse-led. His function was to commence a diagnostic and treatment plan then reviewed by other physicians. We analysed the times according to the four-grade priority scale attributed at triage as RAA manage the two middle grade of the scale (yellow and green codes) leaving the higher and lower grade (red and white codes respectively) to other pathway. Ethical approval was not needed as non clinical study. Waiting-to-be-seen time and LOS (in minutes) were normally distributed and compared with Student’s t-test.

RESULTS

We analysed 38.402 and 44.204 ED visits from pre and post-facilitator implementation respectively. Waiting-to-be-seen time for yellow and green codes was reduced of 21,3% (from 103 to 81 min,p<0.05) and of 23,1% (from 157.5 to 121min,p<0.05) respectively. LOS for yellow and green codes was reduced of 23.2% (from 328 to 251.7 min,p<0.05) and of 17.3% (from 303.6 to 250.8min,p<0.05) respectively. Red codes waiting-to-be-seen time increased from 6.6 to 10.6min whilst their LOS reduced from 205,6 to 181min (-17.9%). Similarly white codes waiting-to-be-seen time increased from 120.1 to 122.3 and LOS reduced from 205,6 to 181min and from 197.3 to 172.6 min(-14.6%). 

DISCUSSION & CONCLUSION

We found a reduction of both waiting-to-be-seen time and LOS during facilitator implementation period for yellow and green codes whilst red and white codes didn’t seem to be affected in their waiting-to-be-seen time but we  found a reduction in their LOS. This may be related to a beneficial indirect effect of the facilitator on the other physicians reducing their workload for each patient. Even if many other variables should be taken into account, according to these results facilitator helped to significantly boost ED patients’ process. Management of ED patients flow is an important instrument to reduce overcrowding and further strategies should be sought and implemented.

Abstract: Approximately 12% of patients are admitted at their initial emergency department (ED) presentation with renal colic. After revisit this percentage increases to 33%. Currently there is no clinical prediction model that explains the probability of admission. In 2015, a multivariate analysis was published as an impetus for further research. A retrospective cohort study was conducted at the emergency department (ED) of the UZ Brussel, identifying clinical risk factors for hospitalisation. Using clinical parameters, we can only explain half the variance, implying that other factors contribute significantly to hospitalisation in renal colic.

Methods: On the retrospectively collected dataset comprising 1207 ED visits, descriptive statistics via chi-square for categorical and one-way ANOVA for numerical variables were performed. Four binary multivariate logistic regression analyses were used to identify contributing factors to hospitalisation.

Results: On average, hospitalised patients were 5 years older than patients who received outpatient care.  There is also an increased likelihood of hospital admission at revisit, previous history of renal colic, intercurrent urine tract infection, and hydronephrosis. The total equivalents of morphine recieved are 2,9 ± 0,61 mg for outpatients and 11,0 ± 1,18 mg when hospitalised (n = 1207, p <0,001). Overall admission ratios correspond to literature: 12.5% after the first visit and 31.7% on second presentation at the ED. This percentage doesn’t increase with subsequent revisits.

The first multivariate analysis identified the following relevant clinical parameters as contributor to hospitalisation: age, revisits, use of pain score, use of diclofenac, paracetamol, anti-emetics, tamsulosin, morphine equivalents received (Nagelkerke R² = 0.481). The second used radiological stone characteristics (Nagelkerke R² = 0,121). A calculus of <5 mm is a predictor for outpatient treatment, whereas a stone size >20 mm increases likelihood of inpatient treatment, as is hydronephrosis. The location of the calculus in the pyelo-urethral system was not significant. Laboratory results were used in the third analysis. Combination of C-reactive protein (CRP), presence of acute kidney injury (AKI) and a positive urine culture were significant predictors. Total white blood-cell count (WBC) was a non-significant contributor. (Nagelkerke R² = 0.124).  The final model combined all significant predictors from the previous analyses, achieving Nagelkerke R² = 0.51.

Discussion: These results imply that radiological stone characteristics can only explain variation in hospitalisation or outpatient treatment to a limited extent. Combined with the clinical parameters described above, approximately 50% of the variation in admission number can be explained. Most of these parameters are related to analgesic therapy, so analgesic optimisation is of paramount importance. In our opinion the use of diclofenac and paracetamol does not increase hospitalisation probability; Rather, analgesic therapy is improved upon admission.

Conclusion: With hard-clinical parameters only half the variance can be explained, implying that other factors that were not taken into account in this study may contribute significantly to hospitalisation in renal colic.

Introduction: Pain is one of the main reasons for consultation in the Emergency Department, reaching 42.8% of patients who require medical assistance.

Objective: To evaluate the perception and management of pain by healthcare professionals in the Emergency Department of the “Hospital Universitario de La Ribera” (Valencia-Spain)

Methodology: A descriptive, prospective and analytical observational study was performed. Data collection was carried out by means of a survey in which respondents were asked about the transmission of information to the patient on aspects related to pain, systems used to categorize pain, knowledge of protocols and their use in fixed and rescue guidelines, their registration, the system used for their evaluation in the patient, the need to prevent pain, the adequacy of pain treatment in the service and the possibility of improving its approach.

A univariate descriptive analysis and an analytical study were carried out in order to explore whether the professional category influenced the perception and management of pain.

Results: 74.25% of the service workers, mostly women, with an average age of 37.013±10.85 years, were interviewed. The most representative group was nurses (52%). The transmission of information to the patient on aspects related to pain refers to being carried out mainly in a non-written form (always 16%, almost always 38.67% and sometimes 28%). The EVA and EVN scales were the most used to categorize pain in the communicative patient (52% and 41.3% respectively). 53.33% of the participants did not use any method to categorize pain in the non-communicative patient. 61.33% know pain control protocols and use them in both fixed and rescue guidelines. Pain is assessed more frequently by asking the patient than by physiological records. 57.3% consider that pain management in the unit is almost always adequate and 44% think it can always be improved.

Analysis by professional categories showed significant differences in the variables need to promote and prevent pain (p=0.048) (higher in the physicians and lower in the auxiliaries), a system used to categorize pain in the communicative patient (p=0,001) (doctors indicated the EVA scale and nurses the EVN scale), pain recording frequency (p=0.016) (nurses refer to always recording pain and doctors some or few times) and pain evaluation frequency asking the patient (p=0.04) (much higher in nursing assistants and lower in doctors).

Conclusions:

In the Emergency Department of the “Hospital Universitario de la Ribera” pain assessment and treatment should be improved in order to unify criteria among professional groups and establish a systematic way of dealing with pain according to the type, severity and characteristics of the patient, implementing and using protocols to improve the approach to pain in patients.

Background

Acute pain is common in emergency patients.  Acute pain management is an important area for research with previous reports highlighting poor pain management impacting negatively on patient experience, but obtaining consent in these circumstances is challenging. For patients experiencing a health emergency, the capacity to make decisions regarding analgesia and to consent to participate in research can be affected by many factors including co-morbidities, stress, emotion and the illness or injury itself. Consent waivers are often granted in seriously compromised patients, but this process is less clear when the patient is conscious but in severe pain. Furthermore, little is known about the patient perspective. 

Methods

A face to face survey was completed from February to April 2019 in a UK major trauma centre ED by two interviewers. Additional physiological information was collected from the pre-hospital and hospital patient care record. The survey was approved and registered with University Hospitals Plymouth NHS Trust, CA_2018-19-12.

Participants were identified through convenience sampling using the inclusion criteria: aged 18 years or over; Glasgow Coma Scale of 15; presented with a traumatic injury or abdominal pain; had been conveyed to hospital by ambulance; and could recall their pre-hospital treatment. Participants provided verbal consent to be interviewed. Bias between interviewers was minimized through set questions. 

The primary outcome was to determine if participants felt they could have provided informed consent at set time points. Secondary measures included patient demographics, physiological and pain data, analgesia and patient perspective comments from open questions. 

Results 

37 participants were surveyed (20 female, 17 male, aged 18 to >85 years). 95% reported past medical problems, 92% were taking one or more regular medications, with 38% on regular analgesia. Abdominal pain made up 78% (n=28) of participants. 

87% of respondents received analgesia in the pre-hospital setting. 97% thought that research to improve acute pain management was a good idea. 

78% reported that pain was at its worst before receiving pre-hospital analgesia and 13% reported it was worse on transfer to, arrival at or in the ED. Pain scores were not recorded in 2 participants at initial pre-hospital contact, 6 participants following initial analgesia and in 10 participants at ED triage. 

Regarding decision-making for written informed consent, 24% felt they couldn’t have provided consent prior to receiving pre-hospital analgesia, which decreased to 11% after initial pain relief and to 5% in the ED. Comments were themed around inability to process, understand and retain information due to pain. 84% reported that they would have been happy to have consent delayed until arrival at the ED; those with concerns reported medical history, drug interactions and allergies as important considerations. 

Conclusion

Emergency care analgesia research is important to patients, and several factors influence a patient’s perceived ability to provide informed consent including environment, pain and pre-existing conditions. When planning analgesia research, patient involvement is key to determining the informed consent process. 

Aim:

To describe the indications, used medication and safety of procedural sedation in a Belgian University Hospital Emergency Department.

Methodes:

We performed a prospective observational cohort study of all patients who underwent procedural sedation and analgesia in a Belgian Emergency Department between April 2017 and April 2018. Standardised forms were used to collect data on patient demographics, indication, performed procedures, used medication and the occurence of adverse events classified by the SIVA adverse event reporting tool.

Results:

171 patients were included in the study. Median age was 53 years, 56% were male. 40% of patients were ASA class 1, 37% were ASA class 2 and 22% were class 3 or higher. The majority of the patients underwent procedural sedation for cardioversion (34%), reduction of fractures (30%) or dislocations (26%). Propofol and ketamine were the most frequently used medications. Adverse events occured in 12% of cases, mostly due to apnoea (33%), hypoxia (19%) and emesis (19%). All of the adverse events were transient. None of the patients suffered an adverse outcome.
Logistic regression analysis revealed ASA class 3 or higher as independent risk factor for adverse events (p=0.023).

Conclusion:

This Belgian cohort study supports the results of international studies showing that procedural sedation in the emergency department is safe, with a 12% adverse event rate and without occurence of adverse outcomes. In line with previous studies, ASA class 3 or higher was found to be an independent risk factor for advers events.

INTRODUCTION: The widely used standard avalanche triage algorithm (Bogle 2010) does not include provision for mass casualty incidents (MCI) nor does it detail the use of extra corporeal membrane oxygenation (ECMO). This study aimed to produce a reliable and validated triage tool for use in avalanche MCI that included updated recommendations for the use of ECMO– the Cardiac Arrest Avalanche Triage Tool (CAAV).

METHODS: The CAAV tool was developed by a focus group of four experts in avalanche rescue. To assess the validity of the tool, four other experts who had never seen the tool used the tool to assigned a triage category to 45 simulated cases and to compare to their own expert opinion. Reliability of the tool among these experts was calculated using the Fleiss test. To assess the accuracy of the tool in a broad population of rescuers an online simulation was given to avalanche rescue providers who were asked to triage 39 simulated cases using the CAAV tool: results were compared to the triage categories given by the four experts.

RESULTS: The CAAV tool is available at www.medstatstudio.com/studies/project.php?pid=19 . When experts used the tool it agreed with their expert opinion in 97% of cases (95% confidence interval: 93% - 99%). Inter-rater reliability for the experts was 0.86. Among the 115 avalanche rescue providers who completed the online simulation, triage assignment using the tool was correct in 63% (95% confidence interval: 57% to 68%). Only 43% of the non-expert participants had accuracy of greater than 80%.

CONCLUSIONS: In this study the CAAV tool showed adequate validity and reliability in expert hands. However, in the broad population of rescuers the tool showed poor accuracy. Further refinement of the tool and simulation testing procedure is clearly necessary before moving towards trials in the field.

BACKGROUND

Major incidents (MI) occur with little or no warning. During an MI emergency department (ED) registered nurses (RN) are among the first to receive, assess and treat patients. Emergency department RNs’ emergency operating plan (EOP) competencies are crucial in effectively mitigating somatic and psychological afflictions that patients may present to the ED. While previous research has indicated the ED nurses’ disaster competencies are low, little is known about the current state of emergency department registered nurses’ EOP competencies in Sweden.

AIM

To assess emergency department registered nurses’ EOP competencies.

METHOD

Study design: A cross sectional online survey was conducted during a six-week period between January and February 2019. Purposive criterion sampling method was utilized in recruiting participants.

Participants:  All registered nurses’ (n ≈ 370) employed at six participating emergency departments in the region of Stockholm, Sweden were included.

A total of 100 questionnaires were completed (response rate = 28%). Competencies were rated utilizing a five-point Likert scale based on Benner’s competence model of clinical competence.

The primary outcome variables are five competencies concerning ED EOPs. 1. Content of the EOP 2. Areas of responsibilities. 3. Differences between decision making processes in the Incident Command System for a major incident vs. non-emergency situations. 4. Hospital levels of preparedness and its significance. 5. Decontamination procedures according to the EOP. Predictor variables included ED experience, education levels and frequency of training.

Data was analyzed using descriptive statistics generating means, standard deviations, frequency counts, and percentages. Kendall’s tau b assessed correlation. A p value of <0.05 was considered significant.

RESULTS

The majority of nurses (77%) had at least 3-5 years of nursing experience. The overall mean of five combined  competencies was 2.95 or just below “competent” on Benner's model. The primary outcome variables (1-5) means ranged from 2.77- 3.27. (1. “contents of the EOP” (mean 2.77 SD 1.25.), 2: “Areas of responsibilities” (mean 2.8 SD 1,23), 3. “decision making processes in the Incident Command System” (mean 2.88 SD 1.21), 4. “Hospital levels of preparedness and its significance.” (mean 3.27 SD 1.18) and 5. “Decontamination procedures according to the EOP” (mean 3.03 SD 1.29).  The strongest positive correlation (r=0,502 p= 0.01) was between clinical experience and self-assessed levels of competency (range mean 1.2 to 3.80 (< 1 year and > 20 years respectively).

CONCLUSION

Nurses’ overall competency concerning disaster preparedness is slightly lower than “competent” according to Benner’s competence estimation model. The majority of nurses lack clinical major incident experience. Accruing actual MI experience may be elusive due to the rarity of MI.  The results of this study however indicate that nurses’ disaster competencies may be inadequate. However, results indicate that ED RNs may increase their disaster medicine competencies through clinical experience, training and education.  Due to the relatively small sample size, the results may be generalized in similar settings with caution.

Introduction: The Bed Surge Capacity is a very important information in the articulation of all phases of the PEIMAF inside the hospital as the pre-hospital organization. It derives the importance of a more precise and timely detection.

Purpose: To evaluate the accuracy of the bed surge capacity in eighteen hospital departments and the surgical availability of the three DEA, through the real-time detection of the number of beds available/readily deliverable at 2 and 24 h from a hypothetical maxiemergency, through four total simulations (three with regard to phase 1 and one for phase 2) both consist of two detection times (T2 and T24). In particular, we analyzed the accuracy of information when obtained from physicians, nurses individually or from integrated surveys.

Materials and methods: The estimation of hospitalization and surgical capacity of the foundation has been assessed on weekdays and holidays, dividing the beds free/readily deliverable by typology (medicines, surgeries, intensive care and subintensives) and Availability of operating theatres.

The creation of new beds was presumed by the possibility of displacement of patients in a lower level of care than that provided at the time of detection, dislocation of patients in a discharge room with assistance of type Nursing, transfer to hospitals with less intensity and rehabilitation facilities or discharge at home.

Results: While in the operative phase of Phase 1 only the nursing coordinators were involved, in the study phase were enrolled both doctors and nurses, with a greater involvement of the second in the first surveys, 11 Nurses in the first day of the I simulation, to then decrease numerically up to a single IC involved in the last two surveys, as it indicates the development of more attention by the medical staff to the simulation.

It has been noted an increase in the total percentage of patients who could be discharged in case of emergency, passing from 22% T2 of the I simulation to 29% of T24 of the simulation II. The increase of patients in this category in the course of the study is reflected in the fact that in the I and III evaluation, in which an equal number of physicians and nurses have been involved in T2 and T24, there is no significant variation in the percentage between the two Detection times, but they are relevant if the average of the I and III simulation is taken into account (22% versus 27%) With evidence of a 5% increase in the category..

Conclusions: From this preliminary data it can be said that to have a complete indication of the possibility of transfer of the patient, it is necessary to take into consideration both the criteria of medical and nursing, for which the choice must be made in team Medical/Nursing.

The first are more focused on severity pathology, progress of the diagnostic-therapeutic pathway, hemodynamic stability of the patient, the second focalise patient care needs (autonomy, presence of invasive devices, catheters, Principals of O2 Administration). Analytical comparison studies are required for the confirmation of the data.

Introduction: after action reports analyze events and improve knowledge about how to prevent and react to unexpected situations. Anyway, there is no consensus among the templates developed for disaster events reporting and there is not a specific model for reporting hospital disaster response.

Hypothesis: we intended to pilot the use of a new assessment tool for hospital response to natural disasters.

Methods: a data collection tool, focused on hospital disaster response to natural disasters, was created modifying the “Utstein-Style Template for Uniform Data Reporting of Acute Medical Response in Disasters” and tested the reaction of the nearest hospitals to the epicenter after the August 24^th, 2016 Central Italy earthquake.

Results: 4 hospitals were included. The completion rate of the tool was of 97.10%. A total of 613 patients accessed the four emergency departments, most of them in Rieti hospital (178; 29.04%). Three hundred and thirty – six patients were classified as earthquake-related (54.81%), most of which with trauma injuries (260; 77.38%).

Discussion: this collection tool proved to be feasible and allowed to retrospectively reconstruct most (97.10%) of the steps of hospital disaster plan deployment and response. Details about activation, patients fluxes, times and actions undertaken were easily reconstructed throughout in-field interviews of hospitals’ managers and consulting patients’ charts. The influx of patients appeared to be quite uniformly distributed across the 4 facilities and, according to our data, hospitals’ capabilities were sufficient to resist the surge.

Conclusions: the Modified Utstein Template for Hospital Disaster Response Reporting is a valid instrument for hospital disaster management reporting. This template could be used for a better comprehension of hospital disaster reaction, debriefing activities, and HDP revisions.

Background: One of the first articles concerning elder abuse was published in 1975. Since then there has been a growing awareness concerning the topic, but there is still a big gap between research and how these findings should be implemented in clinical practice. Medical settings, such as an emergency department (ED), have a potential to be a good location to identify elder abuse because many elderly individuals that have been exposed to abuse need medical expertise to treat their injuries. The main objective of this study was to examine frequency, risk factors and injury patterns of elderly individuals who received care at an emergency department after being a victim to physical abuse.

Methods: The study was conducted as a descriptive, retrospective study where data were collected from medical records during 2011-2012 at Helsingborg General Hospital in the south of Sweden. All patients aged 65 years and above that was seen in the ED were identified and then all patients with the main complaint abuse were included in the study. After all cases of abuse against elderly were identified the medical records for these patients were examined thoroughly to abstract data. Demographic variables such as age, gender and marital status were collected from medical records. Other known risk factors such as psychiatric illness, dementia, stroke and alcohol abuse were registered. Place of injury, if the victim knew the perpetrator, injury patterns and body location, photo documentation of the injuries and if the assault was reported to the police was also abstracted.

Results:  During the study period a total of 39,312 patients ≥ 65 years received care at the ED of Helsingborg General Hospital. Out of those 21 cases of elderly abuse was identified. Several patients had numerous injuries allocated to different body locations. Haematomas were the most frequently documented injury and the head and neck region was the region mostly affected. Some patients showed old scars and haematomas of different ages during the physical examination. Found risk factors were excessive alcohol consumption and comorbidities.

None of the victims had any documented follow-up plan related to the assault.

Conclusion: Statistics from Sweden reports that 13-16 % of all elderly have been victims to some kind of abuse. Even though there has been an increase in research concerning abuse against elderly in the last decades, challenges to identify and intervene against maltreated elderly remains. A large material was used for this study still very few cases of elder abuse was identified, part of this low number can be due to the inclusion criteria and more research is needed. Still there is not enough knowledge concerning elder abuse in Sweden and therefore medical staff face serious problems to recognize and treat these patients at an ED.

Next important step to improve the situation for this patient group would be to introduce a screening tool to identify more persons at risk and develop a follow-up program so that these patients are not left destitute.

Background
Adequate disease specific emergency department (ED) treatment begins with adequate triage to establish urgency and reduce early mortality. Triage in older patients can be challenging due to the presence of multimorbidity, atypical presentation of complaints or the presence of frailty. Our aim was to study the association between disease specific urgency and early mortality in older patients and to study whether the presence of frailty affects this association.

Methods
This was a secondary analysis of the observational multicentre Acutely Presenting Older Patient (APOP) study, in which ED patients aged ≥70 years were prospectively included. Patients were triaged using the Manchester Triage System (MTS) at presentation. Frailty screening was performed using the APOP-screener, which can be administered within 2 minutes at presentation. The primary outcome was 30-day mortality. We assessed whether prediction of mortality was more accurate when frailty was added to MTS by calculating Nagelkerke R² for both models.

Results
We included 2629 ED patients with a median age of 79 (IQR 74-84) years of whom 521 (20.0%) patients were frail according to the APOP screener. Patients were assigned as non-urgent (‘green’, N=717, 27.3%), urgent (‘yellow’, N=1534, 58.3%) and very urgent (‘orange’, N=378, 14.4%). In total 135 (5.1%) patients died within 30 days: 24 (3.3%) non-urgent patients, 84 (5.5%) urgent patients and 27 (7.1%) very urgent patients. Overall, the 30-day mortality rate was higher in frail patients compared to non-frail patients (11.7% vs. 3.4%, p<0.001). This difference was significant within all triage categories. The explained variance of the association between triage and 30-day mortality was higher when in addition to MTS alone (R² 0.009) patients were also screened with the APOP screener (combined R² 0.062).

Conclusion
Combining a frailty measure with the current triage tool improves prediction of early mortality in older ED patients. Adding frailty screening to the routine triage process may help deliver appropriate care to acutely ill older patients.

Background
Frailty screening of older patients in the emergency department (ED) is rarely successfully implemented in routine care. The aim of this study was to evaluate feasibility of screening using the recently validated Acutely Presenting Older Patient (APOP) screener, which identifies older ED patients at highest risk of adverse outcomes within two minutes at presentation.

Methods
This two months’ prospective observational cohort study started after implementation of the APOP screener in ED procedures of the Leiden University Medical Center (LUMC). All consecutive patients aged ≥70 years presenting to the ED were included. The main outcome was adherence to screening by triage-nurses, operationalised by the screening rate. We identified determinants of screening omission by assessing patient-, disease- and organizational related factors. Next to this, feedback of triage-nurses on barriers and facilitators of screening adherence was collected with questionnaires.

Results
In total 986 older patients were included, of which 566 (57.4%) were screened. The screening rate was stable over time. A younger age (OR 1.03 (95%CI 1.01-1.06), p=0.018), triage category “red” (OR 0.14 (95%CI 0.04-0.43), p=0.001) and crowding (>14 ED patients upon arrival) (OR 0.65 (95%CI 0.47-0.88), p=0.005) were independent determinants of screening omission. In line, the most important barriers for screening adherence according to triage-nurses were patient- (“patient was too ill”) and organizational factors (“ED was too busy”).

Conclusion
Screening older patients in routine ED care with the APOP screener was feasible. Since adherence to screening was related to patient and organizational factors, attention for these both aspects could improve implementation.

Introduction

In Denmark (2017) out of 600.000 yearly hospital admissions of elderly ≥ 65 year, 77.5% were acute. Acute admitted elderly who are dependent on homecare may be especially challenged. Nuanced knowledge about their quality of life (QoL) is limited. The aim of this study is to investigate the difference in ratings and definition of QoL between acutely admitted patients ≥ 65 years, with and without homecare.

Methods

A cross sectional study is in progress at three Danish emergency departments (ED). Acutely admitted cognitively well-functioning patients ≥ 65 are invited from August 2018 and interviewed during their admission. The primary outcome is QoL measured by the questionnaire Schedule for the Evaluation of Individual Quality of Life – Direct Weighting (SEIQoL-DW) (scale 0-100). In order to determine their QoL, the patients select and rate the five most important areas of their QoL. In addition, length of stay and hours of received homecare per week are collected from their medical records.

Linear regression analyses will be used to test the associations between homecare (≥ 2 hours per week) and QoL. The most important areas selected and defined by the patients will be described qualitatively. The areas will be condensed into themes to find the participants overall definition of QoL. Difference in QoL between the groups will be tested by un-paired t-test.

A sample size calculation for two-sample means test, level of significance 95%, power 80% and with 10 percent difference in QoL score between the two groups showed that 406 participants is required.

Results

At present, 297 participants are included in the study and 28% of them receive homecare. Mean age is 76 years (min 65 – max 96), 46% are male and 42% of the participants are living alone. Median length of stay is 41 hours (Interquartile range (IQR): 22 – 86) and 63% of the participants are discharged from the ED. Median QoL score is 81.9 (IQR: 70.0 - 90.3) and areas of importance for the patients QoL so far are; family, friends, neighbours, freedom, activities, and health. The time required to complete SEIQoL-DW is 30 min (IQR: 27-35). The inclusion is expected to be completed in June 2019 and analyses on the full data set will be ready in October.

Conclusion

This study is ongoing. The authors expect that a patient perspective on QoL can provide nuanced knowledge on QoL among acutely admitted patients and to be able to detect association between QoL and dependence on homecare.  Aspects that define individual QoL among patients receiving homecare can be used to develop a guide about the most important priorities and adjustments in nursing care and discharge procedures regarding this fragile population.

Background

In England, approximately 10% of patients who contact the ambulance service are triaged as having low urgency health problems which may not necessitate an ambulance response. These patients often receive clinical advice by telephone instead of an ambulance being sent. This has potential to reduce pressure on ambulance service resources and, in doing so, free up ambulance responses for more urgent cases. A recent study  used linked ambulance and other health event data to identify what happens to patients following the decision to give clinical telephone advice and this identified low rates of hospital admissions (2.5% -10.5%) and deaths (0.006%-0.24%) (within 3 days of receiving ambulance telephone advice). This analysis builds on this research to identify why these patients called the ambulance service and what clinical advice they received. 

Methods

Using the same patient population as the previous study (n=2521 patients who received clinical telephone advice from the ambulance service and whose data was linked to other health event data through the Prehospital Outcomes for Evidence Based Evaluation, PhOEBE study), we obtained additional Advanced Medical Priority Dispatch System (AMPDS) about reason for call (‘what’s the problem’) and clinical telephone advice data from the Telephone Advice Service (TAS). For data linkage purposes, this patient population all had other experiences of contacting the ambulance service. AMPDS and TAS data was linked to the PhOEBE study data using Computer Aided Dispatch (CAD) number (a unique ID for each patient) and date and time was used for verification of the linkage. The additional AMPDS and TAS data obtained for this study was text data, therefore a thematic coding framework was developed to code and categorise the data in order to identify reason for call and clinical advice given.

Results

All newly obtained data was successfully linked to the PhOEBE study data. Using the coding framework, we found that for this low urgency patient population, the most common reason for calling the ambulance service was pain (39.35%). Other reasons included diarrhea/vomiting (11.42%), minor health problems (e.g. wound dressing problems, nosebleeds, catheter issues) (9.12%), mental health, alcohol/drugs or crisis problems (8.45%) and difficulty in breathing (8.57%). A paramedic or nurse advised patients what to do next. Most patients were advised to seek in-hours GP care (27.6%) or to self-care (21.4%). 17.9% were advised to seek out-of-hours urgent care and 9.3% were advised to attend ED.

Conclusion

Some callers seek emergency care for low urgency health problems and ambulance services are developing ways to respond to these calls in a more cost efficient way.  Given that most patients were advised primary care or self-care following ambulance telephone advice, and that low subsequent event rates were identified in the previous study, this indicates that telephone advice for low urgency ambulance service callers is largely safe, and has the potential to ensure resources are available for patients with more urgent health problems. Further work is required to understand whether telephone advice is acceptable to patients.

Background

It is well documented that large numbers of people seek help for their healthcare needs in secondary emergency care services, such as Emergency Departments (ED) and the ambulance service, when they could have been treated much closer to home. This is putting increased strain on already overstretched and costly urgent and emergency care (UEC) services, which is unsustainable in the long term.

There is an increasing body of literature that has focused on asking patients how they use UEC services with the intention of identifying the reasons for this behaviour. Other studies have described factors that appear to influence patient satisfaction with UEC services. Whilst informative, these studies do not take into consideration what it is that patients actually want from the UEC system. As a result, services are often implemented without consulting the people who will directly benefit from them. The aim of our study was to discuss patient experiences of accessing UEC services and then identify from the patient perspective, what an ideal UEC system would look like.

Methods

Members of the public in a large English city (population >720,000) were invited to participate in focus groups using a purposeful sampling technique, between September and December 2018. To be eligible to participate, participants must have been in contact with a UEC service (ambulance, walk-in centre, ED, Minor Injuries Unit, out-of-hours GP or NHS111) within the last 12 months and stratified into at least one of the following cohorts: (1) working age (

Results

Four workshops were undertaken with 30 members of the public. Respondents were diverse representing each of the four cohorts. The ideas generated by participants centred around three themes: (1) greater communication from health professionals; (2) linked medical records to ensure consistency of care across the UEC system; (3) a more simplified UEC system which is easier to navigate and access. These ideas were directly influenced by participants past experiences of accessing UEC services, whereby they attempted to identify solutions to the problems they commonly encounter.

Conclusion

This is the first study documenting members of the public’s views of what their ideal UEC system would look like. Participants agreed that services need to work more closely together to provide a more efficient and joined up service. This requires greater communication between health professionals, particularly in relation to discharging patients back into community services. Centralised medical records accessible to all services should be seen as priority. This will ensure continuity of care for patients across the whole healthcare system. Additionally, clarity around what UEC services are available locally, what health conditions are appropriate for these and how people can refer into these services are also important.

Background

The use of emergency ambulances has been increasing in recent years. Emergency medical services (EMS) and EMS research primarily focus on time-critical conditions such as cardiac arrest, respiratory failure, myocardial infarction, stroke and severe trauma – the “first hour quintet”. Little is known about the entire EMS patient population in terms of age profiles, the diagnostic pattern and changes over time.

Aim

We aimed to investigate changes in age profiles and hospital diagnoses among EMS patients from 2007 to 2018. 

Methods

Population-based historic cohort study including EMS patients in the North Denmark Region during 2007, 2014 and 2018. Ambulance data was retrieved from prehospital electronic medical record and data on hospital diagnoses according to International Classification of Diseases (ICD-10) from the regional patient administrative system. We performed descriptive statistics to report the results as frequencies and percentages.

Results

The overall number of EMS patients with hospital contacts increased: 14 551 in 2007, 23 928 in 2014 and 26 560 in 2018, corresponding to an 80% increase. Especially the older age groups (65+) increased in number and fraction from 4 781/32.9% in 2007, to 9 995/41.8% in 2014 and finally 11 980/45.1% in 2018.  Likewise, from 2007 to 2018, non-specific diagnoses increased from 3 993/27% to 10 183/39%. Injuries increased in numbers from 4 999 to 6 537, but decreased in fraction from 34 % to 25 %. Cardio-vascular and respiratory diseases increased in numbers (1 450 to 3 088 and 883 to 2 098) but fractions remained largely unchanged. Finally, psychiatric disease/substance abuse decreased in fraction 962/7% to 1 053/4%.

Discussion and conclusions

The number of EMS patients with subsequent hospital contact almost doubled during the years and number of older patients increased with a factor 2.5. The non-specific diagnoses dominated the pattern with around 40%, while cardiovascular diagnoses constituted only 10-12%. Although time-critical conditions are of great importance in EMS, an entirely different group of patients – the non-specific diagnoses, dominates the population. In addition, more awareness should be directed towards the increasing number of patients with increasing age. In future research, we plan to investigate to which extent demographic changes can explain the increasing age of the EMS population.